The Contribution of Worry Behaviors to the Diagnosis of Generalized Anxiety Disorder

  • Timothy A. BrownEmail author
  • Esther S. Tung


Worry behaviors (i.e., overt acts to avoid or cope with worry-induced distress) have been recognized as being important in the psychopathology and treatment of generalized anxiety disorder (GAD). This study evaluated the worry behaviors criterion proposed for DSM-5 GAD, but was ultimately not adopted due to insufficient evidence. In 800 outpatients with emotional disorders (366 with GAD), most patients with GAD (92.6%) met the proposed worry behaviors criterion, which was at a rate significantly higher than other patient groups (e.g., patients with mood disorders). Patients who met the worry behaviors criterion had more severe GAD than patients who did not. The worry behaviors criterion, and 3 of its 4 constituent behaviors, were associated with no better than “fair” interrater reliability. Diagnostic reliability of GAD was not improved in cases where both interviewers agreed the worry behaviors criterion was met. The worry behaviors criterion significantly predicted DSM-5 GAD holding core GAD features constant (e.g., excessive worry), but this contribution was weak and did not appreciably improve the classification accuracy of GAD diagnostic status. Mixed support was obtained for the discriminant validity of the worry behaviors criterion in relation to mood disorders. Raising the proposed threshold of the criterion (requiring 2 instead of 1 behaviors) did not result in a substantial improvement in reliability, prediction, and classification accuracy. Although additional research is warranted (e.g., importance of worry behaviors in the treatment and natural course of GAD), the results raise questions about the role of worry behaviors in the diagnostic classification of GAD.


Generalized anxiety disorder Worry behaviors Diagnostic criteria DSM-5 



The authors thank Anthony J. Rosellini for his comments on this manuscript.


This research was funded by a grant from the National Institute of Mental Health. (R01 MH039096; PI: Brown).

Compliance with Ethical Standards

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of Interest

Timothy A. Brown and Esther S. Tung declare that they have no conflict of interest.

Experiment Participants

Informed consent was obtained from all individual participants included in the study.


