Theoretischer Hintergrund: Die diagnostischen Kriterien der Generalisierten Angststörung (GAS) und ihr Status als eigenständige psychische Störung waren lange umstritten. Inzwischen liegen neuere epidemiologische Daten vor, die ein präziseres Bild dieser Störung und ihrer Besonderheiten ermöglichen. Methode: Es wird ein systematischer Überblick zu Prävalenz, Verlauf und Komorbidität, zur Beeinträchtigung und zum Inanspruchnahmeverhalten sowie zur Spezifität des Kernsymptoms (Sorgen) erstellt. Ergebnisse: GAS ist eine häufige Störung, die im jungen Erwachsenenalter einsetzt, jedoch auch – anders als andere Angststörungen – hohe Inzidenzraten im mittleren Lebensalter aufweist. Der Verlauf ist eher chronisch. Trotz hoher Komorbidität lässt sich die Störung valide abgrenzen. Klinisch relevante Sorgen erweisen sich als störungsspezifisch. Die Beeinträchtigungen sind auch bei GAS-Patienten ohne Komorbidität beträchtlich. Schlussfolgerung: Der Forschungsstand spricht für die Bedeutung und Eigenständigkeit der Diagnose sowie für die stärkere Beachtung offener Forschungsfragen. / Background: The diagnostic criteria for generalized anxiety disorder (GAD) and its status as an independent mental disorder have been controversial. More recent epidemiological data provide a more precise picture of this disorder and its specific features. Methods: A systematic overview is given in regard to prevalence, course and comorbidity, impairment, and help-seeking behavior as well as to specificity of the core symptom (worries). Results: GAD is a frequent disorder with high incidence rates in middle-age groups, which are not seen in other anxiety disorders. Despite the high comorbidity GAD can be validly distinguished. Clinically relevant worries have been proven as specific for the disorder. The impairments are also considerable for patients without comorbid disorders. Conclusions: Research supports the independent status of GAD and the importance of this diagnosis. Unsolved questions are to be analyzed in future research.

Background and Objectives: To characterize the impact of pregabalin on sleep in patients with generalized anxiety disorder (GAD) and to determine whether the impact is a direct or an indirect effect, mediated through the reduction of anxiety symptoms. Methods: A post-hoc analysis of data from a randomized, double-blind, placebo- and active-controlled study in patients with GAD was conducted. Patients received pregabalin 300 mg/day, venlafaxine XR 75 mg/day or placebo for a week, followed by pregabalin 300-600 mg/day, venlafaxine XR 75-225 mg/day, or placebo for 7 weeks. Treatment effect on sleep was evaluated using the Medical Outcomes Study Sleep Scale. Anxiety symptoms were assessed with the Hamilton Anxiety Rating Scale. A mediation model was used to estimate separately for both treatment arms the direct and indirect treatment effects on sleep disturbance. Results: Compared with placebo (n = 128), treatment with pregabalin (n = 121) significantly reduced scores on the sleep disturbance subscale and Sleep Problems Index II at both week 4 and week 8, and the sleep adequacy subscale at week 8. Venlafaxine XR (n = 125) had no significant effect on these measures. The mediation model indicated that 53% of the total pregabalin effect on sleep disturbance was direct (p < 0.01) and 47% indirect, mediated through anxiety symptoms (p < 0.05). Conclusions: Pregabalin decreased sleep disturbance in patients with GAD both directly, and indirectly by reducing anxiety symptoms. Given the drug specificity of the results, this study provides evidence of an additional important pathway of action for pregabalin and its efficacy in GAD.

The relationship between DSM-IV anxiety disorders and their clinical characteristics in mothers and anxiety in offspring was examined in 933 mother-child pairs from a longitudinal community study. Offspring of mothers with an anxiety disorder had an elevated risk of developing any anxiety disorder, compared with offspring of mothers with no anxiety disorder. Increased risk of anxiety in the offspring was especially associated with maternal social phobia and generalised anxiety disorder, and with maternal diagnoses of early onset, greater number and more severe impairment. These results suggest that the type of maternal anxiety disorder and its severity of manifestation contribute to mother-offspring aggregation of anxiety.

