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Trajectories of functioning after remission from anxiety disorders: 2-year course and outcome predictors

  • S. C. Iancu (a1), N. M. Batelaan (a2), M. B. M. Zweekhorst (a1), J. F. G. Bunders (a1), D. J. Veltman (a2), B. W. J. H. Penninx (a2) and A. J. L. M. van Balkom (a2)...



Anxiety disorders are associated with substantial functional limitations but the course of functioning following symptom remission remains largely unknown.


Using data from the Netherlands Study of Depression and Anxiety (NESDA), we examined the 2-year trajectories of functioning in participants with chronic (n = 586) or remitting anxiety disorders (n = 385) and in healthy controls (n = 585). In participants with remitting anxiety disorders, we identified predictors of functioning from among sociodemographic, clinical and vulnerability variables. Data were analysed using linear mixed models (LMMs). Functioning was assessed with the World Health Organization Disability Assessment Schedule II (WHO DAS II).


At baseline, participants with remitting anxiety disorders functioned significantly better than those with chronic anxiety disorders, but significantly worse than controls. In both anxiety disorder groups, most impairment was reported in social functioning, occupational functioning and cognition. During the follow-up, functioning improved in both groups, probably due to treatments received. Participants who achieved symptom remission experienced moderate improvements in social functioning and cognition but not in occupational functioning. Of those who remitted, 45.8% reported functioning scores similar to healthy controls whereas 28.5% still functioned at the level of those with chronic anxiety disorders. Worse functioning was predicted by severe anxiety disorders, use of psychological treatment, co-morbid depressive disorders and maladaptive personality traits.


In anxiety disorders, symptom remission is accompanied by improvements in functioning but significant functional impairments may persist because of co-morbid disorders, lower functioning prior to the onset of the anxiety disorder or residual subthreshold anxiety symptoms.


Corresponding author

* Address for correspondence: S. C. Iancu, M.Sc., Athena Institute, Department of Innovation in Health and Life Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands. (Email:


