Edsp Study Heterotypic Continuity of Anxiety Disorders
Progression of externalizing disorders into anxiety disorders: Longitudinal transitions in the first three decades of life☆
Abstract
Background
There is a notable comorbidity between externalizing disorders and anxiety disorders, which may be explained by the co-occurrence of two prevalent early-onset disorders, by shared vulnerability and risk factors, or as evidence that one disorder group might be causally related to the other.
Aim
To investigate the longitudinal trajectories of externalizing disorders, their interplay with anxiety disorders, and putative predictors for symptom progression in youth.
Methods
1053 adolescents (14–17 years) from the general population were assessed at baseline and prospectively at 2, 4, and 10-year follow-up using a standardized interview of mental disorders (DIA-X/M-CIDI) to assess "early" (oppositional-defiant disorder, conduct disorder, ADHD) and "late" (antisocial behavior, substance use disorders) externalizing disorders as well as anxiety disorders. Longitudinal associations and predictors for symptom progression were examined using Kaplan-Meier-analyses.
Results
Lifetime prevalence of early externalizing disorders were 9.1% and 6.4% among those with and without any anxiety disorder. A late externalizing disorder was reported by 50.3% of those with an early externalizing disorder and in 26.6% of those with any anxiety disorder. Both early (HR: 1.5, 95%CI: 1.0–2.3) and late externalizing disorders (HR: 2.1, 95%CI: 1.7–2.6) were associated with incident anxiety disorders. Higher parental rejection, lower volitional inhibition, and higher volitional avoidance predicted incident anxiety disorders among those with early externalizing disorders.
Discussion
Early externalizing disorders likely follow a homotypic continuity (to late externalizing disorders) and/or a heterotypic continuity to anxiety disorders, and thus appear as a useful target for prevention and early intervention.
Introduction
Beyond diagnostic classification systems (American Psychiatric Association, 2013), clinical syndromes involving excessive overt and disruptive behaviors are often lumped together as "externalizing disorders" (Carragher, Krueger, Eatong, & Slade, 2015). With an onset typically before adolescence, oppositional defiant disorder (ODD), conduct disorder (CD), and attention-deficit hyperactivity disorder (ADHD) can be labelled as "early" externalizing disorders (Burke and Loeber, 2010, Merikangas et al., 2010). In addition, substance use disorders and antisocial behaviors manifest later, i.e., during or after adolescence, and hence can be considered as "late" externalizing disorders. With considerable overlap among these disorders, lifetime prevalence estimates for ODD range between 10% and 12.6%, with somewhat lower estimates for CD (6.8%) and ADHD (8.7%; Merikangas et al., 2010). For substance use disorders, lifetime estimates vary between 1.3% (Italy) and 15.0% (Ukraine), with a median of 7% across community samples (Merikangas & McClair, 2012).
Apart from the high comorbidity between externalizing disorders (Wichstrom et al., 2012), there is also a notable co-occurrence of externalizing disorders with anxiety disorders. Among children with an early externalizing disorder, 30–60% report an anxiety disorder (Angold et al., 1999, Nock et al., 2007). Vice versa, among those with an anxiety disorder, 10–15% report an early externalizing disorder in the community (Angold et al., 1999) and up to 22% in clinical samples (Verduin & Kendall, 2003). This co-occurrence may be explained as a chance agreement (i.e., the accidental co-occurrence of two prevalent childhood disorders), as the expression of shared underlying family-genetic and environmental vulnerability and risk factors, or as evidence that one group of disorders might be causally related to the other. Analyses on onset patterns and longitudinal associations may help to better understand the symptom progression across these conditions.
There is already some evidence from prospective community studies that symptoms or manifest early externalizing disorders more often precede anxiety disorders than the other way around (Beesdo et al., 2009, Burke et al., 2005, Hofstra et al., 2000, Kim-Cohen et al., 2003, Merikangas et al., 2010). This suggests that early externalizing problems can be regarded as a precursor or risk factor of subsequent anxiety disorders (Bubier & Drabick, 2009). Findings are however inconsistent (Bufferd et al., 2012, Copeland et al., 2013) as a number of - mostly prospective clinical - studies have reported on the reversed temporal order of these disorders, i.e. anxiety disorders preceding externalizing disorders (Foley et al., 2004, Hofstra et al., 2000, Last et al., 1996). It is not clear whether the latter sequence is driven by late-onset externalizing disorders such as substance use disorders or antisocial personality disorder, both of which typically emerge in mid-to late adolescence and young adulthood after the core incidence period for anxiety disorders (Behrendt et al., 2008, Goodwin and Hamilton, 2003). Since onset periods for anxiety and externalizing disorders partly overlap, their co-occurrence and longitudinal associations need to be considered on a more fine-grained diagnostic level, particularly by differentiating between early and late externalizing problems. In addition, externalizing and anxiety disorders are both associated with depressive disorders, which show a strong incidence increase during adolescence. Hence, the link between early and late externalizing disorders and anxiety disorders requires further consideration while also taking depressive disorders into account.
