Measurement of anxious traits: a contemporary review and synthesis

Patient-Reported Outcomes Measurement Information System Outcome Measures and Mental Health in Orthopaedic Trauma Patients During Early Recovery

OBJECTIVES

This study explored the relationships between negative affective states (depression and anxiety), physical/functional status, and emotional well-being during early treatment and later in recovery after orthopaedic trauma injury.

DESIGN

This was a secondary observational analysis from a randomized controlled study performed at a Level-1 trauma center.

PATIENTS

Patients with orthopaedic trauma (N = 101; 43.5 ± 16.4 years, 40.6% women) were followed from acute care to week 12 postdischarge.

MAIN OUTCOME MEASURES

Patient-reported outcomes measurement information system measures of Physical Function, Psychosocial Illness Impact-Positive and Satisfaction with Social Roles and Activities and the Beck Depression Inventory-II and the State-Trait Anxiety Inventory were administered during acute care and at weeks 2, 6, and 12. Secondary measures included hospital length of stay, adverse readmissions, injury severity, and surgery number.

RESULTS

At week 12, 20.9% and 35.3% of patients reported moderate-to-severe depression (Beck Depression Inventory-II score ≥20 points) and anxiety (State-Anxiety score ≥40 points), respectively. Depressed patients had greater length of stay, complex injuries, and more readmissions than those without. The study sample improved patient-reported outcomes measurement information system T-scores for Physical Function and Satisfaction with Social Roles and Activities by 40% and 22.8%, respectively (P < 0.0001), by week 12. Anxiety attenuated improvements in physical function. Both anxiety and depression were associated with lower Psychosocial Illness Impact-Positive scores by week 12.

CONCLUSIONS

Although significant improvements in patient-reported physical function and satisfaction scores occurred in all patients, patients with depression or anxiety likely require additional psychosocial support and resources during acute care to improve overall physical and emotional recovery after trauma.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Developmental effects of stimulus gender and the social context in which it appears on threat detection

This study used a hands-free eye-tracking visual search (VS) task to examine possible developmental differences in target detection. Thirty-two young adults and 27 youth were asked to detect a fearful face (male or female) among a crowd of either neutral or happy faces. Fearful male faces were detected faster than fearful female faces, but only by young adults and only when displayed among neutral faces. Additionally, young adults had shorter scanpath lengths prior to the target detection. Finally, a strong negative correlation emerged between age and detection speed for a male target in a neutral crowd. Using this age-matched VS task, the study found age differences in the way individuals detect a threat in a social-related contextual environment, pointing to subtle differences in the emotion-attention interplay during the course of development. Statement of contribution What is already known on this subject? Visual search of threat detection is critical for survival, specifically regarding expressive faces. Visual search efficiency is affected by both stimulus-driven and higher goal-directed processes. Stimuli and contextual features affect threat speed detection. What does this study add? A novel task was designed to examine age-related differences in visual search. Specific stimuli gender and contextual features yielded age-related differences in threat detection. The study further demonstrates the subtle developmental differences in attention-emotion interaction.

Spiritual Factors Predict State and Trait Anxiety

This research study was designed to examine the effect of spiritual well-being and spirituality on state and trait anxiety. Two hundred and thirty-eight adults in the USA were surveyed using the State-Trait Anxiety Inventory, Duke University Religion Index, Spiritual Well-Being Scale, and Participant Questionnaire. Results indicate that spiritual well-being can predict 39.1 % of an adult's state anxiety and 37.9 % of trait anxiety. Furthermore, frequency of religious attendance, frequency of private religious activity, and intrinsic religiosity can predict 6.2 % of an adult's state anxiety and 8.6 % of trait anxiety. Recommendations for researchers and implications for clinicians are discussed.

Anxiety, locus of control and sociodemographic factors associated with adherence to an annual clinical skin monitoring: a cross-sectional survey among 1000 high-risk French patients involved in a pilot-targeted screening programme for melanoma

OBJECTIVE

The aim of the study was to assess whether adherence to annual clinical skin monitoring is dependent on patient sociodemographic characteristics or personality traits.

