Anxiety sensitivity and subjective social status in relation to anxiety and depressive symptoms and disorders among Latinos in primary care

The present investigation examined the interactive effects of anxiety sensitivity and subjective social status in relation to anxiety and depressive symptoms and psychopathology among 143 Latinos (85.7% female; M_age = 39.0, SD = 10.9; 97.2% used Spanish as their first language) who attended a community-based primary healthcare clinic. Results indicated that the interaction between anxiety sensitivity and subjective social status was significantly associated with number of mood and anxiety disorders, panic, social anxiety, and depressive symptoms. The form of the significant interactions indicated that individuals reporting co-occurring higher levels of anxiety sensitivity and lower levels of subjective social status evidenced the greatest levels of psychopathology and panic, social anxiety, and depressive symptoms. The present findings suggest that there is merit in focusing further scientific attention on the interplay between anxiety sensitivity and subjective social status in regard to understanding, and thus, better intervening to reduce anxiety/depressive vulnerability among Latinos in primary care.     

Training primary care staff to deliver a computer-assisted cognitive-behavioral therapy program for anxiety disorders

Objectives

This paper describes the training approach used with primary care staff to deliver an evidence-based computer-assisted cognitive-behavioral therapy (CBT) program for anxiety disorders within a collaborative care treatment delivery model.

Methods

We describe the training and proficiency evaluation procedures utilized in the Coordinated Anxiety Learning and Management (CALM) study, a large multisite study of collaborative care for anxiety disorders in primary care. Training incorporated readings, didactic presentations, video demonstrations of CBT skills, role-plays, computer-assisted practice, CBT training cases and ongoing group supervision provided by study psychologists.

Results

Proficiency training case data from 15 clinicians are presented. The anxiety clinical specialists (ACSs) were highly proficient at delivering the CBT component of the CALM intervention. The ACSs also provided Likert-scale ratings and open-ended responses about their experiences with the training. Overall, the training was rated very positively and was described as very thorough, indicating a high level of acceptability to clinicians. Recommendations for future training are described.

Conclusions

Primary care staff with none or minimal prior CBT experience can be trained to deliver a computer-assisted, evidence-based treatment for anxiety disorders. The implications for dissemination and transportability of evidenced-based interventions are discussed.     

Identifying anxiety and depressive disorders among primary care patients: a pilot study

One stage case-identification method, using the Arabic Version of the Hospital Anxiety and Depression Scale (HAD) was applied in a pilot study for estimating the prevalence of depressive and anxiety disorders among a group of Saudi primary care attenders. The validity of the Arabic Version of the HAD scale was previously tested and found valid with high sensitivity and specificity. The total prevalence rate of depression was 17% and that of anxiety was 16%. Seven percent of the sample suffered both depression and anxiety i.e. the total percentage of patients with depression, anxiety or both was 26%. Higher morbidity of depression was recorded among females and a higher morbidity of anxiety among male patients.     

Late-life anxiety disorders among Puerto Rican primary care patients: impact on well-being, functioning, and service utilization

With the growing population of older Hispanic adults there is a need for additional research on the mental health care of this patient group. This study explored the impact of anxiety disorders on the health status of 291 older (>/=50 years) Puerto Rican primary care patients (n = 65 with anxiety disorders, n = 226 without anxiety disorders). All analyses controlled for potential confounding variables, including depression diagnosis and physical health burden. Logistic regression indicated that anxiety disorders were associated with higher psychological distress, suicidality, and emergency room service utilization, as well as lower instrumental functioning and perceived health quality. Analysis of covariance indicated that both anxiety disorder status and history of ataque de nervios were related to higher percentages of lifetime somatic symptoms. These data highlight the need for improved recognition and treatment of anxiety disorders in older Puerto Rican adults.     

