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Applied and Preventive Psychology xxx (2011) xxx–xxx

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Applied and Preventive Psychology

journal homepage: www.elsevier.com/locate/app

Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD

Bunmi O. Olatunji a,∗ , Kate B. Wolitzky-Taylor b , Craig N. Sawchuk c , Bethany G. Ciesielski a
a
Vanderbilt University, United States
b
University of California-Los Angeles, United States
c
University of Washington, United States

a r t i c l e i n f o a b s t r a c t

Keywords: Although worry is central to the diagnosis of generalized anxiety disorder (GAD), it is also commonly
Worry observed in other anxiety disorders. In this meta-analytic review, we empirically evaluated the extent to
Anxiety disorders which worry is specific to GAD relative to patients with other anxiety disorders, those with other psychi-
GAD
atric disorders, and nonpsychiatric controls. A total of 47 published studies (N = 8,410) were included in
Meta-analysis
the analysis. The results yielded a large effect size indicating greater severity/frequency of worry, meta-
worry, and domains of worry among anxiety disorder patients v. nonpsychiatric controls (d = 1.64). In
contrast to the many differences emerging from comparisons between anxiety disordered patients and
nonpsychiatric controls, when anxiety disordered patients were compared to people with other psychi-
atric disorders they differed only on severity/frequency and not on meta-worry or domains of worry.
A large effect size indicating greater severity/frequency of worry, meta-worry, and domains of worry
among patients with GAD v. nonpsychiatric controls was also found (d = 2.05). However, differences
between GAD and those with other psychiatric disorders also emerged for severity/frequency of worry.
GAD was associated with greater worry difficulties than other anxiety disorders, which generally did not
differ from those with other psychiatric disorders and each other. The implications of these findings for
conceptualizing worry in GAD and other anxiety disorders, and the potentially moderating effects of age
and gender are discussed.
© 2011 Elsevier Ltd. All rights reserved.

Anxiety disorders are among the most common mental health
conditions, with an estimated annual economic burden of over $42
billion in the United States (Greenberg, Sitisky, & Kessler, 1999).
Anxiety disorders also tend to co-occur with other psychiatric con-
ditions (Kessler, Chiu, Demler, Merikangas, & Walters, 2005), are
associated with high rates of chronic disease (Roy-Byrne et al.,
2008) and medically unexplained physical symptoms (Katon, Lin, &
Kroenke, 2007), and have disproportionately greater rates of med-
ical service utilization (Schmitz & Kruse, 2002).
Worry is a common, and potentially disabling, feature among
many individuals with anxiety. Community estimates suggest that
approximately 6% of the general population will qualify for a diag-
nosis of generalized anxiety disorder (GAD) at some point in their
lifetime (Kessler, Bergland, Demler, Jin, & Walters, 2005), with rates
tending to increase in medical populations (Roy-Byrne & Wagner,
2004). Since the introduction of GAD as a unique diagnostic entity
in the Diagnostic and Statistical Manual of Mental Disorders III (DSM-
III; American Psychiatric Association, 1980), the diagnostic criteria
of GAD have undergone significant changes with each iteration
∗ Corresponding author at: Department of Psychology, Vanderbilt University, 301
Wilson Hall, 111 21st Avenue South, Nashville, TN 37203, United States.
E-mail address: olubunmi.o.olatunji@vanderbilt.edu (B.O. Olatunji).
of the DSM (Ruscio, Chiu, Roy-Byrne, Stang, & Stein, 2007). The
DSM-IV-TR currently characterizes the defining features of GAD
as excessive, uncontrollable worry across a variety of domains,
lasting at least six-months duration, and associated with signif-
icant functional impairments (American Psychiatric Association,
2000). Somatic symptoms are also present, although there is gen-
eral consensus that excessive, chronic worry primarily defines GAD
(Barlow, 2002). It is clear that worry is a central feature of GAD.
However, there is clear value in better understanding worry as a
process that transcends the traditional diagnostic-level approach.
This view is consistent with the well documented notion that
that research efforts to understand the nature of the psychologi-
cal processes underlying psychological phenomena will be more
successful if the phenomena themselves are studied directly as
opposed to the diagnostic categories (Persons, 1986).
1. The nature and function of worry
The nature and function of worry have been a major focus of the-
oretical and empirical efforts over the last several decades. Worry
has been distinguished from anxiety, with research demonstrating
a stronger directional relationship between worry producing anxi-
ety, rather than anxiety producing worry (Gana, Martin, & Canouet,
2001). Borkovec, Robinson, Pruzinsky, and DePree (1983) initially