Der Beitrag diskutiert kritische theoretische und praktische Aspekte der Komorbidität auf der Grundlage von klinischen und epidemiologischen Befunden zur Komorbidität. Angststörungen weisen statistisch hochsignifikante Assoziationen untereinander sowie mit affektiven, psychotischen Störungen, Eβstörungen sowie Substanzstörungen und Persönlichkeitsstörungen auf. Sie gehen zumeist eindeutig den komorbiden Störungen voraus, so daβ Angststörungen als Risikofaktoren für viele andere Formen psychischer Störungen angesehen werden können. Die möglicherweise kausalen pathogenetischen Mechanismen sind jedoch nach wie vor umstritten und sind offensichtlich vielfältig. Der Beitrag diskutiert vor diesem Hintergrund besonders die möglicherweise kritische Bedeutung von Panikattacken als zentraler «Vulnerabilitätsmarker» nicht nur für die Entwicklung von Angststörungen, sondern auch für affektive Erkrankungen. Hier konnte z.B. nachgewiesen werden, daβ initiale Panikattacken nicht nur die Wahrscheinlichkeit für Rückfälle sekundärer Depressionen erhöhen, sondern auch signifikant die Häufigkeit und Länge depressiver Phasen beeinflussen. Die Vielzahl differenzierter Befunde legt nahe, Komorbidität bei der Eingangs- und Verlaufsdiagnostik ebenso wie bei der Indikationsstellung umfassender zu berücksichtigen.

Objective. To examine the natural course of social anxiety disorder (SAD) in the community and to explore predictors for adverse long-term outcomes. Method. A community sample of N=3,021 subjects aged 14-24 was followed-up over 10 years using the DSM-IV/M-CIDI. Persistence of SAD is based on a composite score reflecting the proportion of years affected since onset. Diagnostic stability is the proportion of SAD subjects still affected at follow-up. Results. SAD reveals considerable persistence with more than half of the years observed since onset spent with symptoms. 56.7% of SAD cases revealed stability with at least symptomatic expressions at follow-up; 15.5% met SAD threshold criteria again. 15.1% were completely remitted (no SAD symptoms and no other mental disorders during follow-up). Several clinical features (early onset, generalized subtype, more anxiety cognitions, severe avoidance and impairment, co-occurring panic) and vulnerability characteristics (parental SAD and depression, behavioural inhibition, harm avoidance) predicted higher SAD persistence and -less impressively- diagnostic stability. Conclusion. A persistent course with a considerable degree of fluctuations in symptom severity is characteristic for SAD. Both, consistently meeting full threshold diagnostic criteria and complete remissions are rare. Vulnerability and clinical severity indicators predict poor prognosis and might be helpful markers for intervention needs.

„Comorbidity“ among mental disorders is commonly observed in both clinical and epidemiological samples. The robustness of this observation is rarely questioned; however, what is at issue is its meaning. Is comorbidity „noise“ – nuisance covariance that researchers should eliminate by seeking „pure“ cases for their studies – or a „signal“ – an indication that current diagnostic systems are lacking in parsimony and are not „carving nature at its joints?“ (Krueger, p. 921). With these words, Krueger started a discussion on the structure of mental disorders, which suggested that a 3-factor model of common mental disorders existed in the community. These common factors were labeled „anxious-misery,“ „fear“ (constituting facets of a higher-order internalizing factor), and „externalizing.“ Along with similar evidence from personality research and psychometric explorations and selective evidence from genetic and psychopharmacologic studies, Krueger suggested that this model might not only be phenotypically relevant, but might actually improve our understanding of core processes underlying psychopathology. Since then, this suggestion has become an influential, yet also controversial topic in the scientific community, and has received attention particularly in the context of the current revision process of the Manual of Mental Disorders (Fifth Edition) (DSM-V) and the International Classification of Diseases, 11th Revision (ICD-11). Focusing on anxiety disorders, this article critically discusses the methods and findings of this work, calls into question the model’s developmental stability and utility for clinical use and clinical research, and challenges the wide-ranging implications that have been linked to the findings of this type of exploration. This critical appraisal is intended to flag several significant concerns about the method. In particular, the concerns center around the tendency to attach wide-ranging implications (eg, in terms of clinical research, clinical practice, public health, diagnostic nomenclature) to the undoubtedly interesting statistical explorations.