Dental anxiety in relation to neuroticism and pain sensitivity. A twin study

Predisposing personality traits as well as heightened pain sensitivity and fear of pain have been hypothesized as central factors in the development of dental anxiety. The aim of the study was to estimate the heritability of dental anxiety, and to investigate the genetic and environmental sources of covariance between dental anxiety on one hand, and pain sensitivity and the neuroticism trait on the other. A sample comprising 188 twins, aged 23-35 years (53 monozygotic and 39 dizygotic twin pairs, and 4 single twins whose co-twin did not participate), was included in the study. Measures of dental anxiety and personality were obtained using Corah's Dental Anxiety Scale and the NEO Personality Inventory Revised, respectively. Heat pain and cold pressor pain sensitivity were assessed using standard pain testing procedures. Bivariate Cholesky models were employed to decompose the correlations between phenotypes into genetic and environmental factors. Using models with common additive genetic (A) and individual-specific environmental (E) factors, moderate heritability (i.e., .41) for dental anxiety was demonstrated. Virtually all of the phenotypic correlation between neuroticism and dental anxiety could be accounted for by A. Furthermore, a substantial part of the variance in dental anxiety was due to specific genetic and individual environmental influences unrelated to neuroticism. The phenotypic correlations between dental anxiety and the pain sensitivity indices were close to zero. Thus, while neuroticism and dental anxiety share a sizeable proportion of genetic (but not environmental) risk factors, the results also suggest that these two attributes are distinct entities with overlapping, but not identical, etiologies.     

Alexithymia and anxiety sensitivity in patients with non-cardiac chest pain

The aim of this study was to examine independent and combined influences of alexithymia and anxiety sensitivity on chest pain and life interference in patients with non-cardiac chest pain (NCCP). Theories of NCCP posit a central role for emotion in the experience of chest pain, however, studies have not examined how alexithymia characterized by a difficulty identifying or verbalizing emotions, may influence this relationship. This study examined 231 patients (56% females, M age = 50 years) with chest pain seeking cardiac evaluation, who showed no abnormalities during exercise tolerance testing. Forty percent (40%) scored at or above the moderate range of alexithymia. Whereas health care utilization was associated with elevated alexithymia among men, health care utilization was associated with elevated anxiety sensitivity among women. Hierarchical regression analyses revealed that alexithymia and anxiety sensitivity were both uniquely and independently associated with pain severity and life interference due to pain. Alexithymia-pain links were stronger for men compared to women. Secondary analyses conducted with a subsample suggest that alexithymia may be increasingly stable over time (i.e., 18-month follow-up). Findings are largely congruent with theoretical models of NCCP showing that personality and emotional factors are important in this medically unexplained syndrome.     

Anxiety sensitivity and pain-related anxiety in the prediction of fear responding to bodily sensations: A laboratory test

Objective

The present investigation sought to examine the simultaneous effects of anxiety sensitivity and pain-related anxiety on fear and anxious responding to a 10% carbon dioxide enriched air challenge.

Methods

Participants included 247 adults (53% women; mean age=21.91 years, S.D.=8.41) recruited from the community. At the laboratory, participants were administered a structured clinical interview, completed a battery of self-report measures, and underwent a 10% carbon dioxide enriched air challenge.

Results

Both anxiety sensitivity and pain-related anxiety were significantly and uniquely predictive of post-challenge panic attacks, total post-challenge panic attack symptoms, and intensity of cognitive panic attack symptoms. Anxiety sensitivity, but not pain-related anxiety, also was predictive of post-challenge physical panic symptoms. The observed significant effects for both anxiety sensitivity and pain-related anxiety were evident above and beyond the variance accounted for by gender, age, current level of nonspecific bodily pain, and negative affectivity. Neither anxiety sensitivity nor pain-related anxiety was significantly predictive of change in anxiety focused on bodily sensations or heart rate.

Conclusion

Results suggest that anxiety sensitivity and pain-related anxiety, although related to one another, may be independently important variables underlying fear reactivity to bodily sensations.     

