Laura D. Kubzansky

Anxiety disorders and comorbid medical illness

OBJECTIVE To provide an overview of the role of anxiety disorders in medical illness. METHOD The Anxiety Disorders Association of America held a multidisciplinary conference from which conference leaders and speakers reviewed presentations and discussions, considered literature on prevalence, comorbidity, etiology and treatment, and made recommendations for research. Irritable bowel syndrome (IBS), asthma, cardiovascular disease (CVD), cancer and chronic pain were reviewed. RESULTS A substantial literature supports clinically important associations between psychiatric illness and chronic medical conditions. Most research focuses on depression, finding that depression can adversely affect self-care and increase the risk of incident medical illness, complications and mortality. Anxiety disorders are less well studied, but robust epidemiological and clinical evidence shows that anxiety disorders play an equally important role. Biological theories of the interactions between anxiety and IBS, CVD and chronic pain are presented. Available data suggest that anxiety disorders in medically ill patients should not be ignored and could be considered conjointly with depression when developing strategies for screening and intervention, particularly in primary care. CONCLUSIONS Emerging data offer a strong argument for the role of anxiety in medical illness and suggest that anxiety disorders rival depression in terms of risk, comorbidity and outcome. Research programs designed to advance our understanding of the impact of anxiety disorders on medical illness are needed to develop evidence-based approaches to improving patient care.

Going to the heart of the matter: do negative emotions cause coronary heart disease?

OBJECTIVE Negative emotions, such as anger, anxiety, and depression, have emerged as potentially important risk factors for coronary heart disease. The purpose of this article is to consider the nature and function of emotions, to review epidemiological evidence for an association between the three negative emotions and coronary heart disease (CHD), to discuss briefly the mechanisms by which emotions may be linked to CHD, and to consider this evidence in light of theoretical insights provided by mainstream psychological research on emotions. METHODS We collected articles published between 1980 and 1998 on the relationship between each negative emotion and CHD. We also collected review articles or chapters published during the same time period that considered mechanisms by which emotions may increase CHD risk. We used a qualitative approach to review the published literature. RESULTS Evidence that anxiety is involved in the onset of CHD is strongest, whereas evidence for an association between anger and CHD is limited but suggestive. Although depression has consistently been linked to mortality following a myocardial infarction, evidence for its role in the onset of coronary disease is quite mixed. Numerous unresolved issues leave our current understanding of the emotion-health relationship incomplete. Psychological theories of emotion are considered to help address gaps in our knowledge. CONCLUSION Growing evidence indicates that negative emotions may influence the development of CHD. The focused and specific consideration of negative emotions and their possible role in the etiology of CHD gives insight into current knowledge and suggests important directions for future research.

Is Worrying Bad for Your Heart?: A Prospective Study of Worry and Coronary Heart Disease in the Normative Aging Study

BACKGROUND Worry is an important component of anxiety, which recent work suggests is related to increased incidence of coronary heart disease (CHD). Chronic worry has also been associated with decreased heart rate variability. We hypothesized that high levels of worry may increase CHD risk. METHOD AND RESULTS We examined prospectively the relationship of worry with CHD incidence in the Normative Aging Study, an ongoing cohort of older men. In 1975, 1759 men free of diagnosed CHD completed a Worries Scale, indicating the extent to which they worried about each of five worry domains: social conditions, health, financial, self-definition, and aging. During 20 years of follow-up, 323 cases of incident CHD occurred: 113 cases of nonfatal myocardial infarction (MI); 86 cases of fatal CHD; and 124 cases of angina pectoris. Worry about social conditions was the domain most strongly associated with incident CHD. Compared with men reporting the lowest levels of social conditions worry, men reporting the highest levels had multivariate adjusted relative risks of 2.41 (95% CI, 1.40 to 4.13) for nonfatal MI and 1.48 (95% CI, 0.99 to 2.20) for total CHD (nonfatal MI and fatal CHD). A dose-response relation was found between level of worry and both nonfatal MI (P for trend, .002) and total CHD (P for trend, .04). CONCLUSIONS These results suggest that high levels of worry in specific domains may increase the risk of CHD in older men.

Childhood IQ and adult mental disorders: a test of the cognitive reserve hypothesis.

