Anticipatory anxiety in moderately to highly-anxious oral surgery patients as a screening model for anxiolytics: evaluation of alprazolam

Development and psychometric validity of the perioperative anxiety scale-7 (PAS-7)

BACKGROUND

Preoperative anxiety is a common psychological reaction in perioperative patients. The absence of a valid measurement tool hinders the evaluation of interventions to treat preoperative anxiety in China. This study aims to develop the Perioperative Anxiety Scale-7 (PAS-7) and test its reliability, validity, and cut-off value.

METHODS

A total of 280 patients over 16 years old (M = 55.1, SD = 14.3) who were undergoing elective surgery were recruited to complete the PAS-7 and the Generalized Anxiety Disorder-7 scale (GAD-7) one day before surgery.

RESULTS

The PAS-7 included seven items divided into two dimensions: mental anxiety and somatic anxiety. These two dimensions could explain 74.294% of the population variance. The internal consistency of each dimension ranged from 0.761-0.933. The confirmatory factor analysis showed that the model fit of the scale was good (χ²= 34.798, df = 13, χ²/df = 2.677, CFI = 0.949, TLI = 0.918, SRMR = 0.057, RMSEA = 0.115). The correlations between the GAD-7 and each dimension and the scale's total score were significant (0.711-0.789). A cut-off score of 8, maximizing the Youden Index, yielded a sensitivity of 75% and a specificity of 84.6% (95% CI: 0.88 ~ 0.97).

CONCLUSIONS

The PAS-7 had good reliability and validity and could be used as an effective tool to evaluate preoperative anxiety.

Heart Rate Variability in Dental Science

Dentistry has made progress as a profession by integration with both medicine and other human sciences, especially when it uses empirical metrics to study process and outcome variables. Notably, progress in our understanding of genomic, biomic, and other molecular biological phenomena has been valuable. As has been identified by Drury (1, 2), it is proposed in this commentary that the inclusion of heart rate variability (HRV) as a biomarker of health may further this integrative progress. HRV is derived by various linear and non-linear statistical analyses of the R-R, beat-to-beat ECG interval in microseconds. Over twenty three thousand reports are identified in a recent PubMed search of the term heart rate variability, most of which demonstrate HRV's sensitivity to a wide diversity of physical and psychosocial pathologies. The small literature of dental use of HRV in both assessment and treatment will be selectively reviewed and relevant exemplars for other important health applications of HRV will be discussed. This will lead to a proposed agenda for researching HRV's value to professional dentistry as a human health and wellness profession.

Trait vs. state anxiety in different threatening situations

OBJECTIVE

Anxiety as a uni- or multidimensional construct has been under discussion. The unidimensional approach assumes that there is a general trait anxiety, which predisposes the individuals to increases in state anxiety in various threatening situations. In this case, there should be a correlation between state and trait anxiety in any situation of threat. Therefore, the aim of this study was to investigate the correlation between trait and state anxiety in participants exposed to two different anxiogenic situations: interpersonal threat (Video-Monitored Stroop Test - VMST) and physical threat (third molar extraction - TME).

METHODS

Participants with various levels of trait anxiety (general trait: State-Trait Anxiety Inventory - STAI, Hospital Anxiety and Depression Scale; specific trait: Social Phobia Inventory, Dental Anxiety Scale) had their anxious state evaluated (STAI, self-evaluation of tension level, heart rate, electromyogram activity) before, during and after the VMST or the TME.

RESULTS

In VMST, trait anxiety correlated to state anxiety (psychological parameters) in all test phases. However, in TME, the only trait measurement that correlated to state anxiety (psychological parameters) was the Dental Anxiety Scale.

CONCLUSION

Trait anxiety correlates positively to state anxiety in situations of interpersonal threat, but not of physical threat.

Autonomic dysfunction in mild cognitive impairment: evidence from power spectral analysis of heart rate variability in a cross-sectional case-control study

BACKGROUND

Mild cognitive impairment (MCI) is set to become a major health problem with the exponential ageing of the world's population. The association between MCI and autonomic dysfunction, supported by indirect evidence and rich with clinical implications in terms of progression to dementia and increased risk of mortality and falls, has never been specifically demonstrated.

AIM

To conduct a comprehensive assessment of autonomic function in subjects with MCI by means of power spectral analysis (PSA) of heart rate variability (HRV) at rest and during provocative manoeuvres.