Gastrointestinal symptoms in primary care: prevalence and association with depression and anxiety

OBJECTIVE: Results from general population studies suggest a relationship between gastrointestinal (GI) symptoms, depression, and anxiety. However, no primary care study has investigated this issue. This study investigates the prevalence of GI symptoms in primary care and their association with depression and anxiety. METHOD: Within a cross-sectional survey, 2091 consecutive patients from 15 primary care clinics in the United States completed self-report questionnaires regarding GI symptoms [15-item Patient Health Questionnaire (PHQ-15)], anxiety [seven-item Generalized Anxiety Disorder Scale (GAD-7)], and depression (PHQ-8). Of those, 965 randomly selected patients additionally underwent a criterion standard diagnostic telephone interview (Structured Clinical Interview for DSM-IV) for the most common anxiety disorders. RESULTS: A total of 380 [18% (95% CI, 16.3% to 19.3%)] patients reported to be substantially bothered by at least one GI symptom in the previous 4 weeks. The prevalence of severe levels of depression (PHQ-8 score > or =15) was nearly fivefold in patients with GI symptoms compared to patients without GI symptoms (19.1% vs. 3.9%; P<.001), and the prevalence of severe levels of anxiety (GAD-7 score > or =15) was nearly fourfold in patients with GI symptoms compared to patients without GI symptoms (19.4% vs. 5.6%; P<.001). Similarly, with each additional GI symptom, the odds for an interview-based diagnosis of specific anxiety disorders increased significantly: For example, compared to patients with no GI symptom, the odds ratio (OR) (95% CI) for generalized anxiety disorder in patients with one GI symptom was 3.7 (2.0 to 6.9); in patients with two GI symptoms, OR=6.5 (3.1 to 13.6); and in patients with three GI symptoms, OR=7.2 (2.7 to 18.8). CONCLUSION: GI symptoms are associated significantly with depression and anxiety in primary care. It is suggested to screen as a routine for anxiety and depression in patients with GI symptoms and, if indicated, to initiate specific treatment.     

Levels of anxiety sensitivity in relation to repressive and self-deceptive coping styles

Levels of anxiety sensitivity (AS) were investigated in relation to self-deception and repression in 296 university students. It was hypothesized that a low level of AS, rather than constituting "normal" functioning, would be associated with more general response biases. Scores on the Anxiety Sensitivity Index (ASI; Peterson & Reiss, 1987, 1992) were negatively and significantly correlated with measures of self-deception and denial. Individuals with low AS were significantly more likely to meet an operational definition of repression (i.e., low anxiety and high defensiveness), compared to mid AS and high AS groups. When confronted with a hypothetical health problem, individuals with low AS were less likely to choose a task-oriented response and more likely to choose denial and self-deceptive responses, compared to the other groups. These findings support the observations of Shostak and Peterson (1990) that low AS represents an extreme group that may not be indicative of normal functioning.     

Adjustment disorder with anxiety in old age: Comparing prevalence and clinical management in primary care and mental health care

PurposeAdjustment disorder with anxiety (AjD-A) is a common cause of severe anxiety symptoms, but little is known about its prevalence in old age.MethodsThis cross-sectional study examined the prevalence of AjD-A in outpatients over the age of 60 who consecutively consulted 34 general practitioners and 22 psychiatrists during a 2-week period. The diagnosis of AjD-A was obtained using the optional module for diagnostic of adjustment disorder of the Mini International Neuropsychiatric Interview (MINI). The study procedure also explored comorbid psychiatric conditions and documented recent past stressful life events, as well as social disability and current pharmacological and non-pharmacological management.ResultsOverall, 3651 consecutive subjects were screened (2937 in primary care and 714 in mental health care). The prevalence rate of AjD-A was 3.7% (n = 136). Up to 39% (n = 53) of AjD-A subjects had a comorbid psychiatric condition, mostly of the anxious type. The most frequently stressful life event reported to be associated with the onset of AjD-A was personal illness or health problem (29%). More than 50% of the AjD-A patients were markedly to extremely disabled by their symptoms. Compared to patients who consulted psychiatrists, patients who were seen by primary care physicians were older, had obtained lower scores at the Hamilton Anxiety Rating Scale, benefited less frequently from non-pharmacological management and received benzodiazepines more frequently.ConclusionsAjD-A appears to be a significantly disabling cause of anxiety symptoms in community dwelling elderly persons, in particular those presenting personal health related problems. Improvement of early diagnosis and non-pharmacological management of AjD-A would contribute to limit risks of benzodiazepine overuse, particularly in primary care settings.     

