Review articleThe development and modification of temperamental risk for anxiety disorders: prevention of a lifetime of anxiety?
Introduction
Anxiety disorders are responsible for a major burden in Western society. They are one of the more prevalent problems, affecting around 10% of the population in both younger and adult age groups Andrews et al 1999, Verhulst et al 1997. At the same time, anxiety disorders produce a moderate to severe level of life interference, including reduced employment, reduced social interaction, and increases in medical utilization, alcohol abuse, and suicide Massion et al 1993, Norton et al 1996, Roy-Byrne and Katon 1997. As a result, anxiety disorders account for a large proportion of the burden of disease in Western countries (Greenberg et al 1999). Murray and Lopez (1996) calculated that just two anxiety disorders, panic disorder and obsessive–compulsive disorder, account for 1.9% of the total disability adjusted life years in developed countries. This is more than that accounted for by breast cancer, HIV, schizophrenia, or diabetes. Similar calculations in Australia indicate that generalized anxiety disorder and social phobia together account for a greater burden than HIV/AIDS, cirrhosis of the liver, or melanoma (Mathers et al 1999).
Recent years have seen tremendous advances in treatments for anxiety disorders. Currently, there exist both pharmacologic and psychologic interventions that can produce marked reductions in anxiety and avoidance behavior (e.g., Gould et al 1995, Gould et al 1997; however, analyses of costs have shown that these treatments are not cheap to administer and that the long-term maintenance of treatment effects are moderate for psychologic treatments and poor for pharmacologic interventions (Gould et al 1995). More important, empirically validated treatments for anxiety disorders are rarely accessed by sufferers. Research shows that general medical practitioners are relatively poor at identifying anxiety disorders and typically deliver inadequate treatments for these disorders. Epidemiologic data indicate that less than 30% of adults with anxiety disorders seek help for their disorder and only around 10% sees a psychiatrist or psychologist (Andrews et al 1999). Figures in children may be even lower because childhood anxiety is a low-referral disorder (Weisz and Weiss 1991). In addition, even when appropriate help is sought, this typically happens decades after onset of the disorder. Thus, individuals’ lives are burdened for many years before appropriate help is obtained, and this is only in the small proportion that finds this help. Clearly, there is a need for alternate models of intervention for anxiety disorders. One such model would be to develop prevention programs that can be delivered early and within a public health framework.
To date, there has been little interest in developing programs for the prevention of broad-based anxiety disorders. What little work has been done has typically focused on preventing anxiety in specific situational contexts such as dental work, school transitions, and surgery (for a review, see Spence 2001). In current terms, prevention can be aimed across a whole population (universal), at early indicators or symptoms of a disorder (indicated), or at risk factors for a disorder (selective; Mrazek and Haggerty 1994). Although some work has addressed universal and indicated interventions for anxiety disorders, almost none has been aimed at developing selective interventions (Spence 2001). Selective interventions to prevent the development of a broader anxious style require the identification of clear and modifiable risk factors. In itself, this is an area that is only recently beginning to receive increasing attention. Data are beginning to emerge identifying several risk factors for the development of anxiety. In turn, some of these risk factors have the potential to be modified and then used in prevention programs.
This article aims to provide a brief summary of some of the main and potentially modifiable risk factors for the development of anxiety disorders. A central theme is the role of temperament and possible interactions and influences of various psychosocial factors with temperament. This leads to a discussion of the potential for prevention programs and presentation of preliminary data from our current selective intervention with at-risk preschoolers. Given space limitations and the existence of other comprehensive reviews (see Vasey and Dadds 2001), this article provides only a cursory overview of the evidence with a focus on data from our own laboratory.
Section snippets
Conceptualization of temperament
Although some authors have argued that an individual’s response in a given situation is variable from situation to situation, most theorists agree that there is some degree of consistency within an individual in the nature and degree of their responses. That is, it is assumed that there is some type of individual-difference factor that accounts for variance between individuals, but across situations—most commonly referred to as personality. In a developmental context, authors commonly refer to
The nature of withdrawn temperament
One of the intriguing questions for researchers is what are the components of temperament that may be inherited and how might those be then manifested in a way that has some greater environmental input. Although there are no clear answers to this question, some hints may come from research that examines early precursors to inhibition. Using a retrospective questionnaire format, mothers of clinically anxious and nonclinical children (aged around 10.5 years) were asked to indicate what their
Links between withdrawn temperament and anxiety disorders
Before moving to a discussion of some of the possible psychosocial factors involved in both a withdrawn temperament and the development of anxiety disorders, a brief summary of the literature demonstrating a link between these phenomena is in order.
In a retrospective study of early features of anxiety disorders, we asked mothers of clinically anxious and nonclinical children (aged around 10.5 years) to describe several features of their child’s early years (Rapee and Szollos, in submission).
Parent anxiety
Another strong predictor of anxiety disorders in offspring is a family history of anxiety. Several studies have shown a strong link between anxiety disorders in an individual and anxiety disorders in first-degree relatives Crowe et al 1983, Fyer et al 1995, Noyes et al 1987. Other research has focused specifically on parents and has shown that anxious children and their parents are likely to be concordant for anxiety disorders Beidel and Turner 1997, Last et al 1987. Interestingly, these
Parent-child interaction
A factor that has been almost a truism in its involvement in the development of anxiety disorders is parenting. Across several decades a number of authors have argued that the way in which a parent interacts with and controls a child is a central component of the chances that the child will become anxious. Two broad factors of child rearing have been identified in the literature and associated with anxiety: overprotection/control and criticism/lack of warmth Goldin 1969, Parker 1990. Of these,
Vicarious and instructional learning
There has been a widely held assumption among authors that fears can be acquired following observation or verbal instruction from a fearful model (Rachman 1977). Yet well-controlled empirical examination of this suggestion has been almost nonexistent. Several studies have asked adults to report retrospectively on the likely source of their fears, and these have typically indicated a significant proportion who attribute the onset of fears to observational or instructional mechanisms Menzies and
Risk for anxiety and targets for prevention
From the preceding review, several potential risk factors for the development of anxiety disorders can be identified. Probably the factor with the greatest investigation efforts and support is an inhibited or withdrawn temperament. Somewhat speculatively, it could be argued that the most central feature of this temperament is an avoidant style of coping with potential threat. A related factor is parental anxiety. Parental anxiety is related to offspring temperament through shared genetics, but
An example in progress: the macquarie university preschool intervention program
As an example of what a selective prevention program for anxiety disorders might look like, a brief overview of our current attempt to develop such a program is presented here. Based on the preceding considerations, we have begun to conduct an intervention and education program for the parents of inhibited preschool children to begin to explore the question of whether the development of anxiety disorders can be reduced. Inhibited children, aged 3.5–4.5 years of age, are recruited mainly via
Can anxiety disorders be prevented?
There are both theoretical and empirical reasons to believe that the prevention of anxiety shows some promise. Theoretically, we have discussed several potential risk factors for the development of anxiety disorders that are modifiable. Although experimental support for these risks is generally still far from conclusive, there is reason to believe that at least some of them will be supported as playing a causal role in the development of anxiety. The most extensive evidence at this stage is for
Acknowledgements
The Macquarie University Preschool Intervention Project is supported by National Health and Medical Research Council Grant Nos. 98 0534 and 167201 to the author. I thank Lyn Sweeney, Michelle Ingram, Susan Kennedy, and Susan Edwards for their work on the Macquarie University preschool project.
Aspects of this work were presented at the conference, “Learning and Unlearning Fears: Preparedness, Neural Pathways, and Patients,” held March 21, 2002 in Austin, TX. The conference was supported by an
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