METHODS

This cross-sectional study involved 80 older outpatients (aged ≥ 65) consecutively referred to a geriatric unit and diagnosed with MCI or normal cognition (controls) based on neuropsychological testing. PSA was performed on 5-minute electrocardiographic recordings under three conditions--supine rest with free breathing (baseline), supine rest with paced breathing at 12 breaths/minute (parasympathetic stimulation), and active standing (orthosympathetic stimulation)--with particular focus on the changes from baseline to stimulation of indices of sympathovagal balance: normalized low frequency (LFn) and high frequency (HFn) powers and the LF/HF ratio. Blood pressure (BP) was measured at baseline and during standing. Given its exploratory nature in a clinical population the study included subjects on medications with a potential to affect HRV.

RESULTS

There were no significant differences in HRV indices between the two groups at baseline. MCI subjects exhibited smaller physiological changes in all three HRV indices during active standing, consistently with a dysfunction of the orthosympathetic system. Systolic BP after 10 minutes of standing was lower in MCI subjects, suggesting dysautonomia-related orthostatic BP dysregulation.

CONCLUSIONS

Our study is novel in providing evidence of autonomic dysfunction in MCI. This is associated with orthostatic BP dysregulation and the ongoing follow-up of the study population will determine its prognostic relevance as a predictor of adverse health outcomes.

Psychometric evaluation of a visual analog scale for the assessment of anxiety

BACKGROUND

Fast-acting medications for the management of anxiety are important to patients and society. Measuring early onset, however, requires a sensitive and clinically responsive tool. This study evaluates the psychometric properties of a patient-reported Global Anxiety-Visual Analog Scale (GA-VAS).

METHODS

Data from a double-blind, randomized, placebo-controlled study of lorazepam and paroxetine in patients with Generalized Anxiety Disorder were analyzed to assess the reliability, validity, responsiveness, and utility of the GA-VAS. The GA-VAS was completed at clinic visits and at home during the first week of treatment. Targeted psychometric analyses--test-retest reliabilities, validity correlations, responsiveness statistics, and minimum important differences--were conducted.

RESULTS

The GA-VAS correlates well with other anxiety measures, at Week 4, r=0.60 (p<0.0001) with the Hamilton Rating Scale for Anxiety and r=0.74 (p<0.0001) with the Hospital Anxiety and Depression Scale-Anxiety subscale. In terms of convergent and divergent validity, the GA-VAS correlated -0.54 (p<0.0001), -0.48 (p<0.0001), and -0.68 (p<0.0001) with the SF-36 Emotional Role, Social Function, and Mental Health subscales, respectively, but correlated much lower with the SF-36 physical functioning subscales. Preliminary minimum important difference estimates cluster between 10 and 15 mm.

CONCLUSIONS

The GA-VAS is capable of validly and effectively capturing a reduction in anxiety as quickly as 24 hours post-dose.

Special needs of anxious and phobic dental patients

Dentally anxious and phobic individuals are an underserved special needs population because of their avoidance of treatment. Dentists and their auxiliary staff, with an understanding of the etiologies leading to this potentially serious health obstacle, can enhance the patient's overall quality of life. Techniques are available for dentists to evaluate and treat this critical phenomenon. Through proper information, education, and staff sensitivity, these individuals can be rehabilitated and enjoy improved oral and systemic health.

Clinical evaluation of the Daily Assessment of Symptoms-Anxiety (DAS-A): a new instrument to assess the onset of symptomatic improvement in generalized anxiety disorder

INTRODUCTION

Rapid onset of symptomatic improvement is a desirable characteristic of new generalized anxiety disorder (GAD) treatments. A validated rating scale is needed to assess GAD symptoms during the first days of treatment.

AIMS

To provide clinical data to support the validation of the Daily Assessment of Symptoms-Anxiety (DAS-A), a new instrument to assess onset of symptomatic improvement in GAD.

METHODS

We assessed the ability of the DAS-A to detect onset of symptomatic improvement during the first week of therapy in 169 GAD patients randomized to paroxetine 20 mg/day, lorazepam 4.5 mg/day, or placebo for 4 weeks.