DESIGN

The study was a questionnaire survey.

SETTING AND PARTICIPANTS

Data were collected between February and April 2013 in a sample of 1000 patients at high risk of melanoma who participated in a pilot-targeted screening programme in western France.

OUTCOME MEASURES

Sociodemographic data, overall anxiety level (State-Trait Anxiety Inventory questionnaire), locus of control (Multidimensional Health Locus of Control scale) and levels of anxiety specifically associated with screening and melanoma were collected. Actual participation in the skin monitoring examination was reported by 78 general practitioner investigators.

STATISTICAL ANALYSIS

Statistical analysis was performed using R statistical software. Factors associated with non-adherence were identified by multivariate analysis.

RESULTS

Our analysis included 687 responses (526 adherent patients and 161 non-adherent patients). Non-adherence was higher in younger patients and in men (OR=0.63 (0.41-0.99)). Viewing health status as dependent on external persons (OR=0.90, 95% CI 0.83 to 0.97) or determined by chance (OR=0.89, 95% CI 0.80 to 0.98) and overall anxiety (OR=0.98, 95% CI 0.97 to 0.99) were also factors associated with non-adherence. In contrast, there was no link between anxiety specifically associated with the screening performed or melanoma and patient adherence to monitoring. Adherence was higher in married patients (OR=1.68 95% CI 1.08 to 2.60).

CONCLUSIONS

The results of this study suggest that sociodemographic and psychological characteristics should be considered when including patients at elevated risk of melanoma in a targeted screening programme.

TRIAL REGISTRATION NUMBER

NCT01610531; Post-results.

Modifiable and non-modifiable characteristics associated with sleep disturbance in oncology outpatients during chemotherapy

PURPOSE

In a sample of outpatients with breast, gastrointestinal, gynecological, and lung cancer who received at least two cycles of chemotherapy (CTX), the purposes were to evaluate for inter-individual differences in the severity of sleep disturbance and determine which demographic, clinical, and symptom characteristics were associated with initial levels as well as the trajectories of sleep disturbance.

METHODS

A total of 1331 patients completed study questionnaires in their homes, at six time points over two cycles of CTX (prior to CTX administration, approximately 1 week after CTX administration, and approximately 2 weeks after CTX administration). Questionnaires included demographic, clinical, and symptom assessments (i.e., General Sleep Disturbance Scale, Lee Fatigue Scale, Center for Epidemiological Studies-Depression Scale, Spielberger State-Trait Anxiety Inventories, Attentional Function Index). Hierarchical linear modeling based on full maximum likelihood estimation was performed.

RESULTS

Characteristics associated with higher initial levels of sleep disturbance included higher body mass index, poorer functional status, higher trait anxiety, higher depressive symptoms, and higher evening fatigue. Characteristics associated with the worse trajectories of sleep disturbance were higher levels of education and higher sleep disturbance at enrollment. Characteristics associated with both higher initial levels and worse trajectories of sleep disturbance were higher morning fatigue and worse attentional function.

CONCLUSIONS

A large amount of inter-individual variability exists in sleep disturbance during CTX. The modifiable and non-modifiable characteristics found in this study can be used to identify higher risk patients and provide earlier interventions to reduce sleep disturbance.

Modeling Trait Anxiety: From Computational Processes to Personality

Computational methods are increasingly being applied to the study of psychiatric disorders. Often, this involves fitting models to the behavior of individuals with subclinical character traits that are known vulnerability factors for the development of psychiatric conditions. Anxiety disorders can be examined with reference to the behavior of individuals high in "trait" anxiety, which is a known vulnerability factor for the development of anxiety and mood disorders. However, it is not clear how this self-report measure relates to neural and behavioral processes captured by computational models. This paper reviews emerging computational approaches to the study of trait anxiety, specifying how interacting processes susceptible to analysis using computational models could drive a tendency to experience frequent anxious states and promote vulnerability to the development of clinical disorders. Existing computational studies are described in the light of this perspective and appropriate targets for future studies are discussed.

