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Anxiety and the Problem of Comorbidity
Over the last several decades clinical research on anxiety has recognized that the older term “anxiety neurosis” had limited heuristic value.
Most theories and research on anxiety now recognize that there are a number of specific subtypes of anxiety that cluster under the rubric “anxiety disorders.”
Even though these more specific anxiety disorders share some common features such as the activation of fear in order to detect and avoid threat (Craske, 2003), there are important differences with implications for treatment.
Thus the present volume, like most contemporary perspectives, will focus on specific anxiety disorders rather than treat clinical anxiety as a single homogenous entity.
Psychiatric classification systems like DSM-IV assume that mental disorders like anxiety consists of more specific disorder subtypes with diagnostic boundaries that sharply demarcate one type of disorder from another.
However, a large body of epidemiological, diagnostic, and symptom-based research has challenged this categorical approach to psychiatric nosology, offering much stronger evidence for the dimensional
nature of psychiatric disorders like anxiety and depression (e.g., Melzer, Tom, Brugha,
Fryers, & Meltzer, 2002; Ruscio, Borkovec, & Ruscio, 2001; Ruscio, Ruscio, & Keane,
2002).
One of the strongest challenges to the categorical perspective is the evidence of extensive symptom and disorder comorbidity in both anxiety and depression—that is, the cross-sectional co-occurrence of one or more disorders in the same individual (Clark, Beck, & Alford, 1999).
Only 21% of respondents with a lifetime history of disorder had only one disorder in the National Comorbidity Survey (NCS; Kessler et al., 1994), a National Institute of Mental Health (NIMH) epidemiological study of mental disorders involving a randomized nationally representative sample of 8,098 Americans who were administered the Structured Clinical Interview for DSM-III-R.
Based on a sample of 1,694 outpatients from the Philadelphia Center for Cognitive Therapy evaluated between January, 1986, and October, 1992, only 10.5% of those with a primary mood disorder and 17.8% with panic disorder (with or without agoraphobia avoidance) had a “pure diagnosis” without Axis I or II comorbidity (Somoza, Steer, Beck, & Clark, 1994).
Clearly then, diagnostic comorbidity is the norm rather than the exception, with prognostic comorbidity, in which one disorder predisposes an individual to the development of other disorders (Maser & Cloninger, 1990) also important to consider in the pathogenesis of psychiatric conditions.
Numerous clinical states have reported a high rate of diagnostic comorbidity within the anxiety disorders. For example, a large outpatient study (N = 1,127) found that Anxiety:
A Common but Multifaceted Condition 9 two-thirds of anxiety disorder patients had another current Axis I disorder, and over three-fourths had a lifetime comorbid diagnosis (Brown, Campbell, Lehman, Grisham, & Mancill, 2001). Individuals with an anxiety disorder, then, are much more likely to have at least one or more additional disorders than would be expected by chance (Brown et al., 2001).