RESULTS

On the primary outcome measure, average change from baseline over the first 6 days of DAS-A assessments, lorazepam (-14.5 +/- 1.8 [LS mean, SE]; P= 0.006 vs. placebo) showed a significant improvement versus placebo (-7.85 +/- 1.7), whereas paroxetine (-8.3 +/- 1.7; P= 0.83 vs. placebo) did not. Lorazepam produced a significant treatment effect on the DAS-A at 24 h (P= 0.0004), whereas paroxetine did not (P= 0.5666). Both active drugs produced statistically significant improvement versus placebo on the DAS-A total change score (last-observation carried forward method; LOCF, endpoint). On the DAS-A total change score (observed cases analysis), lorazepam produced statistically significant improvement versus placebo at weeks 1, 2, and 4 (P < 0.05; no week 3 visit), whereas paroxetine, separated from placebo at weeks 2 and 4 (P < 0.05). Both active drugs produced results on the Hamilton Anxiety Rating Scale (HAM-A) at weeks 1 through 4 that were similar to those found on the DAS-A.

CONCLUSIONS

These data indicate that the DAS-A can detect symptomatic improvement in GAD patients treated with lorazepam during the first week of treatment, and, in a secondary analysis, as early as 24 h.

Treatment anxiety in oral and maxillofacial surgery. Results of a German multi-centre trial

BACKGROUND

Oral and Maxillofacial operations can be extremely frightening treatment situations. General data on this phenomenon should be acquired through a multi-centre trial.

METHOD

A 10-page questionnaire was developed which was answered by 600 oral and maxillofacial patients before individual treatment. Control groups consisted of 800 surgical, dental and general practitioners/internal medicine patients. Twenty six medical practices and hospital departments in 11 German cities were involved in the trial.

RESULTS

Both subjective anxiety assessment by patients and objective testing (State Trait Anxiety Inventory; STAI) indicated a high level of treatment anxiety for oral and maxillofacial treatment situations. Oral and Maxillofacial Surgery (OMFS) patients' scores were significantly higher than those of control groups. Especially younger and female patients, patients treated under local anaesthesia and out-patients showed intensive anxiety. Previous treatment experience in OMFS did not modify test results.

CONCLUSION

Managing perioperative anxiety is still a major challenge in OMFS. Irrespective of technical, pharmacological and surgical advances, developing and establishing stress-reducing and anxiolytic perioperative techniques is of considerable importance for both patients and surgeons.

[Treatment anxiety in oral and maxillofacial surgery]

BACKGROUND

Oral and maxillofacial operations are stressful treatment situations for patients. Specific data on this phenomenon were acquired through a multicenter study.

MATERIAL AND METHODS

A 10-page questionnaire was answered by 600 oral and maxillofacial patients before individual treatment. Control groups consisted of 800 surgical, dental, internal medicine and general practitioner patients. 26 practices and hospital departments in 11 German cities were involved in the study.

RESULTS

Both subjective anxiety assessment by patients and objective measurement (State Trait Anxiety Inventory; STAI) indicated a high level of treatment anxiety for oral and maxillofacial treatment. STAI scores for OMFS patients were significantly higher than in control groups. Especially female patients, patients treated under local anaesthesia and out-department patients showed high anxiety scores. Treatment experience in oral and maxillofacial surgery does not modify anxiety in case of recurrent treatment.

CONCLUSION

Managing perioperative anxiety today is still a major challenge in oral and maxillofacial surgery. Irrespective of technical and pharmacological advances further studies on this topic and the development and establishing of stress-reducing and anxiolytic perioperative techniques are of considerable importance.

Acetylcholinesterase/paraoxonase genotype and expression predict anxiety scores in Health, Risk Factors, Exercise Training, and Genetics study

Anxiety involves complex, incompletely understood interactions of genomic, environmental, and experience-derived factors, and is currently being measured by psychological criteria. Here, we report previously nonperceived interrelationships between expression variations and nucleotide polymorphisms of the chromosome 7q21-22 acetylcholinesterase-paraoxonase 1 (ACHE-PON1) locus with the trait- and state-anxiety measures of 461 healthy subjects from the Health, Risk Factors, Exercise Training, and Genetics Family Study. The AChE protein controls the termination of the stress-enhanced acetylcholine signaling, whereas the PON protein displays peroxidase-like activity, thus protecting blood proteins from oxidative stress damages. Serum AChE and PON enzyme activities were both found to be affected by demographic parameters, and showed inverse, reciprocal associations with anxiety measures. Moreover, the transient scores of state anxiety and the susceptibility score of trait anxiety both appeared to be linked to enzyme activities. This finding supported the notion of corresponding gene expression relationships. Parallel polymorphisms in the ACHE and PON1 genes displayed apparent associations with both trait- and state-anxiety scores. Our findings indicate that a significant source of anxiety feelings involves inherited and acquired parameters of acetylcholine regulation that can be readily quantified, which can help explaining part of the human variance for state and trait anxiety.