Physician speciality and pain reduction in patients with depressive symptoms under treatment with venlafaxine

ObjectivesExcessive pain perception may lead to unnecessary diagnostic testing or invasive procedures resulting in iatrogenic complications and prolonged disability. Naturalistic studies on patients with chronic pain and depressive symptoms investigating the impact of medical speciality on treatment outcome in a primary care setting are lacking.MethodsIn this observational study, we examined whether the magnitude of pain reduction in 444 patients with depressive symptomatology under venlafaxine would relate differently to the medical speciality of the 122 treating physicians, namely psychiatrists (n = 110 patients), general practitioners (n = 236 patients), and internists (n = 98 patients).ResultsIndependent of age, gender, patient's region of origin, comorbidity, severity and duration of pain, and depressive symptoms at study entry, patients seemed to benefit significantly less in terms of pain reduction (p < 0.001) and of reduction in severity of depressive symptomatology by psychiatrists as compared to general practitioners (p < 0.019) and internists (p < 0.002).ConclusionsThe findings suggest that patients referred to psychiatrists are more difficult to treat than those referred to general practitioners and internists, and might not have been adequately prepared for psychiatric interventions. A supporting cooperation and networking between psychiatrists and primary care physicians may contribute to an integrated treatment concept and therefore, may lead to a better outcome in this challenging patient group.     

Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment

OBJECTIVE: To determine diagnostic overlap of depression, anxiety and somatization as well as their unique and overlapping contribution to functional impairment. METHOD: Two thousand ninety-one consecutive primary care clinic patients participated in a multicenter cross-sectional survey in 15 primary care clinics in the United States (participation rate, 92%). Depression, anxiety, somatization and functional impairment were assessed using validated scales from the Patient Health Questionnaire (PHQ) (PHQ-8, eight-item depression module; GAD-7, seven-item Generalized Anxiety Disorder Scale; and PHQ-15, 15-item somatic symptom scale) and the Short-Form General Health Survey (SF-20). Multiple linear regression analyses were used to investigate unique and overlapping associations of depression, anxiety and somatization with functional impairment. RESULTS: In over 50% of cases, comorbidities existed between depression, anxiety and somatization. The contribution of the commonalities of depression, anxiety and somatization to functional impairment substantially exceeded the contribution of their independent parts. Nevertheless, depression, anxiety and somatization did have important and individual effects (i.e., separate from their overlap effect) on certain areas of functional impairment. CONCLUSIONS: Given the large syndrome overlap, a potential consideration for future diagnostic classification would be to describe basic diagnostic criteria for a single overarching disorder and to optionally code additional diagnostic features that allow a more detailed classification into specific depressive, anxiety and somatoform subtypes.     