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Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
 ARTICLE IN PRESS
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characterized worry as, “a chain of thoughts and images, negatively
affect-laden and relatively uncontrollable; it represents an attempt
to engage in mental problem-solving on an issue whose outcome is
uncertain but contains the possibility of one or more negative out-
comes; consequently, worry relates closely to the fear process” (p.
10). From this model, worry becomes activated under conditions of
uncertainty and consists largely of a series of “what if” statements
that represent initial stages of problem-solving in the absence of
subsequent action to actually solve the problem (Borkovec, 1985).
Worry can further amplify feelings of anxiety through more catas-
trophic appraisals coupled with one’s perceived inability to cope
(Robichaud & Dugas, 2005).
In contrast to defining worry as thought imagery, worry has
also been articulated as a form of uncontrollable “thought activity”
over the relative probability of future negative events (Pruzinsky &
Borkovec, 1990). The content of the “thought activity” appears to be
primarily verbal/linguistic in nature (Borkovec, 1994). To test this
notion, Rapee (1993) randomly assigned undergraduate students
to one of four task conditions and required them to worry about a
topic of importance while simultaneously performing the task to
which they had been allocated. The tasks differed in their hypo-
thetical ability to interfere with worrying. The competing task that
produced a load on verbal working memory led to greater worry
interference than tasks impacting visual-spatial working memory.
Psychophysiological research also lends support to viewing
worry as a form of thought activity. For example, worry provocation
is related to greater frontal cortical activation in the left hemi-
sphere among worriers than for non-worriers (Carter, Johnson, &
Borkovec, 1986). Furthermore, Hofmann et al. (2005) found that
worry was correlated with greater heart rate and lower respira-
tory sinus arrhythmia when compared to baseline, relaxation, and
anticipatory inductions. Worry was also associated with lower skin
conductance levels and greater left frontal activity compared with
the anticipatory phase, lending further support for the role of ver-
bal/linguistic processing in this cortical region.
Worry may also be characterized by a diminished capacity
to discriminate between threatening and non-threatening cues.
Excessive worry may be associated with a stronger bias towards
responding to non-threatening cues, which in turn interferes
with adaptive behaviors, consequently maintaining chronic anx-
iety symptoms (Salters-Pedneault, Suvak, & Roemer, 2008). Poor
discrimination may create a cognitive context of uncertainty, which
can activate catastrophic thinking. Research has shown that wor-
riers catastrophize more rapidly and are slower than non-worriers
to engage in positive imagery (McKay, 2005). Davey and Levy
(1998) also found that worriers were willing to catastrophize both
a positive aspect of their life and a new hypothetical worry signif-
icantly more than non-worriers. Similarly, Provencher, Freeston,
Dugas, and Ladouceur (2000) found that high worriers generated
more severe catastrophic consequences that were perceived to
be more probable than low worriers. Worry, as anxious appre-
hension for future, negative events, facilitates the processing of
anxiety provoking content at an abstract level in an effort to avoid
aversive catastrophic images and arousal, consequently inhibiting
emotional processing that may help to facilitate anxiety reduction
(Barlow, 2002; Borkovec, Alcaine, & Behar, 2004; Fresco, Heimberg,
Mennin, & Turk, 2002). At the cortical level, worry-induced pre-
frontal activity has been shown to exert a suppressive effect on
other subcortical regions responsible for affect processing (Hoehn-
Saric, Lee, McLeod, & Wong, 2005).
Worry may also function as a form of cognitive avoidance
(Borkovec, Ray, & Stober, 1998), a process of avoiding threaten-
ing/fearful images and reducing/avoiding physiological arousal.
Worry can be maintained through the absence of predicted neg-
ative outcomes occurring and the negatively reinforcing effect
of somatic arousal reduction (Borkovec, 1994). According to the
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
mood-as-input hypothesis, negative mood may also play an impor-
tant role in the maintenance of worry (Davey, Eldridge, Drost, &
MacDonald, 2007). Specifically, persistent negative mood states
may serve as a continuous feedback loop that perpetuates worry
through ongoing uncertainty over whether the perceived threat
has been successfully managed. The perserveration of worry may
also intensify negative mood. For example, individuals with GAD
exposed to a worry induction have been shown to experience more
intense depressed affect while viewing a sad film in comparison to
GAD and non-anxious control participants in neutral and relaxation
inductions (McLaughlin, Mennin, & Farach, 2007).
Although worry may function to help avoid aversive images
and arousal, it also functions to inhibit emotional processing that
may otherwise facilitate anxiety reduction (Borkovec et al., 2004;
Fresco et al., 2002). The inhibition of emotional processing is
reflected in the reduced autonomic arousal that is commonly asso-
ciated with worry (Borkovec, 1994). For example, Borkovec and
Hu (1990) found that GAD subjects in a worry condition dis-
played significantly less heart rate response to threatening as
opposed to neutral images. Furthermore, more intensive worry has
been found to be associated with reduced cardiovascular activity
whereas inductions of relaxed thinking tends to be associated with
greater cardiovascular response (Borkovec, Lyonsfield, Wiser, &
Deihl, 1993). Likewise, decreased vagal tone has also been observed
among GAD patients (Lyonsfield, Borkovec, & Thayer, 1995). As fur-
ther evidence of “autonomic inflexibility” as a feature of worry,
Brosschot, Van Dijk, and Thayer (2007) found that self-reported
worry frequency and duration were associated with lower heart
rate variability during waking among healthy subjects and as well
during sleep. Provocation of worry can also lead to suppressed heart
rate activity during fearful imagery inductions (Peasley-Miklus &
Vrana, 2000). Collectively, these findings suggest that reductions
in arousal during worry may interfere with functional exposure to
threat cues (Barlow, 2002).
Chronic worry may prove difficult to control due to an “incuba-
tion” of intrusive thoughts. For example, Wells and Papageorgiou
(1995) found that worrying about a stressor for a period of 4 min
after exposure led to significantly more intrusions over a subse-
quent three-day period than a settle-down control condition. A
related study primed high and low worriers with a short period of
worry, suppression of worry, or the same period of non-worrying
thoughts (Mathews & Milroy, 1994). High worriers reported more
than twice as many unpleasant thoughts than low worriers across
all conditions. A more recent study also found that replacing
an intrusive thought with another unpleasant thought was posi-
tively associated with more intensive worry and this strategy had
the strongest correlation with overall worry proneness (Watkins,
2004). The incubation effect of worry may be partially explained by
learning theory. For example, Jones and Davey (1990) conducted an
electrodermal conditioning experiment in which subjects mentally
rehearsed the unconditioned stimulus (UCS) following initial fear
conditioning, but prior to a test period involving non-reinforced
presentations of the conditioned stimulus (CS). Subjects who were
asked to rehearse the UCS retained a differential fear conditioned
response (CR) during subsequent non-reinforced presentations of
the CS, but control subjects who were asked to rehearse either a
non-aversive event or an aversive event unrelated to the UCS failed
to retain the differential CR they had acquired during conditioning.
This study provides an experimental analogue of how the worry
process may have an incubation quality that can maintain anxiety
over time.
The notion that worry can also predispose one to increased
worry over time may be more akin to the “rebound effect” of
more frequent worry following attempts at thought suppression
(Merckelbach, Muris, van den Hout, & de Jong, 1991). Thought
suppression is a well-documented strategy among patients with
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obsessive–compulsive disorder that tends to result in more fre-
quent thought intrusions and undermines one’s perception of
thought controllability (Tolin, Abramowitz, Przeworski, & Foa,
2002). Recent research with GAD patients, however, has shown that
relative to a control condition, suppression actually led to a signif-
icant increase in worry controllability in general, characterized by
more success at suppressing worry, less time spent thinking about
worry themes, and less distress associated with worry (McLean
& Broomfield, 2007). These findings suggest that the effects of
thought suppression are not clear-cut and such effects may vary
depending on the nature of the cognitive process (obsession v.
worry) that is being suppressed. Thought suppression for some
worries may bolster the experience of some control which then
leads to a significant and advantageous shift at the metacognitive
level.
Intolerance of uncertainty regarding the outcome of future
events also appears to be relevant to the process of worry. Intol-
erance of uncertainty has been defined as the tendency to react
negatively to situations and events that are perceived to be ambigu-
ous (Dugas, Buhr, & Ladouceur, 2004). Accordingly, ambiguity may
provoke an automatic worry bias towards catastrophic interpreta-
tions which produces ongoing distress. Indeed, studies have shown
that intolerance of uncertainty is highly related to worry even after
controlling for shared variance with other variables (Buhr & Dugas,
2002). Research has also shown that intolerance of uncertainty
appears more highly related to worry than to panic sensations and
obsessional thinking (Dugas, Gosselin, & Ladouceur, 2001). When
compared to other cognitive processes such as cognitive avoid-
ance, the intolerance of uncertainty appears to be the most potent
predictor of excess worry (Laugesen, Dugas, & Bukowski, 2003;
Robichaud, Dugas, & Conway, 2003).
Research has also shown that intolerance of uncertainty is asso-
ciated with certain information processing biases, such as the
overestimation of risk (Dugas et al., 2005). Consistent with this idea,
subjective estimates of risk probability have been found to partially
mediate the relationship between worry propensity and current
mood (Constans, 2001), suggesting that the elevations in distress
are largely a function of risk inflation. Experimental manipulations
of uncertainty during worry have been shown to amplify feel-
ings of intolerability and excess worry levels (Ladouceur, Gosselin,
& Dugas, 2000). The intolerance of uncertainty may therefore be
an important casual risk factor for the development of excessive
worry. Although the available research literature suggests intoler-
ance of uncertainty is related to, but distinct from, worry, further
consideration must be given to discriminating worry from other
cognitive processes associated with worry.
2. Distinguishing worry from associated cognitive
processes
Rumination has been viewed as similar in process and content
to worry (Borkovec et al., 1998), with studies showing that worry
and rumination do indeed overlap (Fresco, Frankel, Mennin, Turk, &
Heimberg, 2002; Segerstrom, Tsao, Alden, & Craske, 2000). In fact,
some have argued that worry and rumination refer to the same
cognitive phenomena (Turner, Beidel, & Stanley, 1992). Worry,
as a sequence of elaborated verbal thoughts, may be initiated in
response to intrusive catastrophic images (Borkovec et al., 1998).
Similarly, rumination, as a persistent mental attempt at resolv-
ing unattained goals, may be initiated by an intrusive concern
over a discrepancy between current state and ideal goals (Martin
& Tesser, 1996). Rumination has also been defined as “behav-
iors and thoughts that passively focus one’s attention to one’s
depressive symptoms and on the implications of these symptoms”
(Nolen-Hoeksema, 1998, p. 239). Although worry and rumination
are unproductive, repetitive thought processes that exacerbate and
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
3
maintain negative affect, worry and rumination can be differenti-
ated in a number of ways (Papageorgiou & Wells, 2001).
First, worry and rumination differ in terms of the temporal
focus of thoughts. Worry tends to be more future-oriented and
less concerned with the past, whereas rumination involves biased
focus on past or current problems (Gladstone & Parker, 2003;
Watkins, Moulds, & Mackintosh, 2005). Second, worry and rumi-
nation differ in the content of the thoughts. Specifically, worry is
generally focused on problem-solving, whereas rumination con-
sists of themes of loss. Furthermore, while worry is generally
associated with a desire to avoid one’s thoughts, rumination tends
to be associated with a greater conviction in the personal relevance
of a situation and a larger need for understanding. Third, worry and
rumination are often related to differential expressions of negative
affect. Worry tends to be characterized by greater anxiety whereas
rumination tends to generate feelings of depression (McLaughlin,
Borkovec, & Sibrava, 2007). Additionally, in comparison to rumina-
tion, worry tends to be more predictive of worsening psychiatric
symptoms across time (Hong, 2007).
The term obsession has also been used interchangeably with
worry in the literature as they both describe a process of perse-
verative thinking. Obsessions have been defined as repetitive and
intrusive thoughts, images, and impulses that lead to subjective
distress, and often are accompanied by some form of resistance
(Rachman, 1997), and people who report more severe worry tend
to be described as more “obsessional” in nature (Gladstone et al.,
2005a). Although it has been shown that worry and obsessions are
very similar in that they both occur in response to stress (Tallis & de
Silva, 1992), Turner et al. (1992) argue that: (1) worry themes are
typically related to normal daily experience whereas obsessions
include themes of dirt, contamination, and doubt; (2) the major-
ity of GAD patients are able to identify either internal or external
triggers for worry, whereas the majority of obsessional patients
seem unable to identify triggers; (3) worry usually occurs as ver-
bal thought whereas obsessions can occur as thoughts, images, or
impulses; (4) worry is generally experienced as less intrusive and
not as strongly resisted in comparison to obsessions; and (5) the
content of clinical worries, unlike clinical obsessions, is not per-
ceived as unacceptable.
Several empirical efforts have supported the differentiation
between worry and obsessions. For example, Wells and Morrison
(1994) found that worry was rated as involving predominantly ver-
bal rather than imagery material, whereas the opposite was true
of obsessions. Furthermore, worry was regarded as more distract-
ing and less involuntary than obsessions (Wells & Morrison, 1994).
Similarly, Clark and Claybourn (1997) found that worry was con-
sidered more disturbing than the ego-dystonic intrusive thoughts,
and that worry was focused on the possible consequences of neg-
ative events, whereas an emphasis on interpretations of personal
meaningfulness of the thoughts was unique to obsessions. The ten-
dency to assume incorrect causal relationships between thoughts
and external reality, or thought action fusion, is also associated
with obsessions, but not worry (Coles, Mennin, & Heimberg, 2001).
Furthermore, relative to worry, obsessions are perceived as more
bizarre, unacceptable, unrealistic, and less likely to occur in non-
clinical samples (Lee, Lee, Kim, Kwon, & Telch, 2005). Obsessions
were also found to be more likely to take the form of impulses,
urges, or images, whereas worry was more likely to take the form
of doubts, apprehensions, or thoughts (Lee et al., 2005).
3. Normal and pathological worry
The view that worry is primarily a means of controlling
emotional experiences by substituting verbal activity for more
physiologically arousing images has greatly informed etiological
models of GAD (Barlow, 2002). However, there is also evidence
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that worry can be an adaptive strategy for coping with stress-
ful life events by preparing and facilitating attempts at active
problem-solving (Davey, 1994; Endler & Parker, 1990). Rather than
the anticipation of catastrophic, negative outcomes, normal lev-
els of worry may mobilize a problem-solving process (Szabo &
Lovibond, 2004). Indeed, worry has been found to be associated
with adaptive coping strategies when controlling for trait anxiety
(e.g., Davey, Hampton, Farrell, & Davidson, 1992). A more recent
study also found that the correlation between positive affect and
worry was significantly negative; however, when trait anxiety was
controlled, the correlation between positive affect and worry was
significantly positive (Olatunji, Schottenbauer, Rodriguez, Glass,
& Arnkoff, 2007). Although excessive worry may be maladaptive,
worry can also be viewed as a functional strategy that helps facil-
itate performance and efficient problem solving in the face of
objective threat. For example, one study found that GAD patients
experienced superior cardiac outcomes relative to agoraphobic
patients, presumably due to GAD worry facilitating some form
of constructive problem solving (Parker, Owen, Brotchie, & Hyett,
2010).
The worry experienced by GAD patients may be viewed as the
extreme end of a continuum ranging from abnormal/pathological
to normal/nonpathological (Davey, 1994). To better understand
how normal and abnormal worry may be operationalized, distinc-
tions must be made between two concepts (Barlow, 2002): (1)
