Recent research published in the Journal of Psychiatric Research has provided insights into the cognitive impairments associated with Generalized Anxiety Disorder (GAD). The study demonstrated that individuals with GAD exhibit significant difficulties with cognitive flexibility and show a heightened ability to recognize negative emotions, such as disgust and anger. Although these cognitive predictors cannot replace existing diagnostic tools, they highlight the significant impact of anxiety.
Generalized Anxiety Disorder (GAD) is a mental health condition characterized by persistent and excessive worry about a variety of topics, events, or activities, which is out of proportion to the actual likelihood or impact of the feared events. People with GAD find it difficult to control their worry, and this anxiety and worry are associated with physical symptoms such as restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbances. This disorder significantly interferes with daily activities and can cause distress in social, occupational, or other important areas of functioning.
Despite the high prevalence of GAD in primary care settings and its substantial impact on individuals’ lives, there remains a gap in understanding the cognitive dimensions of the disorder. GAD is often under-recognized, with many cases remaining undiagnosed. Building on previous findings that suggest cognitive impairments across various domains in GAD patients, researchers aimed to further elucidate these impairments and explore the potential of cognitive tests as diagnostic tools for detecting GAD.
“Generalized Anxiety Disorder is a pain in the neck for psychiatrists (such as me), because they nearly never visit us, but mainly GPs, based on psychosomatic symptoms or pain or poor sleep instead of seeing a specialist for anxiety,” said study author Philip Gorwood, a professor of psychiatry at University of Paris, head of CMME in Sainte-Anne Hospital, and head of a research team at INSERM.
“This is explained by the fact that GAD develops early in life, so it is very difficult to believe ‘I have a disorder.” Instead, patients describe themselves as ‘I am an anxious person.’ We do have many ways to treat them (even psychedelics now) so it is frustrating that access to specialized care is so difficult. For GPs, this is also difficult to detect as their request is mainly to get relief for unspecific symptoms.”
For their study, the researchers recruited patients from three general practitioner offices in the suburbs of Paris, excluding those who were not fluent in French, illiterate, unfamiliar with computer use, or suffering from dementia or delirium. Out of 350 patients approached, 290 consented to participate, and after some exclusions for missing or non-interpretable data, 263 patients remained in the final sample.
Upon enrollment, each participant underwent a detailed assessment process that began with the completion of demographic data and the Generalized Anxiety Disorder-7 (GAD-7) questionnaire—an established self-report tool designed to screen for and assess the severity of generalized anxiety symptoms. Following this initial screening, participants engaged in a series of cognitive tests delivered via an online platform known as Psydatalab.
In addition to these tests, a clinician conducted the Mini International Neuropsychiatric Interview (MINI), a short, structured diagnostic interview for major psychiatric disorders according to DSM-IV and ICD-10 criteria. This interview helped verify the presence of GAD and other mood and anxiety disorders, ensuring a thorough psychiatric evaluation.
The researchers found that individuals with GAD exhibited significant impairments in cognitive flexibility. This was specifically evident in their performance on the Trail-Making Test (TMT). Participants with GAD took considerably longer to complete the TMT-B section of the test compared to those without the disorder.
The TMT-B test, which requires alternating between numbers and letters, assesses cognitive flexibility, a critical function in adapting thoughts and behaviors to changing circumstances. The results suggest that GAD significantly affects this cognitive domain, which may contribute to the difficulties individuals with the disorder face when dealing with everyday changes and stressors.
In addition to challenges with cognitive flexibility, the study found that people with GAD were quicker to recognize negative emotions, particularly disgust and anger, in the Facial Emotion Recognition Test. This rapid recognition of negative emotions aligns with the heightened sensitivity to threat that is typically associated with anxiety disorders.
However, despite their quick identification, participants with GAD also showed a higher rate of misinterpretations of these emotions compared to controls. This finding indicates a complex relationship between speed of recognition and accuracy, suggesting that while individuals with GAD are quick to detect potential threats, they may not always interpret these cues accurately.
“GAD is a disorder that is difficult to acknowledge and therefore to detect,” Gorwood told PsyPost. “All those experiencing a chronic feeling of anxiety (anxious rumination) with possible psychosomatic concerns/pains/problems, should test themselves! Some self-questionnaires are very efficient in doing so (GAD-7) and to make it in an attractive, more scientific one, you may also use the neurocognitive tests we proposed, showing very good predictive value for GAD.”
Moreover, the research examined the role of comorbid conditions, such as other anxiety disorders and major depressive episodes, in the cognitive performance of participants. It was found that the impairments in cognitive flexibility remained significant even after controlling for these comorbidities. But the influence of these additional disorders did affect other aspects of the results, particularly in the emotional recognition tasks, where the faster recognition times were somewhat influenced by the presence of other anxiety disorders.
The results from logistic regression analyses and tests of diagnostic accuracy reinforced the potential of cognitive testing, like the TMT, to not only understand but also potentially detect GAD in clinical settings, despite not reaching the high diagnostic accuracy of more conventional GAD assessments like the GAD-7 questionnaire.
But as with any study, there are some limitations to consider. With only 23 out of 263 participants diagnosed with generalized anxiety disorder, the sample size was relatively small, which may limit statistical power. Despite this, the researchers still found statistically significant results. Future research could consider larger and more diverse samples to confirm these findings and expand the range of cognitive domains tested.
Regarding the long-term aims of the research, Gorwood explained he hopes to facilitate “access to care (indirectly) to increase the possibility of treatment (pharmacological and psychotherapy) for this population.”
The study, “The capacity of cognitive tests to detect generalized anxiety disorder (GAD): A pilot study,” was authored by Axel Baussay, Laura Di Lodovico, Daphnee Poupon, Matthieu Doublet, Nicolas Ramoz, Philibert Duriez, and Philip Gorwood.