Screening for depression and anxiety disorders in primary care patients

Mood and anxiety disorders are highly prevalent in primary health care. In this study we assessed performance of the Hospital Anxiety and Depression Scale (HADS) for screening of depression and anxiety disorders in a population of primary care patients. A total of 503 primary care patients consecutively admitted to the primary care medical center in Kaunas, Lithuania, completed the study. We found that the HADS subscale of depression (HADS-D) at a cutoff score of 6 or more showed the best performance screening for a major depressive episode diagnosed by means of the Mini International Neuropsychiatric Interview (MINI), with a sensitivity of 80%, specificity of 69%, positive predictive value of 80%, negative predictive value of 92%, and area under the receiver operating characteristic (ROC) curve of 0.75. Performance of the HADS-D against MINI diagnosis of dysthymia was weak. The HADS subscale of anxiety (HADS-A) at a cutoff score of 9 or more showed the best performance screening for MINI diagnosis of overall anxiety disorders, with a sensitivity of 77%, specificity of 75%, positive predictive value of 53%, negative predictive value of 90%, and area under the ROC curve of 0.76. These results suggest that in primary care patients HADS is an adequate screening instrument for the MINI diagnoses of major depressive episode, but not for dysthymia at a cutoff score of 6, and for anxiety disorders at a cutoff score of 9.     

The interaction between anxiety sensitivity and cigarette smoking level in relation to sleep onset latency among adolescent cigarette smokers

Cigarette smoking during adolescence is linked to a number of sleep disturbances and has been consistently linked to sleep onset latency among adults. However, little research has examined factors that may influence the relation between cigarette smoking level and sleep onset latency among adolescents. One factor that may be particularly important in this regard is anxiety sensitivity (AS). The current study examined whether cigarette smoking level interacted with AS in its association with sleep onset latency among 94 adolescent (Mage = 15.72) cigarette smokers. As hypothesized, AS interacted with smoking level to relate to sleep onset latency, even after controlling for age and gender. This relation was specific to sleep onset latency as opposed to other types of sleep disturbances, and that adolescents who smoked at higher levels tended to go to sleep later and wake up later than adolescents who smoked at relatively lower levels.     

Low intensity pain reported during elicitation of the H-reflex: no effects of trait anxiety and high intensity cycling exercise

The aims of the experiment were to describe the intensity of pain perceptions experienced in response to elicitation of the H-reflex and examine the roles of trait anxiety and high intensity cycling exercise on those pain responses. Males (n=24) with high (n=12) or low (n=12) trait anxiety provided ratings of pain intensity in response to elicitation of the H-reflex before and after: resting for 20 min, cycling for 20 min at a high intensity (75% of peak oxygen consumption), or cycling for 20 min at a low intensity (40% of peak oxygen consumption). The results indicated that (i). low intensity pain was experienced during the elicitation of the H-reflex; (ii). high trait anxious males did not report more pain during the elicitation of the H-reflex, and (iii). there was no effect of high intensity cycling exercise on reducing post-exercise pain intensity associated with H-reflex elicitation. It is concluded that elicitation of the H-reflex reliably results in a low intensity pain.     

Depression in relation to anxiety, obsessionality and phobia among neurosurgical patients with a primary brain tumor: a 1-year follow-up study

Depression is found to be present in up to 44% of brain tumor patients during their illness process. Anxiety as a comorbid psychiatric disorder with depression has formerly been studied, but phobia or obsessive-compulsive symptoms among brain tumor patients have not yet been noticed.By using a clinical prospective database of primary brain tumor patients (n = 77) we studied the level of depression, anxiety, obsessionality (traits and symptoms) and phobic anxiety symptoms. Psychiatric symptoms were assessed before tumor operation as well as at three months and at one year after operation. The presence of comorbid anxiety, obsessionality and phobic anxiety symptoms was assessed before operation and at follow-ups in depressed and non-depressed patients, separately.Before tumor operation 16% of the patients had depression according to Beck Depression Inventory (BDI), while 10% had depression at three months and 15% at one year after operation.The depressed patients had statistically significantly higher anxiety scores and phobic scores at all three measurement points compared to corresponding scores among non-depressed brain tumor patients. The mean obsessionality scores among depressed brain tumor patients were significantly higher when measured before operation and at one year after the operation compared to non-depressed patients.To our knowledge, this is the first study so far in which comorbidity of psychiatric symptoms has been shown among depressive brain tumor patients. Concurrent comorbid conditions have been shown to be associated with increased severity, morbidity and chronicity of depression. It is recommended that treatment of depressive patients complicated with comorbid psychiatric disorders be planned by psychiatric units.     