OBJECTIVE Cognitive reserve has been proposed as important in the etiology of neuropsychiatric disorders. However, tests of the association between premorbid IQ and adult mental disorders other than schizophrenia have been limited and inconclusive. The authors tested the hypothesis that low childhood IQ is associated with increased risk and severity of adult mental disorders. METHOD Participants were members of a representative 1972-1973 birth cohort of 1,037 males and females in Dunedin, New Zealand, who were followed up to age 32 with 96% retention. WISC-R IQ was assessed at ages 7, 9, and 11. Research diagnoses of DSM mental disorders were made at ages 18, 21, 26, and 32. RESULTS Lower childhood IQ was associated with increased risk of developing schizophrenia spectrum disorder, adult depression, and adult anxiety. Lower childhood IQ was also associated with greater comorbidity and with persistence of depression; the association with persistence of generalized anxiety disorder was nearly significant. Higher childhood IQ predicted increased risk of adult mania. CONCLUSIONS Lower cognitive reserve, as reflected by childhood IQ, is an antecedent of several common psychiatric disorders and also predicts persistence and comorbidity. Thus, many patients who seek mental health treatment may have lower cognitive ability; this should be considered in prevention and treatment planning.

The Heart's Content: The Association Between Positive Psychological Well-Being and Cardiovascular Health

This review investigates the association between positive psychological well-being (PPWB) and cardiovascular disease (CVD). We also consider the mechanisms by which PPWB may be linked with CVD, focusing on the health behaviors (e.g., smoking, alcohol consumption, physical activity, sleep quality and quantity, and food consumption) and biological functions (e.g., cardiovascular, inflammatory, and metabolic processes) that are most relevant for cardiovascular health. Because PPWB is a broad concept, not all aspects of PPWB may be associated with cardiovascular health. Thus, we distinguish between eudaimonic well-being, hedonic well-being, optimism, and other measures of well-being when reviewing the literature. Findings suggest that PPWB protects consistently against CVD, independently of traditional risk factors and ill-being. Specifically, optimism is most robustly associated with a reduced risk of cardiovascular events. In general, PPWB is also positively associated with restorative health behaviors and biological function and inversely associated with deteriorative health behaviors and biological function. Cardiovascular health is more consistently associated with optimism and hedonic well-being than with eudaimonic well-being, although this could be due in part to more limited evidence being available concerning eudaimonic well-being. Some similarities were also evident across different measures of PPWB, which is likely due to measurement overlap. A theoretical context for this research is provided, and suggestions for future research are given, including the need for additional prospective investigations and research that includes multiple constructs of psychological well-being and ill-being.

Is the glass half empty or half full? A prospective study of optimism and coronary heart disease in the normative aging study.

Objective A sense of optimism, which derives from the ways individuals explain causes of daily events, has been shown to protect health, whereas pessimism has been linked to poor physical health. We examined prospectively the relationship of an optimistic or pessimistic explanatory style with coronary heart disease incidence in the Veterans Affairs Normative Aging Study, an ongoing cohort of older men. Methods and Results In 1986, 1306 men completed the revised Minnesota Multiphasic Personality Inventory, from which we derived the bipolar revised Optimism-Pessimism Scale. During an average of 10 years of follow-up, 162 cases of incident coronary heart disease occurred: 71 cases of incident nonfatal myocardial infarction, 31 cases of fatal coronary heart disease, and 60 cases of angina pectoris. Compared with men with high levels of pessimism, those reporting high levels of optimism had multivariate-adjusted relative risks of 0.44 (95% confidence interval = 0.26–0.74) for combined nonfatal myocardial infarction and coronary heart disease death and 0.45 (95% confidence interval = 0.29–0.68) for combined angina pectoris, nonfatal myocardial infarction, and coronary heart disease death. A dose-response relation was found between levels of optimism and each outcome (p value for trend, .002 and .0004, respectively). Conclusions These results suggest that an optimistic explanatory style may protect against risk of coronary heart disease in older men.

Anxiety and coronary heart disease: A synthesis of epidemiological, psychological, and experimental evidence

The purpose of this review is to examine the epidemiological, psychological, and experimental evidence for an association between anxiety and coronary heart disease (CHD). Papers published during the years 1980–1996 on anxiety and CHD and relevant publications from earlier years were selected for this review. Epidemiologic evidence suggests that anxiety may be a risk factor for the development of CHD. Chronic anxiety may increase the risk of CHD by: (a) influencing health behaviors (e.g. smoking); (b) promoting atherogenesis (e.g. via increased risk of hypertension); and (c) triggering fatal coronary events, either through arrhythmia, plaque rupture, coronary vasospasm, or thrombosis. Electrophysiologic evidence is particularly compelling: anxiety appears to be associated with abnormal cardiac autonomic control, which may indicate increased risk of fatal ventricular arrhythmias. The strength, consistency, and dose-response gradient of the association between anxiety and CHD, together with the biologic plausibility of the experimental evidence, suggest that anxiety may contribute to risk of CHD and that the relationship warrants further investigation.