the normative, adaptive process of identifying threats and actively
problem solving or preparing to cope with perceived threats; and,
(2) the process of worry, which is anxiety-laden and character-
ized by the generation of multiple potential negative events, in the
absence of effective attempts to actively solve problems or cope
with outcomes. The former may be viewed as normal worry, which
is further defined as “mild, transient, generally limited in scope,
and experienced by the majority of individuals” (Ruscio, 2002, p.
378). In one of the few studies examining the features of ‘normal’
worry, Tallis, Davey, and Capuzzo (1994) found that most partic-
ipants considered worry to be a routine and mostly acceptable
daily activity, usually concerning various issues and experienced
mostly in the form of narrative thoughts. Normal worry was also
described as present and future-orientated, occurring more at night
before sleep, and focusing on realistic or likely problems, rather
than imaginary or remote.
Although worry content is similar between those that engage
in normal and pathological worry (Borkovec, Shadick, & Hopkins,
1991), pathological worriers typically describe their worry as more
uncontrollable than normal worriers. Worriers also report a more
negative daydreaming style, greater difficulty with attentional
control, greater obsessional-type symptoms, more frequent neg-
ative cognitive intrusions, increased public self-consciousness, and
higher social anxiety than nonworriers (Pruzinsky & Borkovec,
1990). Neuroimaging research has also begun to shed light on
the potential distinctions between normal and pathological worry.
For example, worry has been found to be negatively correlated
with brain activation during aversive imagery in the anterior
cingulate cortex, the prefrontal cortex (dorsolateral, dorsome-
dial, ventrolateral), the parietal cortex, and the insula (Schienle,
Schäfer, Pignanelli, & Vaitl, 2009). Given that these brain regions
are involved in emotion regulation, vivid imagery and memory
retrieval, the association between lowered activity in these regions
and high worry propensity may reflect cognitive disengagement
from aversive imagery. Paulesu et al. (2009) also found that the
anterior cingulate and dorsal medial prefrontal cortex were asso-
ciated with worry triggered by sentences in patients with GAD and
normal controls. However, GAD subjects showed a persistent acti-
vation of these areas even during the resting state that followed
the worrying phase, which significantly correlated with trait worry
levels. These findings suggest that worry is associated with brain
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
regions specifically involved in mentalization and introspective
thinking, and potential dysregulation in the circuitry of this region
may reflect the prolonged experiential difficulties with worry con-
trol in GAD.
Some authors have suggested that prolonged and maladap-
tive worry occurs in people who have tightly organized clusters
of worry-related information stored in long-term memory (Pratt,
Tallis, & Eysenck, 1997). High levels of worry have been shown to
reduce working memory capacity, possibly reflecting how worry
competes for limited information processing resources (see Hayes
& Hirsch, 2007). For example, a recent study had high and low
worriers perform a random key-press task while thinking about
a current worry or a positive personally relevant topic (Hayes,
Hirsch, & Mathews, 2008). Results indicated that high, but not
low, worriers evidenced more restricted capacity to react to the
key press task when provoked with worry as opposed when
instructed to think about a positive topic. The inability of worriers
to redirect their thoughts may lead to further biases in informa-
tion processing, such as catastrophic thinking and overestimating
the likelihood of threat occurrence (Suarez-Morales & Bell, 2006).
Normal worriers also tend to demonstrate an attentional bias
away from threatening material whereas pathological worriers
exhibit an attentional bias towards threat (MacLeod, Mathews, &
Tata, 1986). Pathological worry is also characterized by a broader
scope of worry domains (Roemer, Molina, & Borkovec, 1997) and
pathological worriers will tend to worry for longer periods of
time (Craske, Rapee, Jackel, & Barlow, 1989) relative to normal
worriers.
4. The latent structure of worry
The available evidence reviewed above supports the notion
that normal worry may be qualitatively different from patholog-
ical worry suggesting that worry may be measured as a categorical
variable. However, given that approximately one-fifth of those
reporting clinically significant levels of worry actually meet diag-
nostic criteria for GAD, normal and pathological worry may have
more similarities than previously thought (Ruscio, 2002). This find-
ing also raises the question regarding whether differences between
normal and pathological worry reflect variations in degree or type
of worry. Delineating the latent structure of worry has important
implications for conceptualizing the etiology of GAD. For exam-
ple, if worry is not comprised of underlying latent categories,
then etiological models that posit discontinuity (e.g., experienc-
ing a dichotomous causal factor means having the pathological
form of worry) would be inadequate (Haslam, Williams, Haslam,
Graetz, & Sawyer, 2006). Rather, dimensional variables are gener-
ally characterized by a multifactorial etiology (Haslam, 1997) and
etiological models of worry would then focus on identifying the
various environmental and/or genetic factors that contribute to a
person’s position on a worry continuum.
Taxometrics, a set of statistical procedures designed to uncover
the latent structure (i.e., categorical v. continuous distribution) of
phenomena (Meehl & Golden, 1982), has been a useful tool for
examining the underlying latent structure of other psychologi-
cal constructs. Surprisingly, only two investigations to date have
assessed whether normal and pathological worry are qualitatively
distinct or fall along a single continuum. In an initial taxometric
study utilizing a sample of 1588 college students, Ruscio, Borkovec,
and Ruscio (2001) found evidence supporting a dimensional struc-
ture of worry, suggesting that normal and pathological worry
represent opposite ends of a continuum rather than discrete con-
structs. A more recent comprehensive investigation also found
support for the dimensional view of worry (Olatunji, Broman-Fulks,
Bergman, Green, & Zlomke, 2010), suggesting worry is a dimen-
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sional construct that is present to a greater or lesser extent in all
people.
5. Domains of worry
Most studies have conceptualized and assessed worry in terms
of severity and frequency, using the Penn State Worry Ques-
tionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990) as
the primary means for measuring this construct. Several studies
have provided evidence suggesting that the PSWQ is a valid and
reliable measure of worry (Brown, 2003; Meyer et al., 1990), is
sensitive to treatment effects (i.e., Meyer et al., 1990; Stöber &
Bittencourt, 1998), and is a useful tool for screening those who
are likely to meet diagnostic criteria for GAD (Fresco, Mennin,
Heimberg, & Turk, 2003). Furthermore, the PSWQ has been shown
to demonstrate specificity in that it distinguishes those with GAD
from those with other anxiety disorders, including those with
obsessive–compulsive disorder (Brown, Antony, & Barlow, 1992).
Excessive and uncontrollable worry can be readily observed
in a variety of domains and the domains of worry are typically
assessed with the Worry Domains Questionnaire (WDQ; Tallis,
Eysenck, & Mathews, 1992). The WDQ assesses worry about rela-
tionships, confidence, the future, work, and financial matters. The
WDQ has excellent internal consistency, test-retest reliability, and
convergent validity (Stöber, 1998). Studies employing the WDQ and
similar scales have highlighted core worry themes. For example,
Tallis et al. (1994) found that in a mixed sample of 128 univer-
sity students and working adults, 17% of respondents reported they
worried most often about their competence at work, followed by
academic performance (11%), health issues (10%), financial circum-
stances (10%), and intimate relationships (9%). Social-evaluative
worry also appears to be a prominent theme that differentiates
those high in trait anxiety from those low in trait anxiety (Eysenck
& Van Berkum, 1992). Other studies have found health and injury
(Craske et al., 1989) and familial and interpersonal relationships
(Borkovec et al., 1991; Roemer et al., 1997) to be the most frequently
occurring domains of worry among patients with GAD. Perhaps the
most consistent finding differentiating GAD from nonanxious con-
trols is the degree of worry over seemingly miscellaneous topics,
such as being late for appointments or having car problems. For
example, the relative proportion of worries related to miscella-
neous themes reported by nonanxious controls and those with GAD
is 0–20% and 25–31%, respectively (Borkovec et al., 1991; Craske
et al., 1989; Roemer et al., 1997). The shear frequency and scope of
worry across threat-relevant and miscellaneous areas underscores
the differentiation between normal and pathological worry.
Understanding the function of worry may also characterize the
progression from normal to pathological worry. Worry is a form of
anticipatory problem-solving, helping a person plan and prepare
for future (potentially) negative events. Excessive worriers often
have beliefs about the positive consequences of worrying, which
may reinforce and maintain worry. For example, the absence of
negative outcomes occurring following worry episodes may inad-
vertently reinforce the act of worrying rather than leading to the
correction of faulty appraisals regarding the intensity or likelihood
of the anticipated feared outcomes themselves. Beliefs in worry as
an aid to problem solving and motivation, as protection from neg-
ative emotions, as an act that can directly alter events, and as a
positive personality trait are common features among those more
prone to worry (Francis & Dugas, 2004). As a positive personal-
ity trait, worriers may assume an inflated level of responsibility
for worrying about the health and welfare of others (Cartwright-
Hatton & Wells, 1997). The constellation of positive beliefs about
worry may explain why those high in neuroticism are often more
likely than those low in neuroticism to actually choose to ele-
vate their level of worry under stressful situations (Tamir, 2005).
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
5
Studies have shown that excessive worriers do in fact report sig-
nificantly more positive beliefs about worry than do low worriers
(Borkovec & Roemer, 1995; Freeston, Rheaume, Letarte, Dugas, &
Ladouceur, 1994), although high levels of positive beliefs about
worry tends to be inversely associated with coping abilities (Davey,
Tallis, & Capuzzo, 1996). There is also evidence suggesting that pos-
itive beliefs about worry can further distinguish GAD patients from
nonanxious and nonworried-anxious people (Davis & Valentiner,
2000).
Beliefs about worry can be assessed with the Why Worry
Questionnaire (WWQ; Freeston et al., 1994), which measures the
erroneous belief that: a) worries help to prevent negative events or
to avoid the worst; and, b) worries enable one to find a better way of
doing things by increasing control and helping one to find solutions.
The instrument shows excellent validity (Freeston et al., 1994), very
good internal consistency, and adequate temporal stability over a
five-week period (Dugas, Freeston, Doucet, Lachance, & Ladouceur,
1995). Based on studies employing the WWQ and similar scales,
positive beliefs about worry may emerge from both short-term and
long-term experiences with negative reinforcement that emerges
from the worry process (Borkovec, Hazlett-Stevens, & Diaz, 1999).
By exerting perceived predictability and controllability over future-
oriented events, positive beliefs about worry reinforce ongoing
utilization of worry-like strategies, even when such strategies are
no longer necessary (Cartwright-Hatton & Wells, 1997).
The meta-cognitive theory of GAD suggests that people who
develop pathological worry hold both positive and negative beliefs
about worry (Wells, 1995). According to this approach, patholog-
ical worriers hold positive beliefs about the efficacy of worry as a
problem-solving strategy, which may lead to increased use of and
reliance on worry as a coping mechanism. Positive beliefs motivate
the use of worry and precede the development of negative beliefs
about worry, which reinforce attempts to avoid or suppress worry
(Wells & Butler, 1997). Avoidance and suppression of worry, how-
ever, may result in a short-term increase in intrusions. For example,
Becker, Rinck, Roth, and Margraf (1998) examined the ability to
suppress unwanted thoughts in patients with GAD, speech pho-
bics, and nonanxious controls. All participants spent 5 min thinking
aloud about anything that came to mind while trying not to think
of white bears. In another task, they thought aloud for 5 min while
trying not to think of their main worry. Intrusions of unwanted
thoughts were signaled by button presses and recorded on tape.
The findings showed that GAD patients showed more intrusions of
their main worry than of white bears. However, the opposite was
true for the other participants.
The meta-cognitive view contends that normal worry becomes
pathological when worry itself constitutes the focus of wor-
rying, or the “worry about worry” phenomenon. This process
can be examined with the Meta-Cognitions Questionnaire (MCQ;
Cartwright-Hatton & Wells, 1997). The MCQ assesses positive
beliefs about worry, negative beliefs about the uncontrollability
of thoughts and corresponding danger, concerns about one’s cog-
nitive efficiency, negative beliefs about thoughts in general, and
cognitive self-consciousness. The MCQ has demonstrated good reli-
ability, validity, and specificity to worry, even when controlling for
trait anxiety, and GAD (Cartwright-Hatton & Wells, 1997). More
recent research has proposed that the MCQ’s ability to assess cog-
nitive confidence is the specific factor that predicts worry (Yilmaz,
Gencoz, & Wells, 2008). Meta-cognitions, particularly concerns
about one’s cognitive efficiency, including memory and attentional
functioning, may play a significant role in the development of
excessive worry. However, it has been observed that the associ-
ation between meta-cognitive measures such as the MCQ and GAD
may be partially illusory, given that the measure focuses on per-
ceived lack of control over worry, which is a defining diagnostic
criterion of GAD (Wells, 2005a, 2005b).
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6. Gender differences in worry
The consideration of gender differences may provide valuable
insights into the origins of worry and associated disorders. Research
has consistently shown that the prevalence rates for most anxi-
ety disorders are higher among women compared to men (Craske,
2003). For example, most community epidemiological surveys note
a female to male ratio of GAD at 2:1 (Vesga-López et al., 2008;
Wittchen, Zhao, Kessler, & Eaton, 1994). Disability, as indexed
by social functioning, emotional functioning, and general mental
health, associated with a diagnosis of GAD also tends to be sig-
nificantly greater for women than men (Vesga-López et al., 2008).
Given that the primary symptom for a diagnosis of GAD is exces-
sive and uncontrollable worry, gender differences in worry itself
may largely account for the documented gender differences in the
prevalence of GAD (APA, 2000). Although the absence of gender
differences in worry severity has been reported in the literature
(Brown et al., 1992), most studies support more intense and fre-
quent worry among females than males in adult (Lewinsohn, Gotlib,
Lewinsohn, Seeley, & Allen, 1998; McCann, Stewin, & Short, 1991;
Olatunji et al., 2007) and child (Muris, Meesters, & Gobel, 2001)
samples.
Gender differences in worry may be partially explained by
several processes including ascribing to gender roles and the
propensity to internalize (women) rather than externalize (men)
distress. For example, gender role theory posits that boys and girls
are socialized to develop prescribed traits that are consistent with
their gender (Bem, 1981). Given that chronic worry may be deemed
inconsistent with the male gender role, worry behavior may be
less tolerated in boys. Robichaud et al. (2003) found that although
men and women worry in a similar manner about finances, the
future, interpersonal relationships, and competence in the work-
place, worry over self-confidence was significantly greater among
women. This study also found that women reported a more neg-
ative problem-solving orientation and engaged in more thought
suppression than men, with this gender difference accounting for
the observed gender difference in overall worry. One interpretation
of these findings is that higher levels of stress and lower levels of
mastery in women may contribute to the female preponderance in
worry proneness (Zalta & Chambless, 2008).
7. Worry across the lifespan
Researchers have become increasingly interested in the man-
ifestation of worry across the lifespan. This body of research has
been facilitated by the conversion of measures of worry in adults
to accommodate children and adolescents (i.e., Chorpita, Tracey,
Brown, Collica, & Barlow, 1997). Like gender, age may be viewed
as a moderator of the severity and expression of worry. For exam-
ple, it seems reasonable to predict that social concerns might be
a significant source of worry among children and adolescents,
whereas health and financial issues may be a more relevant source
of worry for older adults. However, the question remains as to what
age can tell us about the causes of excessive worry. To examine
this issue, Vasey, Crnic, and Carter (1994) examined the course of
worry among children aged 5–6, 8–9, and 12–13 years. Although
all groups endorsed worry concerns, worry was more prevalent
among children in the latter two age ranges. The content of worry