Research on the joint and distinct risk factors for externalizing and anxiety disorders remains inconclusive (Bubier and Drabick, 2009, Drabick et al., 2010, Mantymaa et al., 2012). Temperamental dispositions such as higher levels of behavioral inhibition and introversion are mostly, though not exclusively and specifically, linked with anxiety disorders (Mian et al., 2011, Rohrbacher et al., 2008), while an uninhibited temperament was found to be related to externalizing behaviors (Hink et al., 2013). Lower levels of self-regulation are typical for behavioral (externalizing) disorders, whereas higher levels are characteristic for internalizing (anxiety or depressive) disorders (Asselmann et al., 2018). Other temperamental dispositions such as neuroticism have been noted to be associated with both externalizing and internalizing (including anxiety and depressive) disorders (Hink et al., 2013). Environmental factors such as parenting behavior may contribute independently or in interaction with child characteristics to externalizing and anxiety disorders (Ryan & Ollendick, 2018). Also, parental psychopathology has been demonstrated to increase the risk for offspring's externalizing and anxiety disorders (Duncombe, Havighurst, Holland, & Frankling, 2012).
Hence, in the absence of conclusive evidence on onset and progression patterns as well as risk factor constellations, this paper aims to investigate concurrent and prospective associations between externalizing and anxiety disorders. Specifically, we examine the progression from one disorder to another and explore putative predictors for temporal associations in an epidemiological cohort study.
Section snippets
Sample
Data were collected as part of the prospective longitudinal Early Developmental Stages of Psychopathology (EDSP) - study. A random regional population sample of 14- to 24-year-olds was drawn and assessed in 1995 in the metropolitan area of greater Munich, Germany, to study the natural course of early stages of mental disorders and to identify risk factors for the onset and course of mental disorders (N = 3021; baseline response: 70.9%). The EDSP study incorporates a Family Supplement (EDSP-FS;
Cumulative lifetime prevalence
Observed cumulative lifetime prevalence estimates for core symptoms of early externalizing disorders at T1/age 15–18 were 7.2% for any condition, and 4.2% for ADHD, 4.5% for ODD, and 1.0% for CD, respectively. For the anxiety disorders, observed cumulative lifetime prevalences at T3/age 28 were considerably higher: 30.7% met criteria for any anxiety disorder, and rates varied between 2.6% for generalized anxiety disorder and 21.9% for specific phobias; for separation anxiety disorder (assessed
Discussion
This study investigated the longitudinal progression of externalizing disorders during the first three decades of life, disentangling their interplay with anxiety disorders and exploring putative predictors for symptom progression in youth.
Prevalence estimates for either condition as well as their co-occurrence were in accordance with previous community studies (Angold et al., 1999, Beesdo-Baum et al., 2015, Marmorstein, 2007, Nock et al., 2007). Children and adolescents with early
Conclusions
Since common mental disorders such as anxiety and externalizing disorders first emerge in childhood and adolescence, there is a substantial need for prevention and early intervention (Merikangas et al., 2010). Findings support observations on the heterotypic continuity of psychopathology in youth. They further point to the need for early diagnoses of externalizing and anxiety disorders in children and adolescents, particularly when externalizing disorders may be of etiological relevance for
Acknowledgements
This work is part of the Early Developmental Stages of Psychopathology (EDSP) Study and is funded by the German Federal Ministry of Education and Research (BMBF) project no. 01EB9405/6, 01 EB 9901/6, EB01016200, 01EB0140 and 01EB0440. Part of the field work and analyses were also additionally supported by grants of the Deutsche Forschungsgemeinschaft (DFG) LA1148/1-1, WI2246/1-1, WI 709/7-1 and WI 709/8-1. Principal investigators are Dr. Hans-Ulrich Wittchen and Dr. Roselind Lieb who take
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