What Are the Risk and Protective Factors for Anxiety and Obsessive-Compulsive Disorders?

What you need to know

• This comprehensive review examined evidence for risk and protective factors across several anxiety disorders and OCD.

• Very few factors showed strong, consistent evidence as risks or protections for these disorders.

• Early physical trauma was the most robust risk factor identified, specifically for social anxiety disorder.

• Many common factors like gender, personality traits, and early life experiences showed some evidence of influencing risk, but effects were generally small.

• The limited strong evidence highlights the need for more rigorous research on risk factors for anxiety and OCD.

What factors influence the risk of developing anxiety disorders?

Anxiety disorders are extremely common mental health conditions that can significantly impact quality of life. Understanding what factors increase or decrease the risk of developing these disorders is crucial for prevention efforts and improving treatments. However, the evidence for many proposed risk and protective factors has been mixed or inconclusive.

This study aimed to comprehensively evaluate and rate the strength of evidence for various risk and protective factors across several anxiety disorders as well as obsessive-compulsive disorder (OCD). The researchers conducted an “umbrella review,” which systematically assesses evidence from multiple systematic reviews and meta-analyses on a topic.

A rigorous approach to evaluating risk factors

The researchers searched for all published systematic reviews and meta-analyses examining potential risk or protective factors for five disorders:

• Specific phobia
• Social anxiety disorder
• Generalized anxiety disorder
• Panic disorder
• Obsessive-compulsive disorder

They extracted data on 427 potential factors from 216 individual studies included in 19 systematic reviews and meta-analyses. For each factor, they conducted new meta-analyses to calculate the overall effect size and evaluated the strength and consistency of the evidence.

Factors were rated as having convincing, highly suggestive, suggestive, or weak evidence based on criteria like:

• Number of cases studied (over 1,000)
• Statistical significance
• Consistency across studies
• Potential biases

This allowed them to identify which factors had the most robust scientific support as genuine risks or protections.

Limited strong evidence for most factors

Overall, the researchers found that very few factors met the strictest criteria for convincing or highly suggestive evidence. When requiring over 1,000 cases studied, only one factor reached the level of convincing evidence:

• Early physical trauma as a risk factor for social anxiety disorder

The researchers then looked at what factors showed the strongest evidence when removing the requirement for over 1,000 cases. This revealed a handful of additional factors with relatively strong support:

For specific phobia:

• Being male was protective
• Higher neuroticism was a risk factor

For social anxiety disorder:

• Early sexual trauma was a risk factor
• Having dysthymia or major depression were risk factors
• Insecure attachment in childhood was a risk factor
• Higher neuroticism was a risk factor

For generalized anxiety disorder:

• Being male was protective
• Psychological distress at age 33 was a risk factor
• Having borderline personality disorder was a risk factor
• Parental anxiety was a risk factor
• Early physical or sexual trauma were risk factors
• Behavioral inhibition was a risk factor

For panic disorder:

• Being male was protective
• Separation anxiety in childhood was a risk factor
• Early physical trauma was a risk factor
• Smoking cigarettes daily was a risk factor
• Having panic attacks or major depression were risk factors

For OCD:

• Certain parenting styles were risk factors
• Higher neuroticism was a risk factor
• Using cocaine with other drugs was a risk factor

Common threads across disorders

While few individual factors showed very strong evidence, some common themes emerged across multiple anxiety disorders:

• Being male was generally protective
• Higher neuroticism increased risk
• Early traumatic experiences increased risk
• Having other mental health conditions increased risk

The consistency of these associations, even if effects were small, suggests they likely play some role in anxiety risk. However, the limited strong evidence highlights the complex nature of these disorders.

Implications for understanding and preventing anxiety

This comprehensive review reveals both the progress made in identifying anxiety risk factors and the limitations of current research. The lack of factors with convincing evidence does not necessarily mean these factors are not important. Rather, it indicates the need for larger, more rigorous studies.

The findings suggest that anxiety disorders likely result from the combined influence of many genetic and environmental factors, each with relatively small effects. This aligns with our understanding of other complex mental health conditions.

For clinicians and patients, a few key takeaways emerge:

1. Early trauma experiences, particularly physical trauma, appear to be an important risk factor to assess and address.

2. Personality factors like neuroticism may help identify those at higher risk who could benefit from early intervention.

3. The presence of other mental health conditions should prompt screening for anxiety disorders.

4. Many commonly cited risk factors, while showing some effect, may have less influence than previously thought.

Looking ahead: Improving risk prediction and prevention

While this review found limited strong evidence for individual factors, combining multiple factors may improve risk prediction. The authors suggest developing “poly-risk scores” that incorporate both genetic and environmental influences to identify high-risk individuals.

Additionally, prevention efforts may be most effective when targeting multiple risk factors simultaneously. For example, programs addressing both parental mental health and parenting styles could potentially have a greater impact than focusing on either alone.

Importantly, this review also highlights opportunities to improve future research on anxiety risk factors:

• Larger studies with over 1,000 cases are needed to produce more definitive evidence
• More consistent definitions and measurements of risk factors across studies
• Greater focus on protective factors, not just risks
• Consideration of how risk factors may interact or accumulate over time

Conclusions

• Early physical trauma emerged as the most robustly supported risk factor, specifically for social anxiety disorder.

• Common factors like gender, personality traits, and early life experiences likely influence anxiety risk, but effects appear smaller than sometimes assumed.

• The limited strong evidence for most factors reflects the complex nature of anxiety disorders and highlights the need for larger, more rigorous studies.

• Combining multiple risk factors may improve prediction and prevention efforts in the future.

• This comprehensive review provides a foundation for more targeted research to better understand, predict, and ultimately prevent anxiety disorders.