also changed significantly across age groups, with younger chil-
dren reporting more worry about physical well-being, whereas
older children reported more worry about competence, psycho-
logical well-being, and social evaluation. This pattern of findings
suggests that the development of worry may be primarily influ-
enced by environmental contingencies. Consistent with this notion,
Olatunji and Cole (2009) recently found that self-reported worry
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
among children tracked longitudinally across the 3rd to 6th grade
reflected a more state than stable trait dimension.
Excessive worry is a rather common observation among chil-
dren (Bell-Dolan, Last, & Strauss, 1990), with worry uniquely
differentiating children with anxiety disorders from those with
other nonanxious psychiatric disorders (Mattison, Bagnato, &
Brubaker, 1988). Among primary school children, Muris, Meesters,
Merckelbach, Sermon, and Zwakhalen (1998) found that approxi-
mately 70% reported worrying from time to time, with an estimated
5% meeting diagnostic criteria for GAD. The initial emergence of
worry in early childhood may have its origins in specific familial
dynamics, such as attachment style and specific parental rear-
ing behaviors. For example, rejecting and anxious parental rearing
behaviors have been found to be positively related with worry
among primary school children (Muris, Meesters, Merckelbach,
& Hülsenbeck, 2000). Furthermore, avoidantly or ambivalently
attached children displayed higher levels of worry than securely
attached children. Although worry is an important feature of anxi-
ety in children as young as age 5, it appears to increase in prevalence
and complexity through middle childhood (Vasey et al., 1994). The
capacity for children to make associations across a range of per-
ceived threatening outcomes is an important feature of cognitive
development that inherently elevates risk for excess worry (Vasey
& Daleiden, 1994).
As observed in adult samples, excessive worry in children is
highly associated with the entire range of anxiety disorder symp-
toms, with the strongest correlations found with GAD (Muris et al.,
2001). Research has also shown that worry among youth is main-
tained by similar processes found among adults. For example,
Gosselin et al. (2007) noted that children high in worry avoided
worry cues, engaged in thought suppression, and held more faulty
beliefs about the function of worry. These findings are consis-
tent with research among the elderly showing that meta-worry
(i.e., negative beliefs about worry) is significantly associated with
trait worry and the degree of daily worry interference, even when
controlling for trait anxiety (Montorio, Wetherell, & Nuevo, 2006;
Nuevo, Montorio, & Borkovec, 2004). Worry among youth also pro-
duces similar information processing biases as adults. For example,
Suarez and Bell-Dolan (2001) found that among 5th- and 6th-grade
children, worriers interpreted both ambiguous and threatening sit-
uations as more threatening, expressed more worry in response
to the events, and judged these negative events to have a higher
probability of occurring in the future compared to nonworriers.
Furthermore, children and adults who worry at greater levels
than others are more apt to detect potential threat (e.g., Taghavi,
Dalgleish, Moradi, Neshat-Doost, & Yule, 2003), suggesting that
worry may potentiate attention towards threat in the environment.
Excessive worry among older adults has increasingly become
a focus of research (Crittendon & Hopko, 2006; Hopko et al.,
2003). The availability of sound measures of worry has allowed
researchers to assess if older populations are in fact more worry
prone than their younger counterparts. One might predict a robust
relationship between worry and old age given the potential difficul-
ties and experiential base associated with growing older. However,
research has generally failed to support this notion (Wisocki, 1994).
For example, Powers, Wisocki, and Whitbourne (1992) found that
college students aged 18–24 yielded greater overall worry and
worried significantly more about finances and social issues than
community senior center members over the age of 65. Simi-
larly, Doucet, Ladouceur, Freeston, and Dugas (1998) found that
participants aged 75 years or older reported fewer worries than par-
ticipants aged 55–64 and those aged 65–74. Furthermore, younger
adults in the sample (aged 55–64) worried more about their future,
work, and finances than adults aged 65 and above. Although Hunt,
Wisocki, and Yanko (2003) found that adults over age 64 expressed
significantly more worries about health, family concerns, and world
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issues compared to college students, younger adults reported a sig-
nificantly more general, trait-like tendency to worry than did the
older adults.
It does not appear that the elderly necessarily worry more than
younger adults. Rather, age differences in worry content appear to
emerge in patterns that are consistent with common age-related
developmental changes (Diefenbach, Stanley, & Beck, 2001). For
example, a cross-sectional national survey of 8580 household-
ers in Great Britain aged between 16 and 74 years found that
compared to a 16–24 years reference group, worries about rela-
tionships/family, finances/housing and work were lower in the
55–74 years age groups (Lindesay et al., 2006). Furthermore, finan-
cial/housing worries were increased in the 25–44 years group, and
health worries were increased in the 25–64 years groups. Although
it might be concluded that the level of worry declines with age,
the strength of the association between worry domains and men-
tal disorders appears to be either stable or increases among older
adults (Lindesay et al., 2006). Worry about minor issues combined
with the extent to which worry interferes with daily functioning
have also been shown to be the best discriminant variables for
GAD among the elderly (Montorio, Nuevo, Márquez, Izal, & Losada,
2003).
As with younger adults, worry is an important characteristic of
GAD among the elderly (Beck, Stanley, & Zebb, 1996; Stanley, Novy,
Bourland, Beck, & Averill, 2001). For example, Hopko et al. (2000)
found significant correlations between clinician-rated GAD sever-
ity and self-reported symptom severity among older adults who
met diagnostic criteria for GAD. However, only self-reported trait
worry accounted for additional significant variance in the relation-
ship between coexistent depression and clinician severity ratings.
Furthermore, research comparing older adults with GAD has clearly
shown that later-life GAD is characterized by greater distress and
impairment, muscle tension, sleep disturbance, worry frequency,
and uncontrollability of thoughts in comparison to their same-
aged subsyndromal anxious and nonanxious cohorts (Wetherell,
Le Roux, & Gatz, 2003). However, additional research is needed in
delineating the differential mechanisms that contribute to worry,
and its relation to GAD among younger adults and the elderly.
Neuroimaging research has begun to address this issue to some
degree. For example, Mohlman et al. (2009) recently found that
medial orbital cortex volumes were positively related to worry
scores among adults aged 60 and over, independent of GAD sta-
tus, although dorsolateral cortex and amygdala volumes were not.
This finding suggests that at least among older adults, worry may be
associated with neural regions that regulate the control of anxiety-
related symptoms.
8. The treatment of worry
A large body of research has shown that worry is a risk fac-
tor for anxiety-related disorders (Barlow, 2002), and that worry is
characterized by a variety of information processing biases. Accord-
ingly, the attenuation of these biases may lead to a reduction in
worry-related symptoms (Mogg & Bradley, 1998). For example,
Hirsch, Hayes, and Mathews (2009) assigned high worriers to either
practice accessing benign meanings of threat-related homographs
and emotionally ambiguous scenarios or to a control condition in
which threatening or benign meanings were accessed with equal
frequency. The findings showed that the benign group reported
fewer negative thought intrusions, less anxiety during a subse-
quent breathing focus task, and greater residual working memory
capacity while worrying compared to the control group. Another
study randomly assigned twenty-four adult participants reporting
severe worry to five sessions of either computer-delivered atten-
tional retraining or sham training (Hazen, Vasey, & Schmidt, 2009).
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
7
The results showed that, compared to sham-training, the active
retraining program produced significant reductions in both threat
biases and worry symptoms.
Worry may be also be reduced with the implementation of
more effective problem-solving/coping techniques and the estab-
lishment of better stimulus control for the occurrence of worry.
For example, Borkovec, Wilkinson, Folensbee, and Lerman (1983)
developed a stimulus control treatment of worry that consisted
of: (a) learning to identify worrisome thoughts; (b) establishing
a limited worry period to take place at the same time and in the
same location each day; (c) postponing worrisome thoughts until
the worry period; and, (d) making use of the worry period to worry
about concerns and to engage in problem-solving. Borkovec et al.
found that self-labeled worriers that received a 4-week trial of
stimulus control instructions demonstrated a significant decline in
daily worry relative to controls. Learning-based treatments, there-
fore, may effectively reduce excessive worry. However, given that
worry can be operationalized as a form of cognitive avoidance, it
is likely that cognitive-based interventions may yield more robust
treatment effects. To test this notion, Robinson (1989) randomly
assigned high worriers to either a cognitive restructuring, cop-
ing desensitization, placebo, or a wait-list control group. Greater
worry reduction was observed among those assigned to the cogni-
tive restructuring intervention compared to those in the remaining
groups. Although the coping desensitization intervention also pro-
duced some significant worry reductions, worriers assigned to
cognitive restructuring also reported significant increases in atten-
tion and decreases in the frequency of intrusive thoughts.
The actual treatment of worry has been most extensively exam-
ined among patients with GAD. Although excessive worry may
hinder the treatment of GAD (Gould, Safren, Washington, & Otto,
2004), a recent meta-analysis found cognitive behavioral therapy
(CBT) for GAD to be highly effective in reducing pathological trait
worry, yielding an effect size of −1.15 (Covin, Quimet, Seeds, &
Dozois, 2008). The effectiveness of CBT for trait worry among GAD
patients appears to be moderated by age, with younger adults
tending to show a more favorable response to treatment than
older adults (Covin et al., 2008). Treatment gains were also main-
tained during 6- and 12-month follow-up periods. When directly
compared to CBT outcome studies of other anxiety disorders, the
lowest effect sizes are observed among studies of GAD (Newman,
Castonguay, Borkovec, Fisher, & Nordberg, 2008). Given the role
of positive beliefs about worry, perhaps there may be less motiva-
tion among patients to attenuate their worrisome habit. Addressing
treatment motivation in GAD may therefore facilitate treatment
outcome. Towards this end, Westra, Arkowitz, and Dozois (2009)
randomly assigned patients with GAD to receive either moti-
vational interviewing (MI) or no intervention prior to receiving
standard CBT. GAD patients that received MI showed significantly
more reductions in worry symptoms and an increase in homework
compliance, which mediated the impact of treatment group on
worry reduction. Furthermore, the MI intervention was found to be
most beneficial for GAD patients with high baseline worry severity.
The durability of CBT effects may reflect fundamental changes
in cortical regions associated with pathological worry. For exam-
ple, although GAD patients showed higher levels of gamma activity
than control participants in posterior electrode sites that had been
previously associated with negative emotion during worry induc-
tion, following CBT, GAD patients reported less negative affect with
worry inductions and the corresponding gamma sites for the GAD
patients changed in the direction of control participants (Oathes
et al., 2008). Preliminary research also suggests that effective phar-
macotherapy of GAD may be associated with reduced activation
in prefrontal regions, the striatum, insula and paralimbic regions
during exposure to worry cues (Hoehn-Saric, Schlund, & Wong,
2004).
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9. The specificity of worry to GAD
A review of the literature clearly shows that much has been
learned about the nature, function, structure, domains, demo-
graphic correlates, and treatment of worry. However, the existing
literature notes that worry is a shared feature among many anxiety
disorders and relatively few studies have actually examined worry
independent of GAD (Tallis et al., 1994), thereby questioning the
specificity of worry to GAD. To test this notion, Dugas, Freeston,
Ladouceur, et al., (1998) compared primary GAD, secondary GAD,
and other anxiety disorders without GAD across different worry
themes. When comparing worry domains involving relationships,
work, finances, physical threat, and the future, only worry about the
future clearly differentiated GAD patients from non-GAD patients.
Subsequent analysis also showed that patients with primary GAD
worry more about the future than secondary GAD patients who
in turn worry more about the future than other anxiety disorder
patients. Although these findings suggest that current worry is not
entirely specific to GAD, other studies have found that GAD patients
report a higher frequency of worry, higher numbers of different
worry topics, lower subjective controllability, more accompany-
ing bodily symptoms, and more distress during worry compared to
those with social anxiety disorder (Hoyer, Becker, & Roth, 2001).
The amplified worry process may account for the unique con-
stellation of somatic symptoms in GAD (Joormann & Stober, 1999).
However, some have even questioned whether excessive worry
should be required for a diagnosis of GAD at all, as people who
do not report their worry to be excessive, yet are substantially
impaired by their anxiety, would not meet DSM-IV-TR criteria
(Ruscio et al., 2005). Some authors have even argued for broad-
ening the diagnostic criteria for GAD by reducing the minimum
duration of worry to 1 month, reducing the number of physical
symptoms to 2, and eliminating the excessive worry requirement
(Ruscio, Chiu, Roy-Byrne, Stang, & Stein, 2007). While relaxing these
criteria would more than double the prevalence rates, preliminary
data suggest that diagnostic specificity may also slightly improve
as GAD becomes more readily differentiated from other disorders
(Ruscio et al., 2007). Other studies have found that high worriers
had lower scores on negative beliefs about the uncontrollability and
danger of worry than did those with GAD; however, the high wor-
riers also had higher scores on these beliefs than did an unselected
group of college students, suggesting that such beliefs about worry
may be relevant for all people who engage in excess worry and not
just those with a diagnosis of GAD (Ruscio & Borkovec, 2004).
It has been posited that of the anxiety disorders, GAD repre-
sents the condition of maximum associative fluidity of affective
response structures given an underlying processing system marked
by worries across disparate contexts (Lang, 1985). Consistent with
this notion, it has been shown that excessive worry can discrim-
inate GAD from the equally diffuse and broad anxiety disorder,
not otherwise specified diagnosis (Street et al., 1997). However,
the importance of worry specificity to GAD is reinforced by sev-
eral studies providing evidence for the limited validity of the GAD
diagnosis itself (cf. Brown, 1997). Although the features constitut-
ing the diagnostic criteria for GAD have been found to be generally
reliable, the diagnostic reliability of GAD is lower than that of other
anxiety disorders (Brown, Barlow, & Liebowitz, 1994). The limited
validity of the GAD diagnosis may be partially due to the obser-
vation that worry is a shared feature among all anxiety disorders
(Barlow, 2002). In fact, it has been noted that “the ubiquity of worry
across the anxiety disorders would diminish the distinctiveness of
the GAD diagnosis, thereby contributing to its poorer reliability”
(Brown, Moras, Zinbarg, & Barlow, 1993, p. 228).
The view that worry is a unifying process across all the anxiety
disorders is reflected in biopsychosocial models of the etiology and
maintenance of anxiety-related problems (Brown & Barlow, 1992).
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
For example, Barlow (2002) has articulated a model of anxiety that
emphasizes the fundamental process of “anxious apprehension”
(e.g., worry). In this model, anxious apprehension is operationalized
by a future-oriented mood state, characterized by chronic over-
arousal, a sense of uncontrollability, and attentional vigilance for
threat, that involves anticipation and perceived attempts at coping
with future negative events. According to Brown (1997), while the
process of anxious apprehension is common to all anxiety disorders,
the actual content of anxious apprehension varies from disorder to
disorder. Worry may therefore be viewed as a common method of
cognitive avoidance shared by the anxiety disorders, with the focus
of the worry varying according to the anxiety disorder of concern.
This transdiagnostic view has resulted in the development of worry
exposure techniques that can be applied for the treatment of exces-
sive worry across various disorders (van der Heiden & Ten Broeke,
2009).
9.1. Examination of worry in ‘other’ anxiety disorders
The notion that worry is common to anxiety disorders in general
and not necessarily a unique feature of GAD may be best sup-