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Acarturk, C, Smit, F, de Graaf, R, van Straten, A, ten Have, M, Cuijpers, P (2009). Economic costs of social phobia: a population-based study. Journal of Affective Disorders 115, 421429.
Alonso, J, Angermeyer, MC, Bernert, S, Bruffaerts, R, Brugha, TS, Bryson, H, de Girolamo, G, Graaf, R, Demyttenaere, K, Gasquet, I, Haro, JM, Katz, SJ, Kessler, RC, Kovess, V, Lepine, JP, Ormel, J, Polidori, G, Russo, LJ, Vilagut, G, Almansa, J, Arbabzadeh-Bouchez, S, Autonell, J, Bernal, M, Buist-Bouwman, MA, Codony, M, Domingo-Salvany, A, Ferrer, M, Joo, SS, Martinez-Alonso, M, Matschinger, H, Mazzi, F, Morgan, Z, Morosini, P, Palacin, C, Romera, B, Taub, N, Vollebergh, WAM (2004 a). Disability and quality of life impact of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica. Supplementum 420, 3846.
Alonso, J, Ferrer, M, Gandek, B, Ware, JE, Aaronson, NK, Mosconi, P, Rasmussen, NK, Bullinger, M, Fukuhara, S, Kaasa, S, Leplege, A (2004 b). Health-related quality of life associated with chronic conditions in eight countries: results from the International Quality of Life Assessment (IQOLA) Project. Quality of Life Research 13, 283298.
Ballenger, JC (1999). Clinical guidelines for establishing remission in patients with depression and anxiety. Journal of Clinical Psychiatry 60, 2934.
Ballenger, JC (2001). Treatment of anxiety disorders to remission. Journal of Clinical Psychiatry 62, 59.
Bandelow, B (2006). Defining response and remission in anxiety disorders: toward an integrated approach. CNS Spectrums 11, 2128.
Batelaan, N, de Graaf, R, van Balkom, A, Vollebergh, W, Beekman, A (2007 a). Thresholds for health and thresholds for illness: panic disorder versus subthreshold panic disorder. Psychological Medicine 37, 247256.
Batelaan, N, Smit, F, de Graaf, R, van Balkom, A, Vollebergh, W, Beekman, A (2007 b). Economic costs of full-blown and subthreshold panic disorder. Journal of Affective Disorders 104, 127136.
Batelaan, NM, de Graaf, R, Penninx, BWJH, van Balkom, AJLM, Vollebergh, WAM, Beekman, ATF (2010 a). The 2-year prognosis of panic episodes in the general population. Psychological Medicine 40, 147157.
Batelaan, NM, de Graaf, R, Spijker, J, Smit, JH, van Balkom, AJLM, Vollebergh, WAM, Beekman, ATF (2010 b). The course of panic attacks in individuals with panic disorder and subthreshold panic disorder: a population-based study. Journal of Affective Disorders 121, 3038.
Beard, C, Moitra, E, Weisberg, RB, Keller, MB (2010 a). Characteristics and predictors of social phobia course in a longitudinal study of primary-care patients. Depression and Anxiety 27, 839845.
Beard, C, Weisberg, RB, Keller, MB (2010 b). Health-related quality of life across the anxiety disorders: findings from a sample of primary care patients. Journal of Anxiety Disorders 24, 559564.
Beck, AT, Brown, G, Epstein, N, Steer, RA (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology 56, 893897.
Bijl, RV, Ravelli, A (2000). Current and residual functional disability associated with psychopathology: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Psychological Medicine 30, 657668.
Buist-Bouwman, MA, Ormel, J, de Graaf, R, Vollebergh, WAM (2004). Functioning after a major depressive episode: complete or incomplete recovery? Journal of Affective Disorders 82, 363371.
Chopra, PK, Couper, JW, Herrman, H (2004). The assessment of patients with long-term psychotic disorders: application of the WHO Disability Assessment Schedule II. Australian and New Zealand Journal of Psychiatry 38, 753759.
Chwastiak, LA, Von Korff, M (2003). Disability in depression and back pain: evaluation of the World Health Organization Disability Assessment Schedule (WHO DAS II) in a primary care setting. Journal of Clinical Epidemiology 56, 507514.
Cody, MW, Teachman, BA (2010). Post-event processing and memory bias for performance feedback in social anxiety. Journal of Anxiety Disorders 24, 468479.
Cohen, J (1988). Statistical Power Analysis for the Behavioral Sciences. Lawrence Erlbaum Associates: Hillsdale, NJ.
Comer, JS, Blanco, C, Hasin, DS, Liu, S-M, Grant, BF, Turner, JB, Olfson, M (2011). Health-related quality of life across the anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Journal of Clinical Psychiatry 72, 4350.