Social phobia is a common disorder associated with significant psychosocial impairment, representing a substantial public health problem largely determined by the high prevalence, and the lifelong chronicity. Social phobia starts in early childhood or adolescence and is often comorbid with depression, other anxiety disorders, alcohol and substance abuse or eating disorders. This cascade of comorbidity, usually secondary to social phobia, increases the disability associated with the condition. The possibility that social phobia may be a trigger for later developing comorbid disorders directs attention to the need for early effective treatment as a preventive measure. The most recent drug class to be investigated for the psychopharmacological treatment of social phobia is the SSRI group for which there is growing support. The other drug classes that have been evaluated are monoamine oxidase inhibitors (MAOIs), benzodiazepines, and beta-blockers. The SSRIs represent a new and attractive therapeutic choice for patients with generalized social phobia. Recently the first, large scale, placebo-controlled study to assess the efficacy of drug treatment in generalized social phobia has been completed with paroxetine. Paroxetine was more effective in reducing the symptoms than placebo and was well tolerated. Many now regard SSRIs as the drugs of choice in social phobia because of their effectiveness and because they avoid the problems of treatment with benzodiazepines or classical MAOIs.

Background and Objectives: To describe patterns of healthcare utilization among patients with generalized anxiety disorder (GAD) in general practitioner (GP) settings in Germany. Methods: Using a large computerized database with information from GP practices across Germany, we identified all patients, aged > 18 years, with diagnoses of, or prescriptions for, GAD (ICD-10 diagnosis code F41.1) between October 1, 2003 and September 30, 2004 ("GAD patients"). We also constituted an age- and sex-matched comparison group, consisting of randomly selected patients without any GP encounters or prescriptions for anxiety or depression (a common comorbidity in GAD) during the same period. GAD patients were then compared to those in the matched comparison group over the one-year study period. Results: The study sample consisted of 3340 GAD patients and an equal number of matched comparators. Mean age was 53.2 years; 66.3% were women. Over the 12-month study period, GAD patients were more likely than matched comparators to have encounters for various comorbidities, including sleep disorders (odds ratio [OR] = 6.75 [95% CI = 5.31, 8.57]), substance abuse disorders (3.91 [2.89, 5.28]), and digestive system disorders (2.62 [2.36, 2.91]) (all p < 0.01). GAD patients averaged 5.6 more GP encounters (10.5 [SD = 8.8] vs 4.9 [5.7] for comparison group) and 1.4 more specialist referrals (2.3 [2.9] vs 0.9 [1.7]) (both p < 0.01). Only 58.3% of GAD patients received some type of psychotropic medication (i.e., benzodiazepines, antidepressants, and/or sedatives/hypnotics). Conclusions: Patients with GAD in GP practices in Germany have more clinically recognized comorbidities and higher levels of healthcare utilization than patients without anxiety or depression.

Background: The relationship of panic attacks (PA), panic disorder (PD) and agoraphobia (AG) is controversial. The aim of the current study is to prospectively examine the 10-year natural course of PA, PD and AG in the first three decades of life, their stability and their reciprocal transitions. Methods: DSM-IV syndromes were assessed via Composite International Diagnostic Interview – Munich version in a 10-year prospective-longitudinal community study of 3,021 subjects aged 14–24 years at baseline. Results: (1) Incidence patterns for PA (9.4%), PD (with and without AG: 3.4%) and AG (5.3%) revealed differences in age of onset, incidence risk and gender differentiation. (2) Temporally primary PA and PD revealed only a moderately increased risk for subsequent onset of AG, and primary AG had an even lower risk for subsequent PA and PD. (3) In strictly prospective analyses, all baseline groups (PA, PD, AG) had low remission rates (0–23%). Baseline PD with AG or AG with PA were more likely to have follow-up AG, PA and other anxiety disorders and more frequent complications (impairment, disability, help-seeking, comorbidity) as compared to PD without AG and AG without PA. Conclusions: Differences in incidence patterns, syndrome progression and outcome, and syndrome stability over time indicate that AG exists as a clinically significant phobic condition independent of PD. The majority of agoraphobic subjects in this community sample never experienced PA, calling into question the current pathogenic assumptions underlying the classification of AG as merely a consequence of panic. The findings point to the necessity of rethinking diagnostic concepts and DSM diagnostic hierarchies.

