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

Ruscio, Ayelet Meron; Alonso Caballero, Jordi; World Mental Health Survey collaborators

doi:http://dx.doi.org/10.1017/S003329172400182X

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

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Ruscio AM, Rassaby M, Stein MB, Stein DJ, Aguilar-Gaxiola S, Al-Hamzawi A, et al. The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation. Psychol Med. 2024 Oct 4;54(12):1-12. DOI: 10.1017/S003329172400182X

Abstract

Background: Around the world, people living in objectively difficult circumstances who experience symptoms of generalized anxiety disorder (GAD) do not qualify for a diagnosis because their worry is not 'excessive' relative to the context. We carried out the first large-scale, cross-national study to explore the implications of removing this excessiveness requirement. Methods: Data come from the World Health Organization World Mental Health Survey Initiative. A total of 133 614 adults from 12 surveys in Low- or Middle-Income Countries (LMICs) and 16 surveys in High-Income Countries (HICs) were assessed with the Composite International Diagnostic Interview. Non-excessive worriers meeting all other DSM-5 criteria for GAD were compared to respondents meeting all criteria for GAD, and to respondents without GAD, on clinically-relevant correlates. Results: Removing the excessiveness requirement increases the global lifetime prevalence of GAD from 2.6% to 4.0%, with larger increases in LMICs than HICs. Non-excessive and excessive GAD cases worry about many of the same things, although non-excessive cases worry more about health/welfare of loved ones, and less about personal or non-specific concerns, than excessive cases. Non-excessive cases closely resemble excessive cases in socio-demographic characteristics, family history of GAD, and risk of temporally secondary comorbidity and suicidality. Although non-excessive cases are less severe on average, they report impairment comparable to excessive cases and often seek treatment for GAD symptoms. Conclusions: Individuals with non-excessive worry who meet all other DSM-5 criteria for GAD are clinically significant cases. Eliminating the excessiveness requirement would lead to a more defensible GAD diagnosis.