  1. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.Google Scholar
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.CrossRefGoogle Scholar
  3. Andrews, G., Hobbs, M. J., Borkovec, T. D., Beesdo, K., Craske, M. G., Heimberg, R. G., Rapee, R. M., Ruscio, A. M., & Stanley, M. A. (2010). Generalized worry disorder: A review of DSM-IV generalized anxiety disorder and options for DSM-V. Depression and Anxiety, 27, 134–147.CrossRefGoogle Scholar
  4. Beesdo-Baum, K., Jenjahn, E., Höfler, M., Lueken, U., Becker, E. S., & Hoyer, J. (2012). Avoidance, safety behavior, and reassurance seeking in generalized anxiety disorder. Depression and Anxiety, 29, 948–957.CrossRefGoogle Scholar
  5. Brown, T. A., & Barlow, D. H. (2002). Classification of anxiety and mood disorders. In D. H. Barlow (Ed.), Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed., pp. 292–327). New York: Guilford Press.Google Scholar
  6. Brown, T.A., & Barlow, D.H. (2009). A proposal for a dimensional classification system based on the shared features of the DSM-IV anxiety and mood disorders: Implications for assessment and treatment. Psychological Assessment, 21, 256–271.CrossRefGoogle Scholar
  7. Brown, T. A., & Barlow, D. H. (2014). Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5). New York: Oxford University Press.Google Scholar
  8. Brown, T. A., Barlow, D. H., & Liebowitz, M. R. (1994). The empirical basis of generalized anxiety disorder. American Journal of Psychiatry, 151, 1272–1280 tz.CrossRefGoogle Scholar
  9. Brown, T. A., Marten, P. A., & Barlow, D. H. (1995). Discriminant validity of the symptoms constituting the DSM-III-R and DSM-IV associated symptom criterion of generalized anxiety disorder. Journal of Anxiety Disorders, 9, 317–328.CrossRefGoogle Scholar
  10. Brown, T. A., Chorpita, B. F., Korotitsch, W., & Barlow, D. H. (1997). Psychometric properties of the depression anxiety stress scales (DASS) in clinical samples. Behaviour Research and Therapy, 35, 79–89.CrossRefGoogle Scholar
  11. Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology, 107, 179–192.CrossRefGoogle Scholar
  12. Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001a). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110, 585–599.CrossRefGoogle Scholar
  13. Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001b). Reliability of DSM-IV anxiety and mood disorders: Implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110, 49–58.CrossRefGoogle Scholar
  14. Coleman, S. L., Pieterfesa, A. S., Holaway, R. M., Coles, M. E., & Heimberg, R. G. (2011). Content and correlates of checking related to symptoms of obsessive-compulsive disorder and generalized anxiety disorder. Journal of Anxiety Disorders, 25, 293–301.CrossRefGoogle Scholar
  15. Di Nardo, P. A., O’Brien, G. T., Barlow, D. H., Waddell, M. T., & Blanchard, E. B. (1983). Reliability of the DSM-III anxiety disorder categories using a new structured interview. Archives of General Psychiatry, 40, 1070–1074.CrossRefGoogle Scholar
  16. Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998). Generalized anxiety disorder: A preliminary test of a conceptual model. Behaviour Research and Therapy, 36, 215–226.CrossRefGoogle Scholar
  17. Fleiss, J. L., Nee, J. C. M., & Landis, J. R. (1979). Large sample variance of kappa in the case of different sets of raters. Psychological Bulletin, 86, 974–977.CrossRefGoogle Scholar
  18. Kessler, R. C., Gruber, M., Hettema, J. M., Hwang, I., Sampson, N., & Yonkers, K. A. (2008). Comorbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychological Medicine, 38, 365–374.PubMedGoogle Scholar
  19. Lawrence, A. E., & Brown, T. A. (2009). Differentiating generalized anxiety disorder from anxiety disorder not otherwise specified. Journal of Nervous and Mental Disease, 197(12), 879–886.CrossRefGoogle Scholar
  20. Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the depression anxiety stress scales (DASS) with the Beck depression and anxiety inventories. Behaviour Research and Therapy, 33, 335–342.CrossRefGoogle Scholar
  21. Mahoney, A. E., Hobbs, M. J., Newby, J. M., Williams, A. D., Sunderland, M., & Andrews, G. (2016). The worry behaviors inventory: Assessing behavioral avoidance associated with generalized anxiety disorder. Journal of Affective Disorders, 203, 256–264.CrossRefGoogle Scholar
  22. Mannuzza, S., Fyer, A. J., Martin, L. Y., Gallops, M. S., Endicott, J., Gorman, J. M., Liebowitz, M. R., & Klein, D. F. (1989). Reliability of anxiety assessment: I. Diagnostic agreement. Archives of General Psychiatry, 46, 1093–1101.CrossRefGoogle Scholar
  23. Menard, S. (2002). Applied logistic regression analysis (2nd ed.). Thousand Oaks: Sage Publications.CrossRefGoogle Scholar
  24. Di Nardo, P.A., Moras, K., Barlow, D.H., Rapee, R.M., & Brown, T.A. (1993). Reliability of DSM-III-R anxiety disorder categories using the anxiety disorders interview schedule-revised (ADIS-R). Archives of General Psychiatry, 50, 251–256.CrossRefGoogle Scholar
  25. Newman, M. G., & Llera, S. J. (2011). A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry. Clinical Psychology Review, 31, 371–382.CrossRefGoogle Scholar
  26. Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., & Kupfer, D. J. (2013). DSM-5 field trials in the United States and Canada, part II: Test-retest reliability of selected categorical diagnoses. American Journal of Psychiatry, 170, 59–70.CrossRefGoogle Scholar
  27. Rutter, L. A., & Brown, T. A. (2017). Psychometric properties of the generalized anxiety disorder scale – 7 (GAD-7) in outpatients with anxiety and mood disorders. Journal of Psychopathology and Behavioral Assessment, 39, 140–146.CrossRefGoogle Scholar
  28. Schut, A. J., Castonguay, L. G., & Borkovec, T. D. (2001). Compulsive checking behaviors in generalized anxiety disorder. Journal of Clinical Psychology, 57, 705–715.CrossRefGoogle Scholar
  29. Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder. Archives of Internal Medicine, 166, 1092–1097.CrossRefGoogle Scholar
  30. Starcevic, V., Portman, M. E., & Beck, A. T. (2012). Generalized anxiety disorder: Between neglect and epidemic. Journal of Nervous and Mental Disease, 200, 664–667.CrossRefGoogle Scholar
  31. Steiger, J. H. (1980). Tests for comparing elements of a correlation matrix. Psychological Bulletin, 87, 245–251.CrossRefGoogle Scholar
  32. Townsend, M. H., Weissbecker, K. A., Barbee, J. G., Peña, J. M., Snider, L. M., Tynes, L. L., Tynes, S. F., Boudoin, C., Green-Liebovitz, M. I., & Winstead, D. (1999). Compulsive behaviors in generalized anxiety disorder and obsessive-compulsive disorder. Journal of Nervous and Mental Disease, 187, 697–699.CrossRefGoogle Scholar
  33. Williams, J. B. W., Gibbon, M., First, M. B., Spitzer, R. L., Davies, M., Borus, J., Howes, M. J., Kane, J., Pope, H. G., Rounsaville, B., & Wittchen, H. (1992). The structured clinical interview for DSM-III-R (SCID): II. Multisite test-retest reliability. Archives of General Psychiatry, 49, 630–636.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Center for Anxiety & Related Disorders, Department of Psychological and Brain SciencesBoston UniversityBostonUSA

Personalised recommendations