ported by consideration of OCD. There exists considerable overlap
between chronic worry and obsessions, as they are both marked
by excessive and/or uncontrollable cognitive processes associated
with negative affect (Brown et al., 1993). As previously discussed,
important distinctions have been made between worry and obses-
sions as they relate to GAD and OCD (Abramowitz & Foa, 1998; Clark
& Claybourn, 1997). Obsessive rumination, however, is a unique
predictor of worry (Rijsoort, Emmelkamp, & Vervaeke, 2001) and
worry has been proposed to be a cognitive variant of OCD checking
(Tallis & de Silva, 1992). Furthermore, the overlap between worry
and obsessions has prompted consideration of similar treatments
for OCD and GAD, with such treatments yielding promising out-
comes (Starcevic & Bogojevic, 1997). Taken further, perhaps the
topographical distinction between worry and obsessions is unnec-
essary given that the underlying process of the two phenomena
in GAD and OCD may be identical (see Comer, Kendall, Franklin,
Hudson, & Pimentel, 2004). Although there is good evidence that
GAD and OCD can be differentiated by clinicians (Brown & Barlow,
1992; Brown et al., 1993), worry may not be a particularly helpful
symptom in making a diagnostic distinction from OCD if obses-
sions also serve a similar function to worry. In fact, a recent study
found that patients with OCD reported significantly greater use
of meta-worry that those with GAD and depression (Barahmand,
2009).
Although excessive worry about immediate problems may not
differentiate GAD from other anxiety disorders, worry about future
events may be the defining feature of GAD (Dugas, Freeston,
Ladouceur, et al., 1998). The future holds an inherent degree of
uncertainty, with many patients reporting significant discomfort
when faced with such uncertainty. Intolerance of uncertainty has
been proposed to be more specific to worry and GAD than other
anxiety disorders (e.g., Dugas et al., 2004). The intolerance of
uncertainty has also been implicated in OCD (Tolin, Abramowitz,
Brigidi, & Foa, 2003), and recent studies have failed to differenti-
ate worry, GAD, and OCD on this dimension (Holaway, Heimberg,
& Coles, 2006). At least one investigation has also shown that OCD
patients reported greater intolerance of uncertainty than those in a
mixed anxiety disorder group which did include people with GAD
(Steketee, Frost, & Cohen, 1998). To the extent that excessive worry
and obsessions function as cognitive reactions to an inability to
tolerate uncertainty, this functional process may differentiate GAD
and OCD from other anxiety disorders, but not necessarily differ-
entiate GAD from OCD itself.
Excessive worry also does not appear to always differentiate
GAD from panic disorder. For example, higher scores on measures
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of sympathetic arousal, agoraphobic avoidance, and rates of comor-
bid somatization disorder and alcohol dependence distinguished
older adults with panic disorder from those with GAD; however,
only measures of depression and hostility, but not trait anxiety or
worry, distinguished the GAD group from those with panic disor-
der (Mohlman, de Jesus, Gorenstein, Kleber, Gorman, & Papp, 2004).
Patients with GAD and panic disorder show comparable levels of
meta-worry when controlling for general worry frequency (Wells
& Carter, 2001). Furthermore, depressed patients with co-morbid
panic disorder have been found to score higher on measures of
worry compared to those without panic comorbidity (Gladstone
et al., 2005a). Chronic worry in panic disorder tends to be focused on
interoceptive functioning, thereby amplifying anxious responding
and reinforcing perceptions of uncontrollability. Using a panic-
induction paradigm, pre-challenge worry levels among adolescents
predicted post-challenge anxiety and intensity of panic symptoms,
even after controlling for state anxiety and anxiety sensitivity
(Leen-Feldner, Feldner, Tull, Roemer, & Zvolensky, 2006).
Relatively few studies have examined the role of worry in
posttraumatic stress disorder (PTSD), thereby complicating spec-
ulation on the extent to which worry in GAD is distinct from
PTSD. Cognitive models of PTSD propose that cognitive avoidance
strategies, such as thought suppression and rumination, interfere
with successful emotional processing of trauma (Ehlers & Clark,
2000; Foa, Steketee, & Rothbaum, 1989). Prior research has shown
that thought control strategies of worry correlate positively with
symptoms of PTSD (Roussis & Wells, 2006). Furthermore, worry
has been found to be a maladaptive intervening variable in the
association between PTSD and dysfunctional cognitions, result-
ing in greater levels of PTSD and trauma cognitions among motor
vehicle accident victims (Bennett, Beck, & Clapp, 2009). The associ-
ation between worry and trauma-related disorders does not appear
to be specific to PTSD. For example, patients with acute stress
disorder (ASD) have been shown to engage in more worry than
their non-ASD counterparts, with worry being strongly associated
with intrusive, avoidance, and arousal symptom severity (Warda &
Bryant, 1998). A more recent study also found that among women
reporting a history of child sexual abuse (CSA), greater sever-
ity of the CSA was associated with greater worry intensity and
increased use of worry strategies following the CSA was associated
with greater levels of trauma-related symptoms (Scarpa, Wilson,
Welss, Patriquin, & Tanaka, 2009). Furthermore, longitudinal stud-
ies of people involved in motor vehicle accidents have found that
excess worry soon after the accident significantly predicts later
development of PTSD (Holeva, Tarrier, & Wells, 2001). These find-
ings suggest that excessive worry may function as a means for
cognitive/emotional avoidance, conferring increased risk for the
development and maintenance of PTSD-related syndromes.
Relatively few studies have examined the role of worry in spe-
cific phobia and social anxiety disorder. Although cognitive factors,
such as attentional biases for threat and the tendency to overesti-
mate danger are common features of specific phobias (cf. Cisler,
Lohr, Sawchuk, & Olatunji, 2010), excessive worry may be less
prominent given that phobias are more circumscribed fears that
can be more efficiently avoided. However, anxious apprehension is
a central concept among contemporary etiological models of social
anxiety disorder. For example, “within the category of social pho-
bia, an additional complication develops: Because of arousal-driven
negative cognitive activity (or worry), the person actually becomes
distracted from the task at hand if some performance is necessary”
(Barlow, 2002, p. 460). In a study of speech-anxious college stu-
dents, those assigned to engage in worry before giving a speech
demonstrated greater anxiety compared to those in a relaxation
condition (Hazlett-Stevens & Borkovec, 2001). Furthermore, mean
worry levels among participants with principal diagnoses of GAD
and social anxiety disorder did not differ significantly from each
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
9
other, yet both groups were significantly higher than those with
panic disorder (Starcevic et al., 2007). These findings suggest that
worry can amplify anxiety in anticipation of and during social sit-
uations for those that are socially anxious, and the level of worry
experienced may be comparable to those with GAD.
9.2. Examination of worry in mood disorders
Worry may also be a cognitive vulnerability for other disorders,
particularly mood disorders. Research has shown that distinguish-
ing GAD from other mood disorders can be difficult. In fact, recent
research has shown that some patients with depression appear
to be better characterized by use of worry relative to those with
GAD (Barahmand, 2009). The confusion between GAD and mood
disorders may be partially accounted for by an explicit overlap in
core symptoms. For example, four of the six physical and cognitive
symptoms in GAD overlap with major depressive disorder crite-
ria (Zimmerman & Chelminski, 2003). Shared experiences of worry
may also contribute to artifactual comorbidity between GAD and
major depressive disorder (Noyes, 2001). Brown (1997) has also
observed that “the fact that worry and the associated symptoms
of DSM-IV GAD are considered symptoms of negative affect may
account for why GAD and mood disorders cannot be differentiated
on these features” (p. 8). Worry may be viewed as a cognitive avoid-
ance mechanism and part of a general feeling of negative affectivity
shared by GAD and depression (Beck et al., 2001). GAD and dys-
thymia show a relatively high degree of comorbidity (Pini et al.,
1997), with many shared cognitive features between worry and
rumination. Some studies have found that patients with GAD and
major depression do not differ in the frequency and severity of
worry (Starcevic, 1995; Wells & Carter, 2009), while others have
found that excessive worry is reliably higher among those with GAD
(Chelminski & Zimmerman, 2003). Mixed findings in the literature
blur the utility of using excess worry as a feature distinguishing
GAD from other depressive disorders. However, recent studies have
suggested that pre-existing GAD is associated with a significant
risk for developing later-onset mood and anxiety disorders (Ruscio
et al., 2007).
9.3. The present investigation
Excessive, uncontrollable worry has emerged as the defining
features of GAD. As a result, there is a large body of descriptive and
experimental research examining the nature and function of worry
in GAD. Although comprehensive reviews of the theoretical (e.g.,
Comer et al., 2004) and treatment (e.g., Covin et al., 2008) issues
related to worry and GAD are available, very little work has been
invested towards empirically studying the specificity of worry to
GAD relative to the other anxiety disorders. A quantitative descrip-
tion of this literature could allow for stronger inferences to be made
regarding the nature and function of worry. A quantitative analysis
of this literature could also be a useful starting point for making
more meaningful comparisons of worry between anxiety disorders
and other psychiatric conditions.
The present investigation offers a meta-analysis of the worry
literature across the anxiety disorders. Specifically, anxiety disor-
der patients are compared with nonclinical and clinical controls
on worry-related process. It was predicted that anxiety disorder
patients, particularly those with GAD, would demonstrate signif-
icantly greater difficulty with worry than nonclinical and clinical
controls. Compared to other anxiety disorder patients and clinical
controls, those with GAD were also predicted to yield a larger effect
size, indicating greater difficulty with worry. Such a pattern of find-
ings would provide strong evidence for the specificity of worry to
GAD. As indicated above, a review of the literature suggests that
worry-related processes may differ as a function of age, gender, and
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the type of worry (severity/frequency of worry, meta-worry, and
domains of worry). Therefore, the present investigation also exam-
ined the extent to which these variables moderate the association
between worry and the anxiety disorders.
10. Methods
10.1. Selection of studies
Appropriate studies were identified by conducting searches in
both PsycINFO and PubMed between February and April of 2009.
Six separate searches were conducted in each database and the
search criteria were limited to studies that were printed in English
and key words that appeared in the abstract and/or title of the
study. The searches included: (1) “social phobia” and “worry;” (2)
“panic disorder” and “worry;” (3) “post-traumatic” and “worry;”
“PTSD” and “worry;” (4) “generalized anxiety” and “worry;” (5)
“obsessive–compulsive” and “worry;” “OCD” and “worry;” and (6)
“anxiety disorder” and “worry.” Additional studies were obtained
from the references sections of studies found through the searches
in PsycINFO and PubMed when appropriate. These search methods
produced over 2700 articles, of which the abstracts were read and
analyzed for their potential inclusion in the present analysis. These
search procedures yielded 320 distinct, potentially relevant stud-
ies. From these 320 articles, studies were excluded if they were not
empirical, did not utilize a measure that was explicitly referred to
as a measure of worry, or did not have a comparison group. Studies
were also excluded from the analysis if there was no diagnosis of an
anxiety disorder, or if statistical means and SD were not provided
in the published article or readily available from the corresponding
author. As outlined in Table 1, 47 published studies reached crite-
ria for inclusion in the present analysis.1 Table 1 also shows the
different measures of worry used in the final sample of studies.
10.2. A priori comparisons
10.2.1. Anxiety disorders v. non-clinical controls
Studies that included at least one anxiety disorder group and a
non-clinical control group (e.g., undergraduate sample, non-clinical
panickers) were included in this analysis. The non-clinical control
group consisted of people with no diagnosed psychiatric condi-
tions. The available studies comparing an anxiety disorder group
to a non-clinical control group included the following anxiety
disorders: OCD, panic disorder (with and without agoraphobia),
agoraphobia without panic (AWOP), social phobia, specific phobia,
PTSD, and GAD.
10.2.2. Anxiety disorders v. clinical controls
Studies that included at least one anxiety disorder group and at
least one non-anxiety Axis I disorder group were included in this
analysis. Studies included the anxiety disorder groups mentioned
above. Other disorders included as clinical controls included major
depressive disorder and schizophrenia.
10.2.3. Clinical controls v. non-clinical controls
Studies that included at least one group classified as a clinical
control (see above) and at least one non-clinical control group were
included.
1
A study by Becker, Goodwin, Holting, Hoyer, & Margraf (2003) was identified in
our search parameters. However, this study was not included in the meta-analyses
as the sample was redundant with that of Hoyer et al. (2002). A study by Dugas,
Freeston, et al. (1998) was also identified in our search parameters. However, this
study was not included as the comparison groups employed were not clearly demar-
cated in a fashion that was consistent with the control groups included in the
meta-analyses.
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
10.2.4. Individual anxiety disorders v. non-clinical controls
Individual anxiety disorders were compared directly to non-
clinical controls (e.g., panic disorder v. non-clinical controls, social
phobia v. non-clinical controls). The studies described above were
included in this analysis, with the exception of studies that included
only an anxiety disorder in which too few studies reported data for
that anxiety disorder to warrant an individual meta-analytic com-
parison. For example, too few studies directly compared AWOP
to non-clinical controls. Thus, studies including only AWOP v.
non-clinical controls were excluded from this analysis. Compar-
isons that were able to be made based on the available studies
included OCD v. non-clinical controls, social phobia v. non-clinical
controls, panic disorder v. non-clinical controls, specific phobia v.
non-clinical controls, and GAD v. non-clinical controls.
10.2.5. Individual anxiety disorders v. clinical controls
Studies including an anxiety disorder group and a clinical con-
trol group in which there were a sufficient number of studies
reporting data for that particular comparison to warrant a meta-
analytic examination were included. The following comparisons
were able to be made based on the studies available: OCD v. clin-
ical controls, social phobia v. clinical controls, and GAD v. clinical
controls.
10.2.6. Individual anxiety disorder comparisons
All possible comparisons between two different anxiety disor-
ders (e.g., panic disorder v. social phobia, social phobia v. OCD) were
included as a priori comparisons. However, based on the available
literature, some comparisons were not conducted if too few studies
directly compared the two anxiety disorders in question. The fol-
lowing comparisons were made because there were enough studies
(i.e., K ≥ 3) to warrant a meta-analytic comparison: GAD v. OCD,
GAD v. panic disorder, GAD v. social phobia, GAD v. specific phobia,
OCD v. panic disorder, OCD v. social phobia, OCD v. specific phobia,
panic disorder v. social phobia, and social phobia v. specific phobia.
10.3. Outcome measures selection
A number of measures assessing the construct of worry were
included in the outcome analyses (see Table 1). Composite analy-
ses were conducted including all measures for a given comparison.
These measures were classified as falling into one of three types of
worry measures: (a) severity/frequency of worry; (b) meta-worry;
or (c) domains of worry. For example, the PSWQ was categorized
as a severity/frequency measure (author-constructed measures of
duration, frequency, uncontrollability, and severity of worry were
also included in this category), the Anxious Thoughts Inventory
“meta worry” factor was categorized as measure of meta-worry,
and the WDQ was categorized as a domains of worry measure
(author constructed “number of worry topics” measure were also
included in this category).2 The first and second authors indepen-
dently categorized each of the measures with 79% agreement. Any
discrepancies were discussed and resolved by the authors. Sec-
ondary analyses were conducted separately for each of the three
types of worry measures.
10.4. Moderators
The following putative moderators were examined for each of
the a priori comparisons in which significant heterogeneity was
observed: (a) percentage of female participants; and, (b) mean age
2
A complete listing of the measures included in each of the three worry categories
is available upon request.
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B.O. Olatunji et al. / Applied and Preventive Psychology xxx (2011) xxx–xxx 11