Short-term pain for long-term gain: The role of experiential avoidance in the relation between anxiety sensitivity and emotional distress

Research has provided evidence of an interactive effect between anxiety sensitivity (AS) and experiential avoidance (EA) in predicting both anxiety and posttraumatic stress (PTS) symptomatology. Additionally, theory suggests that EA alleviates distress in the short-term, but exacerbates it in the long-term. The present cross-sectional study was developed to replicate the noted findings and examine the interaction (EA × AS) in the context of an emotionally evocative task. It was predicted that, among high AS participants, high EA would (a) reduce the likelihood of experiencing short-term increases in negative affect following the task, and (b) increase the likelihood of anxiety and PTS symptomatology. Undergraduate participants (N = 199) completed a battery of self-report questionnaires and an emotionally evocative task. As predicted, positive associations were observed between AS and both anxiety and PTS symptoms, but only among high EA participants. Additionally, AS only predicted increases in negative affect following the emotionally evocative task for those with lower levels of EA, thus providing empirical evidence of the affect regulatory function of EA among those who fear anxiety-related bodily sensations. These findings help to elucidate the motives for the use of avoidance among those high in AS. Conceptual and clinical implications are discussed.     

Treatment inadequacy in primary and specialized care patients with depressive and/or anxiety disorders

All guidelines on major depressive disorder (MDD) and anxiety disorders recommend pharmacotherapy and/or psychological treatment for moderate to severe disease. The aim of this cross-sectional study was to investigate treatment inadequacy, both pharmacological and psychological, in a large naturalistic cohort of subjects with MDD and anxiety disorders from the Netherlands Study of Depression and Anxiety. All subjects with a current 6-month diagnosis were included (n=1662). Demographic data, clinical features and actual medication use were assessed in face-to-face interviews. In moderate to severe MDD, 43% of the subjects were not treated sufficiently with antidepressants or psychological treatment. In primary health care patients, this undertreatment was 70%. In moderate to severe anxiety disorders, 44% of the subjects were not treated sufficiently with antidepressants, benzodiazepines or psychological treatment. Among antidepressant users with moderate to severe MDD, 21% of the pharmacotherapy was inadequate with respect to drug choice, dose and every day use. Undertreatment and pharmacotherapeutic inadequacy are common in moderate to severe MDD and anxiety disorders. Both are more pronounced in primary care than in specialized care. This may be partly due to differences in disease recognition and help seeking behaviour.     

Distress tolerance in OCD and anxiety disorders,and its relationship with anxiety sensitivity and intolerance of uncertainty

There is a growing interest in the role of distress tolerance (i.e., the capacity to withstand negative emotions) in the onset and maintenance of anxiety. However, both empirical and theoretical knowledge regarding the role of distress tolerance in the anxiety disorders is relatively under examined. Accumulating evidence supports the relationship between difficulties tolerating distress and anxiety in nonclinical populations; however, very few studies have investigated distress tolerance in participants with diagnosed anxiety disorders. Individuals with social anxiety disorder (SAD), generalized anxiety disorder (GAD), panic disorder with and without agoraphobia (PD/A) and obsessive-compulsive disorder (OCD) completed measures of distress tolerance (DT), conceptually related measures (i.e., anxiety sensitivity (AS), intolerance of uncertainty (IU)), and anxiety symptom severity. Results showed that DT was negatively associated with AS and IU. DT was correlated with GAD, SAD and OCD symptoms, but not PD/A symptoms, in individuals with those respective anxiety disorders. DT was no longer a significant predictor of OCD or anxiety disorder symptom severity when AS and IU were also taken into account. There were no between group differences on DT across OCD and the anxiety disorder groups. Implications for the role of distress tolerance in anxiety pathology are discussed.