Costa, PT, McCrae, RR (1995). Domains and facets: hierarchical personality assessment using the revised NEO personality inventory. Journal of Personality Assessment 64, 2150.
Eguchi, M, Noda, Y, Nakano, Y, Kanai, T, Yamamoto, I, Watanabe, N, Lee, K, Ogawa, S, Ietsugu, T, Sasaki, M, Chen, JW, Furukawa, TA (2005). Quality of life and social role functioning in Japanese patients with panic disorder. Journal of Nervous and Mental Disease 193, 686689.
Fehm, L, Pelissolo, A, Furmark, T, Wittchen, HU (2005). Size and burden of social phobia in Europe. European Neuropsychopharmacology 15, 453462.
Fydrich, T, Dowdall, D, Chambless, DL (1992). Reliability and validity of the Beck Anxiety Inventory. Journal of Anxiety Disorders 6, 5561.
Goodwin, RD, Faravelli, C, Rosi, S, Cosci, F, Truglia, E, de Graaf, R, Wittchen, HU (2005). The epidemiology of panic disorder and agoraphobia in Europe. European Neuropsychopharmacology 15, 435443.
Greenberg, PE, Sisitsky, T, Kessler, RC, Finkelstein, SN, Berndt, ER, Davidson, JRT, Ballenger, JC, Fyer, AJ (1999). The economic burden of anxiety disorders in the 1990s. Journal of Clinical Psychiatry 60, 427435.
Gustavsson, A, Svensson, M, Jacobi, F, Allgulander, C, Alonso, J, Beghi, E, Dodel, R, Ekman, M, Faravelli, C, Fratiglioni, L, Gannon, B, Jones, DH, Jennum, P, Jordanova, A, Jonsson, L, Karampampa, K, Knapp, M, Kobelt, G, Kurth, T, Lieb, R, Linde, M, Ljungcrantz, C, Maercker, A, Melin, B, Moscarelli, M, Musayev, A, Norwood, F, Preisig, M, Pugliatti, M, Rehm, J, Salvador-Carulla, L, Schlehofer, B, Simon, R, Steinhausen, H-C, Stovner, LJ, Vallat, J-M, van den Bergh, P, van Os, J, Vos, P, Xu, W, Wittchen, H-U, Jonsson, B, Olesen, J; CDBE2010Study Group (2011). Cost of disorders of the brain in Europe 2010. European Neuropsychopharmacology 21, 718779.
Hartford, J, Kornstein, S, Liebowitz, M, Pigott, T, Russell, J, Detke, M, Walker, D, Ball, S, Dunayevich, E, Dinkel, J, Erickson, J (2007). Duloxetine as an SNRI treatment for generalized anxiety disorder: results from a placebo and active-controlled trial. International Clinical Psychopharmacology 22, 167174.
Jorm, AF, Griffiths, KM, Christensen, H, Medway, J (2002). Research priorities in mental health, part 1: an evaluation of the current research effort against the criteria of disease burden and health system costs. Australian and New Zealand Journal of Psychiatry 36, 322326.
Keller, MB (2003). The lifelong course of social anxiety disorder: a clinical perspective. Acta Psychiatrica Scandinavica. Supplementum 417, 8594.
Keller, MB (2006). Social anxiety disorder clinical course and outcome: review of Harvard/Brown Anxiety Research Project (HARP) findings. Journal of Clinical Psychiatry 67, 1419.
Kessler, RC (2003). The impairments caused by social phobia in the general population: implications for intervention. Acta Psychiatrica Scandinavica. Supplementum 417, 1927.
Konrad, J, Stanisława, S, Joanna, K (2010). Factors accounting for psychosocial functioning in patients with low back pain. European Spine Journal 19, 613623.
Lecrubier, Y, Judge, R (1997). Long-term evaluation of paroxetine, clomipramine and placebo in panic disorder. Acta Psychiatrica Scandinavica 95, 153160.
Leon, AC, Portera, L, Weissman, MM (1995). The social costs of anxiety disorders. British Journal of Psychiatry 166, 1922.
Lieb, R, Becker, E, Altamura, C (2005). The epidemiology of generalized anxiety disorder in Europe. European Neuropsychopharmacology 15, 445452.
Lochner, C, Mogotsi, M, du Toit, PL, Kaminer, D, Niehaus, DJ, Stein, DJ (2003). Quality of life in anxiety disorders: a comparison of obsessive-compulsive disorder, social anxiety disorder, and panic disorder. Psychopathology 36, 255262.
Marks, IM, Mathews, AM (1979). Brief standard self-rating for phobic patients. Behaviour Research and Therapy 17, 263267.
Mavissakalian, MR, Perel, JM, Talbott-Green, M, Sloan, C (1998). Gauging the effectiveness of extended imipramine treatment for panic disorder with agoraphobia. Biological Psychiatry 43, 848854.
Melse, JM, Essink-Bot, ML, Kramers, PGN, Hoeymans, N (2000). A national burden of disease calculation: Dutch disability-adjusted life-years. American Journal of Public Health 90, 12411247.
Mendlowicz, MV, Stein, MB (2000). Quality of life in individuals with anxiety disorders. American Journal of Psychiatry 157, 669682.