Table 1
Study characteristics.

Study Name N % female Mean age % white Measure

Andor, Gerlach, and Rist (2008) 67 71.65 37.30 Not given PSWQ
Andreescu, Belnap, Rollman, Houck, Ciliberti, and Mazumdar (2008) 167 66.00 73.20 90.5 PSWQ
Beck et al. (1996) 88 68.20 67.15 93.2 PSWQ
Behar, Alcaine, Zuellig, and Borkovec (2003) 272 75.40 36.90 92.4 PSWQ
Belloch, Del Valle, Morillo, Carrio, and Cabedo (2009) 117 68.50 Not given 35.12 TCQ-worry
Borkovec and Roemer (1995) 46 Not given Not given Not given RWQ
Borkovec and Roemer (1995) 128 Not given Not given Not given RWQ
Brown et al. (1992) 468 Not given Not given Not given PSWQ
Brown et al. (1993) 63 55.65 36.17 Not given PSWQ
Campbell, Rapee, and Spence (2001) 139 41.85 9.84 Not given CAWS
Chelminski and Zimmerman (2003) 697 39.50 38.80 90.9 PSWQ
Chorpita et al. (1997) 34 50.00 12.4 Not given PSWQ-C
Clark, Antony, Beck, Swinson, and Steer (2005) 408 67.00 33.00 88.75 PSWQ
Coles and Heimberg (2005) 97 63.00 32.25 Not given PSWQ
Conrad, Isaac, and Roth (2008) 70 59.50 44.18 70.50 PSWQ
Coplan et al. (2006) 30 53.30 39.23 Not given PSWQ
Diefenbach, Hopko, Feigon, Stanley, Novy, & Beck, 2003 49 66.85 66.23 92.35 PSWQ
Dugas et al. (1998) 44 70.40 36.85 Not given PSWQ
Dupuy, Beaudoin, Rheaume, Ladouceur, and Dugas (2001) 96 64.95 37.35 Not given PSWQ
Gladstone et al. (2005a) 286 65.00 41.20 Not given BMWS
Henning, Turk, Mennin, Fresco, and Heimberg (2007) 107 62.75 31.55 Not given PSWQ
Holaway et al. (2006) 263 69.20 18.70 61.60 PSWQ
Hoyer et al. (2001) 89 45.33 40.03 Not given # worry contents; duration
daily worry (WorryTF)
Hoyer, Becker, and Margraf (2002) 2025 Not given Not given Not given Clinical
intensity/frequency worry;
uncontrollability ratings
Kim and Grant (2001) 81 32.25 43.73 Not given TPQ-Anticipatory Worry
Krain et al. (2008) 29 45.75 15.30 Not given PSWQ-C
Ladouceur, Blais, Freeston, and Dugas (1998) 29 68.57 33.70 Not given PSWQ
Lyonsfield et al. (1995) 30 Not given Not given Not given PSWQ
Mantella et al. (2008) 111 67.70 74.15 87.80 PSWQ
Mohlman et al. (2004) 50 46.00 67.28 90.00 PSWQ
Morillo, Belloch, and Garcia-Soriano (2007) 83 72.00 36.23 Not given PSWQ
Morrison and Wells (2003) 158 43.13 39.67 Not given MCQ-worry
Morrison and Wells (2007) 100 64.42 27.30 Not given AnTI
Montorio et al. (2003) 81 52.40 72.75 Not given WAQ
OC Working Group (2007) 626 61.50 38.75 92.50 PSWQ
Pestle, Chorpita, and Schiffman (2008) 186 33.80 15.79 14.70 PSWQ-C
Price and Mohlman (2007) 57 55.50 67.05 89.00 PSWQ
Roemer, Borkovec, Posa, and Borkovec (1995) 83 Not given Not given Not given PSWQ
Schut, Castonguay, and Borkovec (2001) 88 76.83 27.11 88.49 PSWQ
Sica et al. (2004) 110 56.00 30.20 Not given WDQ
Stanley, Beck, and Zebb (1996) 144 70.55 65.23 88.85 WS
Stöber and Borkovec (2002) 34 73.50 38.20 Not given PSWQ
Szabo and Lovibond (2004) 89 53.50 10.00 Not given PSWQ-C
Weeks et al. (2005) 197 42.50 32.76 79.00 PSWQ
Wells and Carter (2001) 96 58.30 34.93 Not given AnTI
Wells (1994a) 30 50.00 Not given Not given AnTI
Wetherell et al. (2003) 68 79.35 68.10 82.90 PSWQ

Note. Penn State Worry Scale (PWSQ; Meyer et al., 1990), Worry Domains Questionnaire (WDQ; Tallis et al., 1992), Reasons to Worry Questionnaire (RWQ; Borkovec &
Roemer, 1995), Child & Adolescent Worry Scale (CAWS; Campbell & Rapee, 1994), Worry Topics Frequency (WorryTF; Hoyer et al., 2001), Though Control Questionnaire-
Revised-Worry Subscale (TCQ-R-W; Wells & Davies, 1994), Brief Measure of Worry Scale (BMWS; Gladstone et al., 2005b), Meta-Cognitions Questionnaire – Worry subscale
(MCQ-W; Cartwright-Hatton & Wells, 1997), Tridimensional Personality Questionnaire – Worry Subscale (TPQ; Cloninger, 1987), Anxious Thoughts Inventory (AnTI; Wells,
1994b), Worry & Anxiety Questionnaire (WAQ; Dugas et al., 1995), Worry Scale (WS; Wisocki, Handen, & Morse, 1986).

of the sample. Moderator analyses were conducted on the compos-
ite analyses (i.e., including all available measures together) for any
comparison in which the effect size and heterogeneity index were
statistically significant.
10.5. Statistical analysis
Database. A database was created using Comprehensive Meta-
analysis Program (CMA) Version 2 (Biostat; Borenstein, Hedges,
Higgins & Rothstein, 2005). CMA has been used for the analyses
of several published meta-analyses (e.g., Cepeda-Benito, Reynoso
& Erath, 2004; Prochaska, Delucchi, & Hall, 2004; Wolitzky-Taylor,
Horowitz, Powers & Telch, 2008). For each study, means and stan-
dard deviations of the different conditions were entered into the
database. Effect sizes for each measure were calculated for the a
priori comparisons (e.g., clinical controls v. non-clinical controls).
Data for each putative moderator were also entered for each study
in the database.
Effect size calculation. For each study, we computed effect sizes
for one or more of the comparisons of interest. When studies
included multiple groups that were suitable for comparison, mul-
tiple effect sizes were obtained. For example, a study comparing
worry among GAD, social phobia, and major depressive disorder,
would yield effect sizes for “anxiety disorders v. clinical controls,”
“GAD v. clinical controls,” “social phobia v. clinical controls,” and
“GAD v. social phobia.”
For studies including more than one of the same type of group
(e.g., panic disorder without agoraphobia and panic disorder with
agoraphobia; three different anxiety disorders), separate effect
sizes were calculated for each group and were then aggregated into
an average effect size. Analyses for each comparison used only these
pooled effect size outcomes. For example, a study comparing GAD

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and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
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to two different types of non-clinical control groups would yield
only one pooled “GAD v. non-clinical control” effect size. This pro-
cedure decreased the risk that studies with several groups that were
part of the same larger group would be more influential than those
with fewer groups. Total scores on a given measure were used as
the dependent variable unless either: (a) only individual subscales
were reported, in which case all subscale scores were entered; or
(b) a specific subscale was entered for analysis of a particular worry
measure type (e.g., Worry & Anxiety Questionnaire “minor things”
was entered for the domains measure analyses separate from the
other subscales, which were entered in the “severity/frequency”
analyses). In order to ensure that the comparisons reported were
based on a meaningful number of studies and that fail-safe N anal-
yses could be conducted, comparisons were not made when only
one or two studies were available for a particular comparison. This
commonly practiced, conservative approach (e.g., Bar-Haim, Lamy,
Pergamin, Bakermans-Kraneburg, & van Ijzendoorn, 2007) also lim-
its the likelihood of a given effect size being driven by a study outlier
(McKay, 2008).
For all comparisons, Cohen’s d was selected as the index of effect
size, with d-values of 0.2, 0.5, and 0.8 representing small, medium,
and large effect sizes, respectively. Average effect sizes for each
outcome were weighted in each relevant comparison using the
inverse variance estimate. Weighting of sample size was done in
order to minimize the risk that a small, outlying sample would exert
a disproportionate influence over the final effect size for a given
comparison (Rosenthal, 1991). The use of random-effects models
also helped to weight the studies appropriately, and was used to
increase the generalizability of findings beyond the studies that
were able to be included in the meta-analysis. In addition, in order
to account for the bias that may be present by including only pub-
lished studies (i.e., file drawer effect); a fail-safe N (FSN) analysis
was conducted for each comparison. The FSN is the number of addi-
tional ‘negative’ studies (studies in which the intervention effect
was zero) that would be needed to increase the P value for the
meta-analysis to above 0.05
For each comparison, we calculated the statistical significance
(p-value) of the effect size, the within-comparison heterogeneity
index (Q), and the p-value for the heterogeneity index. We also
calculated the standard error (Sed), variance, and 95% confidence
intervals (CI) for the effect sizes. These statistics, reported in Table 2,
provide information on the stability, significance, and range of the
true effect size.
10.6. Moderator analyses
Moderator analyses were also conducted within the CMA
program using the moderator platform. Because all putative mod-
erators were continuous, regression parameters are reported.
Because several studies did not include the relevant data needed,
outcome analyses were first conducted with all available studies.
Moderator analyses were undertaken on the subsample of studies
that included the necessary data. These analyses were conducted
separately to minimize loss of data and maximize the number of
studies included in the primary outcome analyses. Moderator anal-
yses were conducted for comparisons in which the heterogeneity
index was statistically significant. Moderator analyses were con-
ducted for the composite analyses, but not conducted separately
for each type of worry measure (e.g., meta-worry measures).
11. Results
11.1. Basic study information
The meta-analysis included 47 published studies, totaling
8366 participants with an average age of 40.27 years. The sam-
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
ples were predominantly female (59.21%) and white (79.36%).
The majority of studies used the PSWQ as the worry measure
(59.57%). Table 1 reports basic study characteristics for all studies
included in the meta-analysis. Tables 2 and 3 show the stud-
ies included in the meta-analysis by specific comparison. Table 4
reports all outcome data. Table 5 summarizes the moderator
findings.
11.2. A priori comparisons
All anxiety disorders v. non-clinical controls. Forty-one studies
were included in this comparison, yielding 60 outcomes. A large
effect was observed, d = 1.64, p < .001, indicating that those with
anxiety disorders reported significantly greater worry than non-
clinical control groups. The heterogeneity index was statistically
significant, Q(59) = 1160.70, p < .001, suggesting that the studies
varied with respect to the magnitude of this effect. The FSN analysis
indicated that the findings were robust with regard to publication
bias (FSN = 36,973; z = 48.69, p < .001). Both putative moderators
were statistically significant. A larger effect was observed (i.e.,
greater difference between anxiety disorder and non-clinical con-
trol groups) as the percentage of females increased, Q(1) = 324.98,
p < .001, and as age increased, Q(1) = 167.02, p < .001.
Thirty-two studies yielding 34 outcomes for comparison
included a measure that fell into the “worry severity/frequency”
category. When considering this subgroup of studies, a large effect
was observed favoring anxiety disorders, d = 2.45, p < .001, indi-
cating that those with anxiety disorders reported significantly
greater severity/frequency of worry than non-clinical controls. The
heterogeneity index was significant, Q(33) = 596.03, p < .001. The
findings were robust with regard to publication bias (FSN = 23,590;
z = 53.25, p < .001). Six studies producing 16 outcomes for com-
parison included measures that were categorized as meta-worry
measures. A moderate effect was observed, d = .48, p < .001, indi-
cating that those with anxiety disorders reported greater worry
about their worry and/or using meta-cognitive strategies mod-
erately more than non-clinical controls. The heterogeneity index
was significant, Q(15) = 61.95, p < .001. The finding was robust,
FSN = 235, z = 7.75, p < .001. Seven studies yielding 12 outcomes
included measures that assessed domains of worry. This compar-
ison produced a large effect size suggesting those with anxiety
disorders worry more about specific life events measured than
non-clinical controls, d = .90, p < .001. The heterogeneity index
was statistically significant, Q(11) = 90.36, p < .001. The findings
were robust with regard to publication bias (FSN = 419, z = 11.75,
p < .001).
11.3. All anxiety disorders v. clinical control groups
Eight studies were included in this comparison, producing
nine outcomes, yielding a moderate, non-significant effect size
favoring anxiety disorders, d = .37, p = .14. This suggests that dif-
ferences between those with anxiety disorders and those with
other diagnoses do not significantly differ with regard to over-
all worry. However, a different pattern emerged when examining
types of worry measures separately. When including only those
measures that assess worry severity/frequency (six studies produc-
ing seven outcomes), a moderate and statistically significant effect
was observed favoring anxiety disorders, d = .60, p < .05, suggest-
ing patients with anxiety disorders report greater severity and/or
frequency of worry than clinical controls. This effect was robust,
FSN = 86, z = 7.11, p < .001. Too few studies were available to conduct
the meta-analytic comparison of the meta-worry and the domains
of worry separately.
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No. of Pages 24
Table 2
Studies included in comparisons: anxiety disorders v. non-clinical controls and clinical controls.