Synergistic Effects of Traffic-Related Air Pollution and Exposure to Violence on Urban Asthma Etiology

Background Disproportionate life stress and consequent physiologic alteration (i.e., immune dysregulation) has been proposed as a major pathway linking socioeconomic position, environmental exposures, and health disparities. Asthma, for example, disproportionately affects lower-income urban communities, where air pollution and social stressors may be elevated. Objectives We aimed to examine the role of exposure to violence (ETV), as a chronic stressor, in altering susceptibility to traffic-related air pollution in asthma etiology. Methods We developed geographic information systems (GIS)–based models to retrospectively estimate residential exposures to traffic-related pollution for 413 children in a community-based pregnancy cohort, recruited in East Boston, Massachusetts, between 1987 and 1993, using monthly nitrogen dioxide measurements for 13 sites over 18 years. We merged pollution estimates with questionnaire data on lifetime ETV and examined the effects of both on childhood asthma etiology. Results Correcting for potential confounders, we found an elevated risk of asthma with a 1-SD (4.3 ppb) increase in NO2 exposure solely among children with above-median ETV [odds ratio (OR) = 1.63; 95% confidence interval (CI), 1.14–2.33)]. Among children always living in the same community, with lesser exposure measurement error, this association was magnified (OR = 2.40; 95% CI, 1.48–3.88). Of multiple exposure periods, year-of-diagnosis NO2 was most predictive of asthma outcomes. Conclusions We found an association between traffic-related air pollution and asthma solely among urban children exposed to violence. Future studies should consider socially patterned susceptibility, common spatial distributions of social and physical environmental factors, and potential synergies among these. Prospective assessment of physical and social exposures may help determine causal pathways and critical exposure periods.

Positive emotion and health : Going beyond the negative

This study examined the relationships between positive emotions and health. Two positive emotions were considered, hope and curiosity, in conjunction with 3 physician-diagnosed disease outcomes: hypertension, diabetes mellitus, and respiratory tract infections. Medical data were abstracted over a 2-year period from 1,041 patient records from a multispecialty medical practice, and emotions were assessed through a mailed questionnaire. Across 3 disease outcomes, higher levels of hope were associated with a decreased likelihood of having or developing a disease. Higher levels of curiosity were also associated with decreased likelihood of hypertension and diabetes mellitus. Results suggest that positive emotion may play a protective role in the development of disease.

Socioeconomic status, hostility, and risk factor clustering in the normative aging study: Any help from the concept of allostatic load?

ObjectiveTo examine the relationships between socioeconomic status (SES), psychosocial vulnerability (hostility), and allostatic load. Allostatic load refers to the cumulative physiological cost of adaptation to stress.MethodWe examined the relationships, between SES (as measured by educational attainment), hostility, and allostatic load in the Normative Aging Study, a longitudinal study of community-dwelling men aged 21 to 80 years and free of known chronic medical conditions at entry in the 1960s. In 1986, the revised Minnesota Multiphasic Personality Inventory was administered by mail, from which a hostility measure was derived by summing the scores from three Cook-Medley subscales: Hostile Affect, Hostile Attribution, Aggressive Responding. An index of allostatic load was constructed from data collected during physical exams conducted between 1987 and 1990 (i.e. measures reflecting “wear and tear” on the cardiovascular, endocrine, and metabolic systems). Cross-sectional relationships between education, hostility, and allostatic load were examined in 818 men.ResultsSeparate linear regression analyses indicated that lower levels of educational attainment and greater hostility were both associated with higher allostatic load scores (p<.05 andp<.01, respectively). Less education was also associated with higher hostility (p<.001). When allostatic load was regressed simultaneously on education and hostility, the effect of education was attenuated, while hostility (p<.05) maintained an independent affect.ConclusionsOur findings suggest that lower levels of education and greater hostility are associated with greater “wear and tear” on the body. The effects of education on allostatic load may be mediated by hostility.