Michelson, D, Lydiard, B, Pollack, MH, Tamura, RN, Hoog, SL, Tepner, R, Demitrack, MA, Tollefson, GD (1998). Outcome assessment and clinical improvement in panic disorder: evidence from a randomized controlled trial of fluoxetine and placebo. American Journal of Psychiatry 155, 15701577.
Olatunji, BO, Cisler, JM, Tolin, DF (2007). Quality of life in the anxiety disorders: a meta-analytic review. Clinical Psychology Review 27, 572581.
Ormel, J, Oldehinkel, AJ, Nolen, WA, Vollebergh, W (2004). Psychosocial disability before, during, and after a major depressive episode: a 3-wave population-based study of state, scar, and trait effects. Archives of General Psychiatry 61, 387392.
Ormel, J, Vonkorff, M, Vandenbrink, W, Katon, W, Brilman, E, Oldehinkel, T (1993). Depression, anxiety, and social disability show synchrony of change in primary care patients. American Journal of Public Health 83, 385390.
Penninx, BWJH, Beekman, ATF, Smit, JH, Zitman, FG, Nolen, WA, Spinhoven, P, Cuijpers, P, de Jong, PJ, van Marwijk, HWJ, Assendelft, WJJ, van der Meer, K, Verhaak, P, Wensing, M, de Graaf, R, Hoogendijk, WJ, Ormel, J, van Dyck, R (2008). The Netherlands Study of Depression and Anxiety (NESDA): rationale, objectives and methods. International Journal of Methods in Psychiatric Research 17, 121140.
Perini, SJ, Slade, T, Andrews, G (2006). Generic effectiveness measures: sensitivity to symptom change in anxiety disorders. Journal of Affective Disorders 90, 123130.
Pollack, MH, Otto, MW, Worthington, JJ, Manfro, GG, Wolkow, R (1998). Sertraline in the treatment of panic disorder: a flexible-dose multicenter trial. Archives of General Psychiatry 55, 10101016.
Rodriguez, BF, Bruce, SE, Pagano, ME, Keller, MB (2005). Relationships among psychosocial functioning, diagnostic comorbidity, and the recurrence of generalized anxiety disorder, panic disorder, and major depression. Journal of Anxiety Disorders 19, 752766.
Rubin, HC, Rapaport, MH, Levine, B, Gladsjo, JK, Rabin, A, Auerbach, M, Judd, LL, Kaplan, R (2000). Quality of well being in panic disorder: the assessment of psychiatric and general disability. Journal of Affective Disorders 57, 217221.
Rucci, P, Gherardi, S, Tansella, M, Piccinelli, M, Berardi, D, Bisoffi, G, Corsino, MA, Pini, S (2003). Subthreshold psychiatric disorders in primary care: prevalence and associated characteristics. Journal of Affective Disorders 76, 171181.
Saarni, SI, Harkanen, T, Sintonen, H, Suvisaari, J, Koskinen, S, Aromaa, A, Lonnqvist, J (2006). The impact of 29 chronic conditions on health-related quality of life: a general population survey in Finland using 15D and EQ-5D. Quality of Life Research 15, 14031414.
Saarni, SI, Suvisaari, J, Sintonen, H, Pirkola, S, Koskinen, S, Aromaa, A, Lonnqvist, J (2007). Impact of psychiatric disorders on health-related quality of life: general population survey. British Journal of Psychiatry 190, 326332.
Scheibe, G, Albus, M (1997). Predictors and outcome in panic disorder: a 2-year prospective follow-up study. Psychopathology 30, 177184.
Scholten, WD, Batelaan, NM, van Balkom, AJ, Penninx, B, Smit, JH, van Oppen, P (2013). Recurrence of anxiety disorders and its predictors. Journal of Affective Disorders 147, 180185.
Sheehan, DV, Harnett-Sheehan, K, Spann, ME, Thompson, HF, Prakash, A (2011). Assessing remission in major depressive disorder and generalized anxiety disorder clinical trials with the discan metric of the Sheehan disability scale. International Clinical Psychopharmacology 26, 7583.
Skapinakis, P, Lewis, G, Davies, S, Brugha, T, Prince, M, Singleton, N (2011). Panic disorder and subthreshold panic in the UK general population: epidemiology, comorbidity and functional limitation. European Psychiatry 26, 354362.
Spak, F, Hensing, G, Allebeck, P (1998). Sick-leave in women with alcohol dependence or abuse: effects of additional psychiatric disorders. Social Psychiatry and Psychiatric Epidemiology 33, 613619.
Stansfeld, S, Marmot, M (1992). Deriving a survey measure of social support: the reliability and validity of the Close Persons Questionnaire. Social Science and Medicine 35, 10271035.
Stopa, L, Clark, DM (2000). Social phobia and interpretation of social events. Behaviour Research and Therapy 38, 273283.