Study Anx v. NCC Anx v. CC CC v. NCC OCD v. NCC PD v. NCC SAD v. NCC SP v. NCC GAD v. NCC OCD v. CC SAD v. CC SP v. CC GAD v. CC

Andor et al. (2008) 3.29 3.29

Andreescu et al. (2008) 2.48 2.48
Beck et al. (1996) 3.17 3.17
Behar et al. (2003) 3.18 5.08
Belloch et al. (2009) −0.68 −0.23 −0.22 −0.48 −0.19
Borkovec and Roemer (1995)a −0.06 to 1.04 −0.06 to 1.04
Borkovec and Roemer (1995)a 0.39 to 0.98 0.39 to 0.98
Brown et al. (1992) 1.82 2.04 1.56 1.37 0.86 3.27

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Campbell et al. (2001)a 0.08 to 0.88 0.05 to 0.72 −0.001 to 1.46 0.05 to 0.49

B.O. Olatunji et al. / Applied and Preventive Psychology xxx (2011) xxx–xxx
Chelminski and Zimmerman (2003) 1.06 −0.07 1.11 0.84 0.93 0.98 0.78 1.78 −0.22 −0.14 −0.30 0.63
Chorpita et al. (1997) 2.56 3.52
Clark et al. (2005) 1.65 1.65
Coles and Heimberg (2005) 4.82 4.82
Conrad et al. (2008) 4.78 4.78
Coplan et al. (2006) 4.10 4.10
Diefenbach et al. (2003) 2.96 2.96
Dugas et al. (1998) 2.58 2.58
Dupuy et al. (2001) 2.45 2.48
Gladstone et al. (2005a) 2.05 0.33 1.56 3.25 2.00 1.37 1.63 2.64 1.13 0.07 −0.28 0.83
Henning et al. (2007) 4.53 4.53
Holaway et al. (2006) 1.92 0.65 2.48
Hoyer et al. (2001)a 0.25 to 0.52 −0.36 to −0.29 0.85 to 1.33
Hoyer et al. (2002)a 1.21 to 1.39 0.18 to 0.58 0.43 to 0.56 1.33 to 1.42 0.73 to 0.82 0.54 to 0.71 3.06 to 4.10 0.45 to 0.45 0.18 to 0.19 0.10 to 0.13 1.79 to 2.44
Kim and Grant (2001) 1.51 1.51 1.03
Krain et al. (2008) 2.00 2.00
Ladouceur et al. (1998) 2.46 2.46
Lyonsfield et al. (1995) 1.34 1.34
Mantella et al. (2008) 2.58 2.58
Morillo et al. (2007) 1.43 0.27 1.43 0.27
Morrison and Wells (2003) −0.27 −0.70 −0.27
Montorio et al. (2003)a 1.92 to 3.15 1.92 to 3.15
OC Working Group (2007) 1.32 1.32
Pestle et al. (2008) 0.75 1.42
Price and Mohlman (2007) 1.52 1.52
Roemer et al. (1995) 3.40 3.40
Schut et al. (2001) 2.92 2.92
Sica et al. (2004) 0.40 0.41 0.40
Stanley et al. (1996) 1.64 1.64
Stöber and Borkovec (2002) 5.90 5.90
Weeks et al. (2005) 2.25 2.25
Wells and Carter (2001)a 0.73 to 1.04 0.12 to 1.20 −0.27 to 1.43 1.25 to 1.79
Wells (1994a) 1.84 2.37 1.31
Wetherell et al. (2003) 3.52 3.52
Total 1.64 0.37 0.70 1.25 1.02 0.62 0.80 2.05 0.43 0.50 −0.08 1.31

Note. Anx = anxiety disorders; NCC = non-clinical controls; CC = clinical controls; PD = panic disorder; SAD = social anxiety disorder; SP = specific phobia; GAD = generalized anxiety disorder; OCD = obsessive–compulsive disorder.
a
Indicates study with multiple outcomes included in comparison (i.e., multiple factors or subscales entered because total not provided). Values shown are range of effect sizes.

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14 B.O. Olatunji et al. / Applied and Preventive Psychology xxx (2011) xxx–xxx

11.4. Clinical controls v. non-clinical controls

0.07 to 0.12
SAD/SP
Four studies producing five outcomes were included in this

−0.19
0.45

0.17

0.10
comparison, yielding a moderate effect size favoring clinical con-
trols over non-clinical controls, d = .70, p < .01. This effect was
robust (FSN = 100; z = 8.96, p < .001). The heterogeneity index was
significant, Q(4) = 33.48, p < .01. Percentage of female participants

−1.42 to 1.43
moderated this effect, with more females associated with a smaller
effect (i.e., smaller difference in worry between clinical and
PD/SAD

−0.04
non-clinical controls), Q(1) = 4.41, p < .05. Too few studies in this
0.15

0.49

0.69
0.18
comparison reported mean age of sample to warrant a moderator
analysis.
Three studies including four outcomes used measures that
0.35 to 0.45

assessed into worry severity/frequency. When considering this

subset of studies, a large effect was observed, d = .91, p < .001,
OCD/SP

indicating that clinical controls reported greater severity and/or

0.88

0.66

0.51
0.07

frequency of worry than non-clinical controls. This finding was

robust with regard to publication bias, FSN = 110, z = 8.96, p < .001.
Too few studies in this comparison included measures that fell
0.26 to 0.28

into the meta-worry and domains of worry categories to warrant

OCD/SAD

meta-analytic comparison.
−0.08
0.46

0.87

0.38

Note. PD = panic disorder; SAD = social anxiety disorder; SP = specific phobia; GAD = generalized anxiety disorder; OCD = obsessive–compulsive disorder.

11.5. Individual anxiety disorders v. non-clinical controls

Too few studies (K ≤ 2) were available to allow for the fol-

OCD/PD

lowing comparisons: PTSD v. non-clinical controls and AWOP v.

0.57

0.35

0.35
−0.05

non-clinical controls.
OCD v. non-clinical controls. Twelve studies producing six-
teen outcomes compared an OCD group to a non-clinical
control group on worry. A large and robust effect favor-
1.43 to 1.96

ing OCD was observed, d = 1.04, p < .001, FSN = 1389, z = 18.36,
GAD/SP

p < .001. Heterogeneity among the studies included was observed,

1.67

1.13

1.31
0.42

Q(15) = 147.05, p < .001. More female participants was associ-

ated with greater effects (i.e., greater differences between OCD
and non-clinical controls on worry), Q(1) = 5.54, p < .05; and
older age was also associated with greater effects, Q(1) = 18.00,
−0.99 to 0.27

−0.16 to 1.00

p < .001.
1.08 to 1.44
1.27 to 1.60
GAD/SAD

When considering those studies that used worry measures

assessing severity/frequency of worry (nine studies producing ten
1.08

0.88
0.63

0.70

comparisons), a large effect was observed, d = 1.48, p < .001. The het-
erogeneity index was statistically significant, Q(9) = 50.39, p < .001
and the effect was robust, FSN = 1242, z = 21.93, p < .001. Too few
−0.26 to 1.33

studies included meta-worry and domains measures for this com-

parison to warrant meta-analytic comparison.
GAD/PD

Panic disorder v. non-clinical controls. Six studies yielding eight

−0.04
0.92

0.97
0.12

0.63

outcomes were included in this comparison, resulting in a large

effect favoring panic disorder, d = 1.02, p < .001, suggesting those
with panic disorder report significantly higher overall worry than
non-clinical control groups. As with the above comparisons, sig-
−0.13 to 0.36
Studies included in comparisons among anxiety disorders.

0.96 to 1.06

nificant heterogeneity was observed, Q(7) = 70.26, p < .001, and the
GAD/OCD

effect was robust with regard to the file drawer effect (FSN = 226,
−0.28

−0.06

z = 10.58, p < .001). Mean age did not moderate this effect. Greater
0.63
0.59

0.98

0.38

effects were associated with a larger percentage of females in the

samples, Q(1) = 9.14, p < .01.
A large effect was observed when considering those stud-
Chelminski and Zimmerman (2003)

ies (three studies and three total outcomes) that included

severity/frequency measures of worry, d = 1.47, p < .001. The hetero-
geneity index was statistically significant, Q(2) = 12.65, p < .01, and
the effect was robust, FSN = 107, z = 11.86, p < .001. Too few studies
Wells and Carter (2001)
Gladstone et al. (2005a)

Mohlman et al. (2004)

Campbell et al. (2001)

comparing panic disorder to non-clinical controls used meta-worry

Brown et al. (1992)
Brown et al. (1993)

Hoyer et al. (2001)

Hoyer et al. (2002)

or domains of worry to warrant meta-analytic comparison.

Sica et al. (2004)

Social phobia v. non-clinical controls. Eight studies yielding 15

Wells (1994a)

outcomes compared social phobia to non-clinical controls, yielding

a moderate effect favoring social phobia, d = .62, p < .001, thereby
Study
Table 3

Total

indicating that those with social phobia report significantly greater

worry as compared to non-clinical controls. Significant hetero-

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Table 4
Summary statistics for each comparison.

Comparison K N d Sed Var. 95% C.I. Q (df)

Anxiety disorders v. non-clinical controls

Anx v. NCC 60 6906 1.64*** .12 .01 1.42 to 1.87 (59) 1160.70***
OCD v. NCC 16 3525 1.04*** .18 .03 0.69 to 1.39 (15) 147.05***
PD v. NCC 8 722 1.02*** .29 .09 0.45 to 1.59 (7) 70.26***
SAD v. NCC 15 2384 0.62*** .14 .02 0.35 to 0.89 (14) 99.75***
SP v. NCC 5 2096 0.80*** .12 .02 0.56 to 1.04 (4) 14.75**
GAD v. NCC 53 4425 2.05*** .19 .04 1.69 to 2.42 (52) 128.13***
Anxiety disorders v. clinical controls
Anx v. CC 9 1822 0.37 .26 .07 −0.13 to 0.87 (8) 127.68***
OCD v. CC 7 649 0.43 .22 .05 −0.004 to 0.85 (6) 25.74***
SAD v. CC 5 860 0.50 .41 .17 −0.31 to 1.31 (4) 90.66***
SP v. CC 4 614 −0.08 .12 .01 −0.31 to 0.15 (3) 2.94
GAD v. CC 5 1160 1.31*** .28 .08 0.77 to 1.86 (4) 21.26***
Clinical controls v. non-clinical controls
CC v. NCC 5 2236 0.70** .26 .07 0.19 to 1.22 (4) 33.48**
Individual anxiety disorder comparisons
GAD v. OCD 11 365 0.38** .15 .02 0.10 to 0.67 (10) 21.31*
GAD v. PD 7 558 0.63*** .09 .01 0.46 to 0.81 (6) 30.18***
GAD v. SAD 14 635 0.70*** .18 .03 0.34 to 1.06 (13) 78.70***
GAD v. SP 5 409 1.31*** .28 .08 0.77 to 1.85 (4) 18.92**
OCD v. PD 3 439 0.35* .16 .03 0.03 to 0.67 (2) 2.83
OCD v. SAD 5 423 0.38* .16 .02 0.08 to 0.68 (4) 7.08
OCD v. SP 5 367 0.51*** .13 .02 0.26 to 0.76 (4) 4.13
PD v. SAD 8 640 0.18 .24 .06 −0.30 to 0.66 (6) 44.88***
SAD v. SP 5 618 0.10 .07 .01 −0.03 to 0.25 (4) 4.27

Note. t p < .10, *p < .05, **p < .01, ***p < .001. PD = panic disorder; GAD = generalized anxiety disorder; OCD = obsessive–compulsive disorder; SP = specific phobia; PTSD = post-
traumatic stress disorder; SAD = social anxiety disorder; Anx = anxiety disorders; CC = clinical controls; K = number of outcomes included; N = number of participants included
in the comparison; d = effect size; Sed = standard error of the effect size; var = variance; 95% C.I. = 95% confidence intervals; Q = heterogeneity index; df = degrees of freedom.

geneity across the studies was observed, Q(14) = 99.75, p < .001.
The moderate effect was robust (FSN = 590, z = 12.44, p < .001).
Moderator analyses revealed that as mean age of the sample
increased, a larger effect was observed, Q(1) = 72.72, p < .001. Per-
centage of female participants in the sample did not moderate the
effect.
When considering studies including severity/frequency mea-
sures of worry (five studies with a total of six outcomes included),
a large effect was observed favoring social phobia, d = .84, p < .001.
The heterogeneity index was significant, Q(5) = 27.61, p < .001, and
the effect was robust, z = 13.79, p < .001. A moderate effect favor-
ing social phobia was observed when considering studies in this
comparison using measures that fell into the domains of worry
category (three studies including nine outcomes for comparison),
d = .51, p < .05. Studies included in this comparison were hetero-
geneous with respect to effects, Q(8) = 55.50, p < .001. The effect
was robust with regard to publication bias, FSN = 47, z = 4.85,
p < .001. Too few studies compared social phobia to non-clinical
controls using meta-worry measures to warrant meta-analytic
comparison.
Specific phobia v. non-clinical controls. Four studies produced
five outcomes for this comparison, yielding a large effect favoring
specific phobia, d = .80, p < .001, indicating that those with specific
phobia reported more overall worry than non-clinical controls.
The heterogeneity index was statistically significant, Q(4) = 14.75,
p < .01 and the effect was robust, FSN = 208, z = 12.78, p < .001. There
were an insufficient number of studies in this comparison that
reported data for the putative moderators to warrant moderator
analyses. No subgroup analyses were conducted given that all of
the outcomes used measures that assessed severity/frequency of
worry.
GAD v. non-clinical controls. Thirty-four studies comprised of
53 outcomes compared GAD to non-clinical controls, yielding a
large effect favoring GAD, d = 2.05, p < .001. The heterogeneity index
was statistically significant, Q(52) = 128.13, p < .001. This effect was
robust to the file drawer effect (FSN = 30,691; z = 45.93, p < .001).