Relationships among pain intensity, pain-related distress, and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis

The current study aimed to examine the relationships between movement and resting pain intensity, pain-related distress, and psychological distress in participants scheduled for total knee arthroplasty (TKA). This study examined the impact of anxiety, depression, and pain catastrophizing on the relationship between pain intensity and pain-related distress. Data analyzed for the current study (N = 346) were collected at baseline as part of a larger Randomized Controlled Trial investigating the efficacy of TENS for TKA (TANK Study). Participants provided demographic information, pain intensity and pain-related distress, and completed validated measures of depression, anxiety, and pain catastrophizing. Only 58% of the sample reported resting pain >0 while 92% of the sample reported movement pain >0. Both movement and resting pain intensity correlated significantly with distress (r_s = .86, p < .01 and .79, p < .01, respectively). About three quarters to two thirds of the sample (78% for resting pain and 65% for movement pain) reported different pain intensity and pain-related distress. Both pain intensity and pain-related distress demonstrated significant relationships with anxiety, depression, and catastrophizing. Of participants reporting pain, those reporting higher anxiety reported higher levels of distress compared to pain intensity. These findings suggest that anxious patients may be particularly distressed by movement pain preceding TKA. Future research is needed to investigate the utility of brief psychological interventions for pre-surgical TKA patients.

Trait and state anxiety reduce the mere exposure effect

The mere exposure effect refers to an affective preference elicited by exposure to previously unfamiliar items. Although it is a well-established finding, its mechanism remains uncertain, with some positing that it reflects affective processes and others positing that it reflects perceptual or motor fluency with repeated items. Here we examined whether individual differences in trait and state anxiety, which have been associated with the experience of emotion, influence the mere exposure effect. Participants' trait (Study 1) and state (Study 2) anxiety were characterized with the State-Trait Anxiety Inventory. Greater trait and state anxiety correlated with greater negative affect and lesser positive affect. In both experiments, greater anxiety was associated with a reduced mere exposure effect. Measures of fluency (response times at study and test) were unrelated to the mere exposure effect. These findings support the role of affective processes in the mere exposure effect, and offer a new insight into the nature of anxiety such that anxiety is associated with a reduced experience of positive affect typically associated with familiarity.

Reliability, validity and sensitivity of a computerized visual analog scale measuring state anxiety

BACKGROUND AND OBJECTIVES

Assessment of state anxiety is frequently required in clinical and research settings, but its measurement using standard multi-item inventories entails practical challenges. Such inventories are increasingly complemented by paper-and-pencil, single-item visual analog scales measuring state anxiety (VAS-A), which allow rapid assessment of current anxiety states. Computerized versions of VAS-A offer additional advantages, including facilitated and accurate data collection and analysis, and applicability to computer-based protocols. Here, we establish the psychometric properties of a computerized VAS-A.

METHODS

Experiment 1 assessed the reliability, convergent validity, and discriminant validity of the computerized VAS-A in a non-selected sample. Experiment 2 assessed its sensitivity to increase in state anxiety following social stress induction, in participants with high levels of social anxiety.

RESULTS

Experiment 1 demonstrated the computerized VAS-A's test-retest reliability (r = .44, p < .001); convergent validity with the State-Trait Anxiety Inventory's state subscale (STAI-State; r = .60, p < .001); and discriminant validity as indicated by significantly lower correlations between VAS-A and different psychological measures relative to the correlation between VAS-A and STAI-State. Experiment 2 demonstrated the VAS-A's sensitivity to changes in state anxiety via a significant pre- to during-stressor rise in VAS-A scores (F(1,48) = 25.13, p < .001).

LIMITATIONS

Set-order administration of measures, absence of clinically-anxious population, and gender-unbalanced samples.