Stout, RL, Dolan, R, Dyck, I, Eisen, J, Keller, MB (2001). Course of social functioning after remission from panic disorder. Comprehensive Psychiatry 42, 441447.
Tenorio-Martinez, R, del Carmen Lara-Munoz, M, Elena Medina-Mora, M (2009). Measurement of problems in activities and participation in patients with anxiety, depression and schizophrenia using the ICF checklist. Social Psychiatry and Psychiatric Epidemiology 44, 377384.
Twisk, JWR (2007). Applied Longitudinal Data Analysis for Epidemiology. A Practical Guide. Cambridge University Press: Cambridge.
Üstün, TB, Kostanjsek, N, Chatterji, S, Rehm, J (2010). Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0). World Health Organization: Geneva, Switzerland.
Van Zuuren, FJ (1988). The Fear Questionnaire. Some data on validity, reliability and layout. British Journal of Psychiatry 153, 659662.
Verboom, CE, Sentse, M, Sijtsema, JJ, Nolen, WA, Ormel, J, Penninx, BWJH (2011). Explaining heterogeneity in disability with major depressive disorder: effects of personal and environmental characteristics. Journal of Affective Disorders 132, 7178.
Wacker, H, Battegay, R, Mullejans, R, Schlosser, C (eds) (2006). Using the CIDI-C in the General Population. Elsevier Science: Amsterdam.
Waghorn, G, Chant, D, White, P, Whiteford, H (2005). Disability, employment and work performance among people with ICD-10 anxiety disorders. Australian and New Zealand Journal of Psychiatry 39, 5566.
Wells, KB, Stewart, A, Hays, RD, Burnam, MA, Rogers, W, Daniels, M, Berry, S, Greenfield, S, Ware, J (1989). The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. Journal of the American Medical Association 262, 914919.
WHO (2001). International Classification of Functioning, Disability and Health (ICF). World Health Organization: Geneva.
Wiebe, JS, Christensen, AJ (1996). Patient adherence in chronic illness: personality and coping in context. Journal of Personality 64, 815835.
Wilson, JK, Rapee, RM (2005 a). The interpretation of negative social events in social phobia with versus without comorbid mood disorder. Journal of Anxiety Disorders 19, 245274.
Wilson, JK, Rapee, RM (2005 b). The interpretation of negative social events in social phobia: changes during treatment and relationship to outcome. Behaviour Research and Therapy 43, 373389.
Wittchen, HU (1994). Reliability and validity studies of the WHO–Composite International Diagnostic Interview (CIDI): a critical review. Journal of Psychiatric Research 28, 5784.
Wittchen, HU, Burke, JD, Semler, G, Pfister, H, Von Cranach, M, Zaudig, M (1989). Recall and dating of psychiatric symptoms: test-retest reliability of time-related symptom questions in a standardized psychiatric interview. Archives of General Psychiatry 46, 437443.
Wittchen, HU, Fehm, L (2003). Epidemiology and natural course of social fears and social phobia. Acta Psychiatrica Scandinavica. Supplementum 417, 418.
Wittchen, HU, Jacobi, F (2005). Size and burden of mental disorders in Europe: a critical review and appraisal of 27 studies. European Neuropsychopharmacology 15, 357376.
Wittchen, HU, Jacobi, F, Rehm, J, Gustavsson, A, Svensson, M, Jonsson, B, Olesen, J, Allgulander, C, Alonso, J, Faravelli, C, Fratiglioni, L, Jennum, P, Lieb, R, Maercker, A, van Os, J, Preisig, M, Salvador-Carulla, L, Simon, R, Steinhausen, HC (2011). The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology 21, 655679.
Wittchen, HU, Robins, LN, Cottler, LB, Sartorius, N, Burke, JD, Regier, D (1991). Cross-cultural feasibility, reliability and sources of variance of the Composite International Diagnostic Interview (CIDI). British Journal of Psychiatry 159, 645653.
Yonkers, KA, Bruce, SE, Dyck, IR, Keller, MB (2003). Chronicity, relapse, and illness – course of panic disorder, social phobia, and generalized anxiety disorder: findings in men and women from 8 years of follow-up. Depression and Anxiety 17, 173179.


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Trajectories of functioning after remission from anxiety disorders: 2-year course and outcome predictors

  • S. C. Iancu (a1), N. M. Batelaan (a2), M. B. M. Zweekhorst (a1), J. F. G. Bunders (a1), D. J. Veltman (a2), B. W. J. H. Penninx (a2) and A. J. L. M. van Balkom (a2)...


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