Hintergrund: Angststörungen gehören zu den häufigsten psychischen Störungen im Jugend- und Erwachsenenalter. Ein Großteil der Betroffenen bleibt meist unbehandelt. Informationen über die Behandlungswahrscheinlichkeit bei Jugendlichen und jungen Erwachsenen in Abhängigkeit von der Störungs- und Behandlungsart, Lebensalter, Geschlecht und Komorbidität liegen bisher nicht vor. Methode: In einer repräsentativen Stichprobe 14- bis 34-Jähriger aus dem Großraum München (Early Developmental Stages of Psychopathology Studie, N = 3021) werden die Prävalenz und Lebenszeitinzidenz von Angststörungen sowie ihre Behandlungsraten mittels M-CIDI erfasst und differenziert für Lebensalter, Komorbidität und Geschlecht präsentiert. Ergebnisse: 30% der Befragten berichteten mindestens eine Angststörung in ihrem Leben. Fast die Hälfte der Betroffenen (43%) suchte irgendeine Behandlung, ein Drittel (28%) suchte einen Psychotherapeuten auf. Für die meisten Angststörungen lagen hohe Quoten psychotherapeutischer Behandlungen vor (Range: 50–61%). Jugendliche berichteten seltener als Erwachsene irgendeine Behandlung, eine psychotherapeutische Behandlung, die Konsultation eines Psychiaters oder Hausarztes. Frauen nahmen häufiger eine Psychotherapie in Anspruch als Männer. Das Vorliegen einer komorbiden Angst- oder depressiven Störung erhöhte die Behandlungswahrscheinlichkeit. Diskussion: Verglichen mit europäischen Studien berichtete die Stichprobe relativ häufig eine Behandlung, auch eine psychotherapeutische. Dies kann eine Folge des großen Behandlungsangebotes in München sein. Dennoch bleibt der Großteil der jungen Betroffenen unbehandelt. Zur Prävention langfristiger Beeinträchtigungen sowie sekundärer psychischer Störungen sollte das Versorgungssystem verstärkt auf diese Bevölkerungsgruppe ausgerichtet werden. / Background: Anxiety disorders are among the most frequent mental disorders in adolescence and adulthood. Most of the affected individuals do not receive treatment. Information about treatment use among adolescents and young adults, differentiated for the kind of treatment and anxiety disorder, age, gender and co-morbidity, is still missing. Methods: In a representative sample of 14–34 year-old adolescents and young adults of the Munich area (Early Developmental Stages of Psychopathology study, N = 3,021) prevalence and lifetime incidence of anxiety disorders and treatment use are assessed using the M-CIDI and will be presented for age, co-morbidity and gender. Results: 30% of all participants reported at least one lifetime diagnosis of an anxiety disorder. Almost half of those affected (43%) received some kind of treatment; one third (28%) received psychotherapy. Psychotherapy use was frequent in most anxiety disorders (range: 50–61%). Older individuals more frequently reported any treatment, psychotherapy, consultations with psychiatrists or general practitioners. Women used psychotherapy more often than men. Co-morbid anxiety or depressive disorders increased the probability of treatment use. Discussion: As compared to European estimations, we found relatively high rates of treatment use. This may be due to the many treatment possibilities in the Munich area. Nevertheless, most young people affected do not receive treatment. Considering the long-term effects of anxiety disorders and in order to prevent secondary disorders, efforts should be increased to reach these young individuals.