CONCLUSIONS

The adequate psychometric characteristics, combined with simple and rapid administration, make the computerized VAS-A a valuable self-rating tool for state anxiety. It may prove particularly useful for clinical and research settings where multi-item inventories are less applicable, including computer-based treatment and assessment protocols. The VAS-A is freely available: http://people.socsci.tau.ac.il/mu/anxietytrauma/visual-analog-scale/.

Overestimation of mortality risk and preoperative anxiety in patients undergoing elective general surgery procedures: a propensity matched analysis

BACKGROUND

Deficiencies in risk communication have been identified in perioperative medicine. Objective measurement of risk overestimation by general surgery patients has not been performed. In addition, it is unknown if surgical risk overestimation is associated with the development of preoperative anxiety. The main objective of the current investigation was to examine the association between overestimation of surgical mortality risk and the development of preoperative anxiety.

METHODS

Patients estimation of surgical morality risk was compared to the actual mortality risk obtained by the American College of Surgeons national database. Preoperative anxiety was evaluated using a validated instrument. Propensity matched analysis was performed to examine an independent association between mortality risk overestimation and preoperative anxiety.

RESULTS

138 patients completed the study. 40 out of 138 (29%) patients overestimated their surgical mortality risk by at least 5%. 31 out of 138 (22%) patients estimated their surgical mortality risk by at least 10%. Patients who overestimated mortality risk (≥5%) were more likely to have postponed the surgery voluntarily, 9 out of 40 (23%) compared to patients who did not overestimate risk, 1 out of 98 (1%), P < 0.001. After propensity matching to control for covariate imbalances, overestimation of mortality risk was associated with the development of preoperative anxiety, OR (95%CI) of 9.5 (2.7-32.9).

CONCLUSIONS

Overestimation of perioperative mortality risk is common in patients undergoing general surgery and it is associated with preoperative anxiety and voluntarily delays of surgical treatment. Improved communication strategies are needed to minimize misleading risk perception in surgical patients.

The psychometric properties of the Cognitive-Somatic Anxiety Questionnaire in Chinese undergraduate students and clinical patients

BACKGROUND

The present study was conducted to develop a Chinese version of the 14-item Cognitive-Somatic Anxiety Questionnaire (CSAQ) and examine its psychometric properties.

METHODS

The original English version of the CSAQ was first translated into Chinese and then backtranslated and modified until cross-language equivalence was established. This version was then completed by 2168 undergraduate students and 289 clinical patients with mental disorder in China. The Mood and Anxiety Symptoms Questionnaire (MASQ) was also administered to students. Confirmatory factor analysis was performed to examine the two-factor construct, and the CSAQ's internal consistency, test-retest reliability, and concurrent and discriminant validity were also evaluated.

RESULTS

The two-factor model (cognitive and somatic) of the CSAQ was confirmed, and the scale showed an adequate model fit in the student and clinical samples. The CSAQ showed adequate internal consistency (student sample: Cronbach's α=0.82, mean inter-item correlation coefficient=0.25; clinical sample: Cronbach's α=0.81, mean inter-item correlation coefficient=0.23) and good stability (2-week test-retest reliability in student sample, 0.84). The coefficient of correlation between CSAQ and overall anxious symptoms MASQ scores among students was 0.64.

CONCLUSIONS

The Chinese version of the CSAQ is a promising instrument for reliable and valid measurement of anxiety in Chinese populations.

Anxiety and speaking in people who stutter: an investigation using the emotional Stroop task

People with anxiety disorders show an attentional bias towards threat or negative emotion words. This exploratory study examined whether people who stutter (PWS), who can be anxious when speaking, show similar bias and whether reactions to threat words also influence speech motor planning and execution. Comparisons were made between 31 PWS and 31 fluent controls in a modified emotional Stroop task where, depending on a visual cue, participants named the colour of threat and neutral words at either a normal or fast articulation rate. In a manual version of the same task participants pressed the corresponding colour button with either a long or short duration. PWS but not controls were slower to respond to threat words than neutral words, however, this emotionality effect was only evident for verbal responding. Emotionality did not interact with speech rate, but the size of the emotionality effect among PWS did correlate with frequency of stuttering. Results suggest PWS show an attentional bias to threat words similar to that found in people with anxiety disorder. In addition, this bias appears to be contingent on engaging the speech production system as a response modality. No evidence was found to indicate that emotional reactivity during the Stroop task constrains or destabilises, perhaps via arousal mechanisms, speech motor adjustment or execution for PWS.