Table 5
Summary of moderator findings.

Comparison Increase in % fem Increase in % fem Increase in % white Increase in % white Increase in age Increase in age
assoc w/ greater assoc w/ smaller assoc w/ larger assoc w/smaller assoc w/ larger assoc w/ smaller
effects effects effects effects effects differences

Composite clinical groups v. controls

Anx v. NCC x x x
CC v. NCC x
Individual anxiety disorders v. non-clinical controls
OCD v. NCC x x x
PD v. NCC x
SAD v. NCC x
GAD v. NCC x x
Individual anxiety disorders v. clinical controls
GAD v. CC x
Individual anxiety disorder comparisons
GAD v. OCD x
GAD v. PD x x
GAD v. SAD x

Note. PD = panic disorder; GAD = generalized anxiety disorder; OCD = obsessive–compulsive disorder; SP = specific phobia; PTSD = post-traumatic stress disorder; SAD = social
anxiety disorder; Anx = anxiety disorders; CC = clinical controls.

Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
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16 B.O. Olatunji et al. / Applied and Preventive Psychology xxx (2011) xxx–xxx
Larger differences between GAD and control groups were associ-
ated with samples including more females, Q(1) = 296.90, p < .001,
and older age groups, Q(1) = 77.44, p < .001.
Twenty-eight studies producing 29 outcomes used measures in
the worry severity/frequency category. This comparison yielded
a large effect size, d = 3.06, p < .001, with GAD patients reporting
significantly greater worry severity/frequency than controls. The
heterogeneity index was statistically significant, Q(28) = 290.90,
p < .001. The findings were robust with regard to publication bias,
FSN = 17,135, z = 46.88, p < .001. Three studies yielding 13 outcomes
for comparison used meta-worry measures. This comparison pro-
duced a moderate effect favoring GAD, d = .64, p < .001, suggesting
those with GAD reported more “worry about worry” and other
types of meta-cognitive strategies. The heterogeneity index was
statistically significant, Q(12) = 26.83, p < .001, and the effect was
robust, FSN = 278, z = 9.27, p < .001. Finally, six studies producing 10
outcomes for comparison used measures that fell into the domains
of worry category. When considering this subset of studies, a large
effect favoring GAD was observed, d = .90, p < .001. Effects included
in this comparison were heterogeneous, Q(9) = 54.07, p < .001, and
the overall effect was robust, FSN – 256, z = 10.10, p < .001.
11.6. Individual anxiety disorders v. clinical controls
Too few studies were available to allow for meta-analytic com-
parison of panic disorder v. clinical controls, PTSD v. clinical controls
and AWOP v. clinical controls.
OCD v. clinical controls. Six studies producing seven out-
comes were included in this comparison. A moderate effect size
approached significance, d = .43, p = .05, indicating that participants
with OCD reported significantly higher levels of worry than par-
ticipants with other, non-anxiety disorders. However, this finding
was not robust with regard to publication bias and thus should be
interpreted with caution (FSN = 25). When considering only those
studies that used measures assessing severity/frequency of worry,
a statistically significant effect size was observed favoring OCD,
d = .53, p < .05. However, similar to the composite effect size, this
effect was not robust, FSN = 30. Too few studies included meta-
worry or domains of worry measures to warrant meta-analytic
comparison.
Social phobia v. clinical controls. Four studies producing five out-
comes compared social phobia to a clinical control group yielding
a moderate but non-significant effect size, d = .50, p = .22. This find-
ing indicates that no differences were observed on overall worry
between social phobia and clinical control groups. No subgroup
analyses were conducted as all available measures fell into the
severity/frequency category,
Specific phobia v. clinical controls. Three studies yielding four
outcomes reported data for this comparison, producing a small,
non-significant effect size, d = −.08, p = .51, indicating that those
with specific phobia and those with other non-anxiety disorders
did not significantly differ with respect to overall worry. Like-
wise, the heterogeneity index was also non-significant, Q(3) = 2.94,
p = .40. Because all measures included in the composite analysis
were measures falling into the severity/frequency of worry cate-
gory, no subgroup analyses were conducted.
GAD v. clinical controls. Four studies were included in this com-
parison, consisting of five outcomes. A large effect was observed
favoring GAD participants, d = 1.31, p < .01. This effect was robust
with regard to publication bias, FSN = 133, z = 10.29, p < .001. Signif-
icant heterogeneity was observed, Q(4) = 21.26, p < .001. Percentage
of female participants did not moderate this effect. However,
mean age of the sample did significantly moderate the effect,
with increasing age associated with smaller effects (i.e., smaller
difference in worry between GAD and clinical control groups),
Q(1) = 7.32, p < .01. Because all of the outcomes in the composite
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
comparison included severity/frequency measures, no subgroup
analyses were conducted.
11.7. Individual anxiety disorder comparisons
Too few studies were available (K ≤ 2) to warrant meta-analytic
comparison of the following: GAD v. AWOP, GAD v. PTSD, OCD v.
AWOP, OCD v. PTSD, panic disorder v. AWOP, panic disorder v. spe-
cific phobia, panic disorder v. PTSD, social phobia v. AWOP, social
phobia v. PTSD, specific phobia v. AWOP, and PTSD v. specific pho-
bia,
GAD v. OCD. Seven studies were included in this compari-
son, consisting of eleven outcomes that yielded a moderate effect
size favoring GAD, d = .38, p < .01, indicating that those with GAD
reported greater levels of worry compared to those with OCD.
Heterogeneity was statistically significant, Q(10) = 21.31, p < .05.
Despite its statistical significance, the effect was not robust with
regard to publication bias, FSN = 31, suggesting that this finding
should be interpreted with caution. Moderator analyses revealed
that greater percentages of females in the samples were associated
with smaller effects (i.e., smaller differences between GAD and OCD
on worry measures), although this finding only approached signif-
icance, Q(1) = 3.44, p = .06. No other variables examined moderated
this effect.
Similar to the composite analysis, a moderate effect favoring
GAD was observed when considering the severity/frequency mea-
sures only (five studies with six outcomes), d = .53, p < .01, but the
effect was not robust (FSN = 30). No studies used meta-worry mea-
sures, and too few studies used measures in the domains of worry
category to warrant meta-analytic comparisons.
GAD v. panic disorder. Five studies including seven outcomes
compared GAD to panic disorder on worry. A moderate and
robust effect was observed, d = .58, p < .01 (FSN = 67, z = 6.33,
p < .001), favoring GAD. This suggests that participants with GAD
reported significantly greater overall worry than participants with
panic disorder. The heterogeneity index was statistically signif-
icant, Q(6) = 30.18, p < .001. A greater percentage of females was
marginally associated with smaller effects (i.e., smaller differences
between GAD and panic disorder, favoring GAD), Q(1) = 2.91, p < .09.
When including only those studies using worry measures
assessing severity/frequency of worry, a similar pattern emerged.
Four studies (four outcomes) yielded a moderate effect size
indicating those with GAD reported significantly greater worry
severity/frequency than those with panic disorder, d = .64, p < .001.
This effect was robust (FSN = 24, z = 5.18, p < .001). There were an
insufficient number of studies including the other types of worry
measures to warrant meta-analytic comparisons.
GAD v. social phobia. Seven studies produced fourteen outcomes
that were included in this comparison, yielding a large and robust
effect size, d = .70, p < .01, FSN = 318, z = 9.54, p < .001, indicating that
overall worry is significantly greater among those with GAD com-
pared to those with social phobia. The heterogeneity index was
statistically significant, Q(13) = 78.70, p < .001. Only one putative
moderator significantly impacted the strength and direction of this
effect, with older mean age associated with greater effects (i.e.,
greater differences between GAD and social phobia), Q(1) = 29.73,
p < .001.
Secondary analyses on each type of worry measure were able
to be conducted for the severity/frequency and the domains of
worry measures. A large and robust effect was observed for the
severity/frequency measures (five studies producing six outcomes)
indicating those with GAD reported greater severity of worry than
those with social phobia, d = 1.09, p < .001, FSN = 172, z = 10.65,
p < .001. In contrast, the effect size when including only measures
assessing the domains of worry was not statistically significant,
d = .28, p = .36.
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GAD v. specific phobia. Four studies including five outcomes
compared GAD to specific phobia on measures of worry, yield-
ing a large effect favoring GAD, d = 1.31, p < .001. This effect was
robust with regard to publication bias (FSN = 130, z = 10.15, p < .001).
Effects for the individual studies were significantly heterogeneous,
Q(4) = 18.92, p < .001. Too few studies comparing GAD to specific
phobia provided data to allow for moderator analyses. Because
all measures for this comparison fell into the severity/frequency
of worry category of measures, no secondary analyses were con-
ducted on each subgroup of measures.
OCD v. panic disorder. Three studies including three outcomes
were included in this comparison, producing a small effect size,
d = .35, p < .05, indicating that those with OCD reported signif-
icantly higher levels of overall worry than those with panic
disorder. However, this finding was not robust with regard to
publication bias, FSN = 2. The heterogeneity index was not statis-
tically significant, Q(2) = 2.83, p = .24. All measures included in this
comparison assessed the severity/frequency of worry, and thus
no additional analyses were conducted for each type of worry
measure.
OCD v. social phobia. Four studies producing five outcomes
were included in this comparison, yielding a statistically signifi-
cant but not robust effect size favoring OCD, d = .38, p < .05 (FSN = 9).
Heterogeneity was not statistically significant, Q(4) = 7.08, p = .13.
All measures included in this comparison fell into the sever-
ity/frequency category of measures, and therefore, no subsequent
subgroup analyses were conducted.
OCD v. specific phobia. Four studies producing five outcomes
were included in this comparison, yielding a moderate, statisti-
cally significant but not robust effect size favoring OCD, d = .51,
p < .001 (FSN = 16). Heterogeneity was not statistically significant,
Q(4) = 4.13, p = .39. All measures included in this comparison fell
into the severity/frequency category of measures, and thus no sub-
group analyses were conducted by measure type.
Panic disorder v. social phobia. Five studies yielding seven out-
comes were included in this analysis. A small, non-significant
effect was observed, d = .18, p = .47, indicating that those with panic
disorder and social phobia did not report significantly different
levels of worry. However, the heterogeneity index was statisti-
cally significant, Q(6) = 44.88, p < .001, indicating that the group
of individual effect sizes was heterogeneous. When considering
severity/frequency measures of worry alone (which included three
studies producing three outcomes), a similar pattern emerged, with
a small, non-significant effect observed, d = .18, p = .18. Too few
studies included the other types of measures to warrant meta-
analytic comparison.
Social phobia v. specific phobia. Four studies (yielding five out-
comes) compared social phobia to specific phobia on worry,
resulting in a small, non-significant effect size, d = .10, p = .15.
Heterogeneity among the studies included was not statistically sig-
nificant, Q(4) = 4.27, p = .37. All studies included measures that fell
into the severity/frequency measure of worry category only, and
thus no additional analyses were conducted on separate types of
measures.
12. General discussion
The present meta-analysis examined differences in worry
between patients with anxiety disorders, those with other psychi-
atric disorders (clinical controls), and nonclinical controls. A large
effect was observed such that those with anxiety disorders reported
significantly greater difficulties with worry than non-clinical con-
trols. A large effect size favoring clinical controls over non-clinical
controls was also found. However, the worry effect size for those
with anxiety disorders did not significantly differ from clinical con-
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
17
trols. These findings suggest that difficulties with worry in general
do not differentiate those with anxiety disorders from those with
other psychiatric disorders. This finding may reflect the observation
that worry, broadly defined, can be considered a symptom of neg-
ative affect that is common to most psychiatric disorders (Brown,
1997). However, examination of different aspects of worry revealed
a significant effect size favoring anxiety disorder patients over clin-
ical controls for the severity/frequency of worry. These findings
cast doubt on the notion that meta-worry and domains of worry
are unique to patients with anxiety disorders. The severity and fre-
quency of worry does appear to be a distinct and differentiating
feature of the anxiety disorders from other psychiatric conditions.
12.1. Specificity of Worry to GAD
Excessive worry is generally regarded as the defining diagnostic
feature of GAD (APA, 2000). This view is consistent with research
suggesting that patients with GAD may have a lower worry thresh-
old given that they worry more frequently about daily hassles than
other patient groups (Hoyer et al., 2001). Although several con-
temporary models of GAD have been proposed (cf. Behar, DiMarco,
Hekler, Mohlman, & Staples, 2009), a common factor across the
models involves the function of worry to facilitate avoidance of
negative internal affective experiences. However, worry is a con-
stituent process that is shared across the anxiety disorders with
differences primarily only in the content of worry (e.g., worry about
embarrassment in social phobia; worry about contamination in
OCD, worry about daily hassles in GAD) or in the means of coping
with worry (Barlow, 2002). In fact, worry has also been implicated
as an important feature in other disorders (Sassaroli et al., 2005).
Accordingly, there may be no difference in terms of the actual pro-
cess of worrying between GAD and other disorders. Examination of
specific anxiety disorder diagnoses revealed significant effect sizes,
relative to non-clinical controls, for OCD, panic disorder, social
phobia, specific phobia, and GAD. This pattern was relatively consis-
tent across the three worry domains (severity/frequency of worry,
meta-worry, and domains of worry). However, when compared to
mood disorder controls, a significant large overall worry effect size
was observed only for GAD. The finding that most other anxiety
disorder groups do not significantly differ from clinical controls
suggests that there are aspects of GAD, beyond general psychiatric
distress, that are specifically linked to worry.
Although limited data prevented more comprehensive compar-
isons within the anxiety disorders, a clear pattern of findings did
emerge. Specifically, a significant worry effect size favoring GAD
over other anxiety disorder diagnoses was observed. Furthermore,
the effect size for other anxiety disorder diagnoses generally did not
significantly differ from each other. This finding suggests that while
worry may be a common process across the anxiety disorders, the
severity and intensity of worry may be especially pronounced in
GAD. Although a significant effect size indicating that those with
GAD report greater worry levels relative to OCD was observed,
the effect was not robust with regard to publication bias. Unfor-
tunately, an overwhelming amount of the research on worry in the
anxiety disorders has been conducted in the context of OCD. The
unreliability of the finding of elevated worry among patients with
GAD compared to those with OCD highlights the need for further
research on the nature and function of worry in other anxiety dis-
orders, particularly in OCD. The unreliable differentiation between
GAD and OCD in the present investigation may reflect the difficult
distinction between worry in GAD and obsessions in OCD (Comer
et al., 2004). The underlying process of worry and obsessions may
very well be identical and future research is needed to further
examine the implications that this may have for the diagnostic
differentiation of GAD from OCD.
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18
Content
Broad
Specific Phobia
NonAnxious Disorders
Content
Specific
(Hypochondriasis, Eating Disorders, etc.)
Non-clinical Controls
Low
Worry Spectrum
Fig. 1. Conceptual model of the severity and content of worry across the anxiety
disorders relative to other disorders.
Excessive worry has become a central process in etiological
models of GAD (Borkovec & Inz, 1990; Borkovec et al., 2004).
Descriptive and experimental research suggests that the unique
role of worry in GAD may be largely explained by intolerance
of uncertainty, especially about the future (Dugas et al., 2001,
2005). Although indirect evidence suggest that worry about unpre-
dictable future threat may also be prominent in PTSD (Grillon, Pine,
Lissek, Rabin, & Vythilingam, 2009), there is a paucity of research
directly examining the role of worry in PTSD. Indeed, substan-
tive comparisons involving PTSD could not be made in the present
investigation. The paucity of research on the role of worry in PTSD
is surprising given that stable, individual differences in cognitive
vulnerabilities present in people prior to trauma may serve as a
vulnerability factor for latter symptom development (cf. Elwood,
Hahn, Olatunji, & Williams, 2009). Furthermore, excessive worry
proneness may contribute to the development of PTSD by prevent-
ing natural emotional processing after the trauma. Worry may also
function to maintain PTSD by reinforcing engagement in uncon-
trollable thinking about the possibility of future trauma. Treatment
interventions targeting the elimination of excess worry tendencies
may permit natural emotional processing and a return to normal
cognition in PTSD (Wells & Sembi, 2004).
As depicted in Fig. 1, difficulties with worry may vary along a
continuum of severity and frequency with the most severe and fre-
quent forms meeting diagnostic criteria for GAD. Milder forms of
worry severity and frequency may be observed in other anxiety-
related conditions to varying degrees. This interpretation is in line
with taxometric research showing that normal and pathological
worry represents opposite ends of a continuum rather than dis-
crete constructs (Olatunji et al., 2010; Ruscio et al., 2001). Among
the other anxiety disorders, OCD is also characterized by excessive
worry, although obsessional content and worry content can be dif-
ficult to distinguish (Coles et al., 2001). These data also suggest that
social phobia and specific phobia may not be uniquely associated
with excessive worry. Indeed, the effect size for those with social
phobia and specific phobia did not significantly differ with respect
to overall worry when compared to clinical controls. Social pho-
bia and specific phobia may be less associated with worry given
that the nature of threat implicated in the two anxiety disorders
can be more refined and content specific, whereas the nature of
threat in other anxiety disorders tends to be broad. The conceptual
model in Fig. 1 also suggests that non-anxious disorders, broadly
defined, generally fall below the anxiety disorders along the worry
spectrum. However, this model is an oversimplification, as non-
anxious disorders may also vary along the worry continuum. In fact,
depression may fall above some anxiety disorders along the worry
spectrum, given the substantial overlap between rumination and
worry (Borkovec et al., 1998; Fresco et al., 2002).
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
B.O. Olatunji et al. / Applied and Preventive Psychology xxx (2011) xxx–xxx
12.2. The effects of worry domains
GAD
OCD
The finding that anxiety disorder patients, particularly those
with GAD, were differentiated from clinical controls by the
Panic
severity/frequency of worry may have important psychometric
PTSD
implications. First, the construct of worry is not unitary and clear
SAD distinctions must be made when worry is operationalized in terms
of severity and frequency, as a meta-cognitive process, or in terms
of the specific domains of worry. Although these different lower-
order worry domains are likely to be captured by a higher-order
general worry propensity factor, they may be associated with dis-
tinct processes. Second, the use of worry measures, such as the
PSWQ, that assess excessive and uncontrollable worry levels will
High magnify differences between anxiety disorder patients, particularly
those with GAD, and other psychiatric conditions. Of the various
topics that people worry about, GAD appears to be best categorized
by worry about miscellaneous topics and daily hassles (Borkovec
et al., 1991; Craske et al., 1989; Roemer et al., 1997). However,
worry about miscellaneous topics and daily hassles in GAD could be
conceptualized as an artifact of the tendency to worry excessively.
When worry is assessed as a meta-cognitive process and spe-
cific domains, substantial overlap between the anxiety disorders
and other psychiatric disorders is observed. Meta-cognitive worry
is also seen in other disorders marked by intrusive thoughts in
which the intrusions activate additional anxious thoughts about
the ability to control the intrusions. For example, patients with
hypochondriasis may have intrusive negative thoughts about ill-
ness (“I am going to get ill and die”) which may lead to additional
worry about such thoughts (“I worry that I cannot control my
thoughts about illness and death”). This interpretation is consis-
tent with research showing that hypochondriasis is best predicted
by specific meta-worries about lack of control over thoughts about
illness (Bouman & Meijer, 1999). A similar process may also
be observed in schizophrenic-spectrum disorders where patients
come to worry about their lack of control over delusional thoughts
(Freeman & Garety, 1999; Morrison & Wells, 2007). Likewise,
depression is also marked by intrusive self-deprecating thoughts,
with symptoms being exacerbated by worry over the inability to
control the intensity or frequency of these thoughts (Papageorgiou
& Wells, 1999). These findings suggest that topics of worry may be
similar among patients with anxiety disorders and those with other
psychiatric diagnosis, although it remains unclear if worry across
these disorders emerge from a similar mechanism (Starcevic, 1995).
12.3. Gender as moderator of worry effects
The present study also found that an increase in the number of
females was associated with larger differences in worry between
anxiety and non-clinical control groups, whereas the proportion of
females had a limited impact on the effect size when comparing
clinical to non-clinical controls. Worry could possibly function as
a stronger risk factor for the development of anxiety-related psy-
chopathology for women compared to men. Although it has been
proposed that gender differences in worry may originate as a func-
tion of gender role differences or as an artifact of women being more
prone to internalizing negative affect (cf. Robichaud et al., 2003), a
comprehensive model that fully accounts for the gender differences
in worry remains elusive. Future research is needed to clarify the
pathways through which gender differences in worry confer risk
for the development of anxiety disorders, especially GAD, among
men and women. Such research may help identify additional mod-
erators of the sex differences in chronic worry that influence the
onset and course of the anxiety disorders.
Various biological explanations can also be offered to account
for the gender differences in worry. Genetic markers associated
with depression risk have also been linked to GAD (Norrholm &
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B.O. Olatunji et al. / Applied and Preventive Psychology xxx (2011) xxx–xxx
Ressler, 2009), and these markers may differentiate the genders.
Women may also be more vulnerable to depressive rumination and
worry during the premenstrual period, the postpartum period, and
menopause, each of which is marked by hormonal fluctuations (cf.
Nolen-Hoeksema, 1987). However, consistent evidence supporting
biological explanations of the gender differences in worry is lack-
ing. Alternatively, gender differences in depression may be partially
accounted for by a tendency towards a self-focused ruminative cop-
ing style in women as opposed to a more active behavioral coping
style in men (Nolen-Hoeksema, 1995). Maladaptive responses to
worry, such as engaging in meta-worry, among women may fur-
ther amplify worry levels and subsequent higher risk for developing
anxiety-related psychopathology, particularly GAD. The analysis
comparing the clinical control groups to non-clinical controls did
find that female gender was associated with a smaller effect size
for worry differences. This finding suggests that for women, ele-
vated worry does a relatively poorer job of distinguishing those
with non-anxious disorders from non-clinical controls. Although
gender differences in worry may underlie gender differences in
symptom presentation of some non-anxious disorders (MacSwain
et al., 2009), gender differences in maladaptive responses to worry
may be more specific to the development of anxiety disorders rel-
ative to other psychiatric disorders.
12.4. Age as a moderator of anxiety sensitivity effects
The present investigation revealed a greater difference in worry
between patients with anxiety disorders and non-clinical controls
as age increased. Among older adults, elevated worry is relatively
robust in distinguishing those with anxious disorders from non-
clinical controls. Although older adults may experience less general
trait-like worry than younger adults (Hunt et al., 2003; Powers
et al., 1992), this investigation suggests that perhaps the pres-
ence of worry among older adults may be a stronger risk factor
for the development of anxiety-related psychopathology compared
to the presence of worry among younger adults. Given that GAD
is the most common anxiety disorder in late life and is associ-
ated with poor overall quality of life (Porensky et al., 2009), the
risk conferred by excessive worry in older adults may be specific
to GAD development. However, mean age of the sample in the
present investigation moderated the effect comparing those with
GAD with clinical controls such that smaller differences in worry
were observed. Excessive worry does not appear adequate for dis-
criminating those with GAD from those with non-anxious disorders
among older adults.
The differential moderating effect of age on worry between
those with GAD and clinical controls relative to those with GAD
and non-clinical controls highlights the need for further research on
the nature and function of worry across the lifespan. Although such
research may substantially advance our current knowledge, there
remains a paucity of research on the relationship between worry
and anxiety disorders among the elderly and youth. Given the find-
ing that older adults generally report less worry than younger
adults (Hunt et al., 2003; Powers et al., 1992), future research is
needed to delineate how worry in older age groups can meaning-
fully distinguish those with anxious disorders from non-clinical
controls. This finding may be partially explained as an artifact
of severity if future research were to reveal that anxiety disor-
ders among older adults are associated with more distress and
dysfunction than anxiety disorders among younger populations.
Future research is also needed to account for why worry is not
particularly meaningful in distinguishing those with GAD from clin-
ical controls among older adults. Accounting for this effect will
likely require more systematic research on the nature and func-
tion of worry in the anxiety and non-anxious disorders across the
lifespan.
Please cite this article in press as: Olatunji, B. O., et al. Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD. Applied
and Preventive Psychology (2011), doi:10.1016/j.appsy.2011.03.001
19
12.5. Conclusions and future directions
A large body of research has identified worry as a core feature
of GAD, yet worry is also commonly experienced in other anxiety
disorders. Although missing data did not permit all comparisons
of interest, the present investigation suggests that worry, oper-
ationalized by frequency and severity, is more readily observed
and distinctive in GAD. The global assessment of worry revealed
no differences between patients with anxiety disorders relative to
patients with other psychiatric disorders. This suggests that opera-
tionailizing worry as a meta-cognitive process or in terms of worry
domains may not reliably distinguish patients with GAD and other
anxiety disorders from those with non-anxious disorders. It may be
the case that the observed specificity of the frequency and severity
of worry to GAD is an artifact of the diagnosis of GAD as being cen-
trally defined by worry. Indeed, excessive worry occurring more
days than not for at least 6 months, across a number of events or
activities, and that is difficult to control characterized the core diag-
nostic criteria for GAD (APA, 2000). Worry about the implications
of a prior panic attack or its consequences (e.g., losing control, hav-
ing a heart attack, and “going crazy”) is a criteria for a diagnosis of
panic disorder, such worry criteria is more specific than the worry
criteria needed for a diagnosis of GAD.
Reconciling the specificity of the frequency and severity of worry
to GAD and the observation that the clinical diagnosis of GAD is cur-
rently defined by excessive worry will require additional research.
Studies must also examine the features of GAD in the presence
and absence of the excessive worry criterion. Some preliminary
research has begun to address this question. For example, Ruscio
et al. (2005) found that those meeting all criteria for GAD other
than the excessiveness criteria displayed somewhat milder symp-
toms than those with excessive worry. However, excessive GAD
worriers resembled nonworriers in a number of important ways,
including number of months in the episode over the past year,
diagnostic levels of uncontrollability, distress, or impairment, vari-
ous sociodemographic features, and familial aggregation of GAD. A
more recent study also found that GAD with and without excessive
worry had comparable socio-demographic, symptom, chronicity,
impairment, depressive symptoms, and treatment-seeking profiles
(Lee, Ma, Tsang, & Kwok, 2009). However, it remains to be seen if
those with GAD whose worry is not deemed to be excessive have
worry levels that are similar to those with other anxiety disor-
ders. The comparability of GAD patients with and without excessive
worry begs the question of whether excessive worry should be
retained in the diagnostic criteria for GAD. Although difficulties are
apparent in arriving at a consensus on what constitutes excessive
worry, if GAD without excessive worry maintains worry levels that
surpass those with other anxiety disorders, then one might con-
clude that difficulties with worry and its consequences are unique
to the phenomenology of GAD.
Determination of the specificity of worry in GAD may also
require consideration of differential patterns of comorbidity across
the anxiety disorders. Given that depression is more comorbid with
some anxiety disorders (i.e., GAD) compared to others (Barlow,
2002), and the prominent role of rumination in depression that
may potentiate worry effects, differential patterns of comorbidity
may also be an important moderator for future consideration when
examining the specificity of worry to GAD. Another limitation of the
present investigation is that levels of worry were obtained contem-
poraneously with psychiatric diagnoses so these findings cannot
be used to imply or show that worry is causal in the development
of GAD and the anxiety disorders. Indeed, it could be argued that
excessive worry is a consequence, rather than a cause, of having
specific anxiety disorders diagnoses. Similarly, trait worry may be
a cause of GAD but a consequence of other anxiety disorders. How-
ever, definitive claims along those lines cannot be made based on
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20 B.O. Olatunji et al. / Applied and Preventive Psychology xxx (2011) xxx–xxx
the current investigation. Such a view may require some evidence
of differential function of worry in GAD v. other anxiety disorders.
Although research along these lines is lacking, one study did present
findings suggesting that fear of negative emotion drives excessive
worry in general, regardless of diagnostic status, while fears of
failure or ineffectiveness are more specific motivators of worry in
GAD (Hazlett-Stevens & Craske, 2003). This finding supports the
notion that there may be some utility to supplementing exposure-
based interventions that target the fear of emotion in GAD with an
interpersonal skills component targeting sources of worry based
on maladaptive views of social relations. The longitudinal assess-
ment of trait worry during childhood in relation to the subsequent
development of anxiety disorder diagnosis will be needed to further
define the differential function of excessive worry.
The present investigation suggests that gender and age do influ-
ence the worry-anxiety disorders association. It will be vital for
future research to begin to identify other potential moderations of
the worry-anxiety disorder association, as this may have impor-
tant treatment implications. If worry is fundamentally a strategy
to cope with the fear of negative emotion, then careful consid-
eration of the interaction between individual differences in one’s
ability to regulate negative emotions and worry may advance cur-
rent understanding of the development of the anxiety disorders
(Kashdan, Zvolensky, & McLeish, 2008), especially GAD. That is,
inflexible emotion regulatory strategies may amplify the extent to
which worry confers risk for the development of GAD. In addition
to research examining individual differences in other personal-
ity traits as moderators of the relationship between worry and
GAD, examination of more systemic moderators is also needed.
For example, research has shown that African-Americans report
significantly lower levels of trait worry than Caucasians (Carter
et al., 2005) and worry among African-Americans appears to be
best predicted by psychological distress and best predicted by low
perceived control among Caucasians (Chapman, Kertz, & Woodruff-
Borden, 2009). Despite these racial differences in levels of trait
worry and predictors of worry, epidemiological research has found
no racial differences in the prevalence of any anxiety disorder
(Kessler et al., 1994). Reconciling these findings will require closer
examination of the moderating effects of race and ethnicity on
the association between worry and anxiety disorder symptoms.
Unfortunately, examination of Table 1 suggests that available
research investigating the role of worry in the anxiety disorders
has employed mostly Caucasian samples. Broadening the context in
which worry is investigated in future research may ultimately lead
to a more precise understanding of the cause(s) and consequence(s)
of worry and its implication for anxiety and its disorders.
All of the papers marked with an asterisk indicate studies
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