EDUCATIONAL OBJECTIVES

The reader will be able to: (1) explain the importance of cognitive aspects of anxiety, such as attentional biases, in the possible cause and/or maintenance of anxiety in people who stutter, (2) explain how the emotional Stroop task can be used as a measure of attentional bias to threat information, and (3) evaluate the findings with respect to the relationship between attentional bias to threat information and speech production in people who stutter.

Psychosocial and organizational work environment of nurse managers and self-reported depressive symptoms: cross-sectional analysis from a cohort of nurse managers

OBJECTIVES

The association between depressive symptoms and psycho-organisational work environment has been established in the literature. Some studies have evaluated depressive symptoms in healthcare workers, but little research has been carried out among nurse managers. The aim of the study is to evaluate the depressive symptoms prevalence among nurse managers' population and work environment factors.

MATERIAL AND METHODS

A descriptive correlational research design was used. Data were collected from 296 nurse managers in five hospitals in the eastern area of France between 2007 and 2008. Health outcomes were evaluated by measuring depressive symptoms (CES-D scale), the exposure data by assessing psycho-organisational work environment with effort-reward imbalance-model of Siegrist. Multiple logistic regressions were used to describe the strength of the association between depressive symptoms and effort-reward imbalance adjusted for personal and occupational characteristics of the nurse managers.

RESULTS

Among the nurse managers, a third had depressive symptoms, and 18% presented an effort-reward imbalance (ratio: ≥ 1). A significant association was found between depressive symptoms and effort-reward imbalance (OR = 10.81, 95% CI: 5.1-23, p < 10(-3)), and with esteem as a reward (OR = 3.21, 95% CI: 1.6-6.3, p < 10(-2)).

CONCLUSION

In view of the hierarchical situation of nurse managers and their primary roles in hospitals, it is necessary to take prevention measures to improve their work environment and health.

Regulator of calcineurin 1 modulates expression of innate anxiety and anxiogenic responses to selective serotonin reuptake inhibitor treatment

Regulator of calcineurin 1 (RCAN1) controls the activity of calcium/calmodulin-dependent phosphatase calcineurin (CaN), which has been implicated in human anxiety disorders. Previously, we reported that RCAN1 functioned as an inhibitor of CaN activity in the brain. However, we now find enhanced phosphorylation of a CaN substrate, cAMP response element-binding protein (CREB), in the brains of Rcan1 knock-out (KO) mice. Consistent with enhanced CREB activation, we also observe enhanced expression of a CREB transcriptional target, brain-derived neurotrophic factor (BDNF) in Rcan1 KO mice. We also discovered that RCAN1 deletion or blockade of RCAN1-CaN interaction reduced CaN and protein phosphatase-1 localization to nuclear-enriched protein fractions and promoted CREB activation. Because of the potential links between CREB, BDNF, and anxiety, we examined the role of RCAN1 in the expression of innate anxiety. Rcan1 KO mice displayed reduced anxiety in several tests of unconditioned anxiety. Acute pharmacological inhibition of CaN rescued these deficits while transgenic overexpression of human RCAN1 increased anxiety. Finally, we found that Rcan1 KO mice lacked the early anxiogenic response to the selective serotonin reuptake inhibitor (SSRI) fluoxetine and had improved latency for its therapeutic anxiolytic effects. Together, our study suggests that RCAN1 plays an important role in the expression of anxiety-related and SSRI-related behaviors through CaN-dependent signaling pathways. These results identify RCAN1 as a mediator of innate emotional states and possible therapeutic target for anxiety.