Empirical researchThe role of experiential avoidance in the relation between anxiety disorder diagnoses and future physical health symptoms in a community sample of young adult women☆
Introduction
Anxiety disorders are the most prevalent mental health problem in the United States (Kessler et al., 2005), and disproportionally affect women (McLean, Asnaani, Litz, & Hofmann, 2011). Often beginning at an early age (Kessler et al., 2005), anxiety disorders are associated with considerable disability and impairment across occupational, relationship, and physical health domains (Kariuki-Nyuthe and Stein, 2015, McLean et al., 2011, Roy-Byrne et al., 2008). With regard to the latter, the physical health problems experienced by individuals with anxiety disorders include obesity, diabetes, allergies, cancer, cataracts, thyroid problems, pain-related conditions, psoriasis, and cardiovascular, heart, gastrointestinal, and respiratory diseases (El-Gabalawy et al., 2011, Gili et al., 2010, Niles et al., 2015, Roy-Byrne et al., 2008, Sanna et al., 2013, Sareen et al., 2006, Scott et al., 2007). Anxiety disorders are also associated with high medical burden (defined as three or more medical diagnoses; Sanna et al., 2013) and multiple indices of health-related disability. For example, individuals with anxiety disorders report heightened intensity of physical health symptoms (Oh, Cho, Chung, Kim, & Chu, 2014), increased difficulty carrying out daily activities (Kessler et al., 2003, McCauley et al., 2007, Merikangas et al., 2007, Sareen et al., 2006), and poor general physical health (El-Gabalawy et al., 2011). Research also indicates a synergistic effect of anxiety disorders and physical illness on physical disability, with the combination resulting in greater disability than the additive effect of each problem individually (Scott et al., 2009).
It is this disability that likely contributes to increased health care utilization by individuals with anxiety disorders. For example, anxiety disorders are related to more frequent use of primary care services, including non-psychotropic medications, emergency department visits, inpatient admissions, and costly medical tests and procedures (Feldman et al., 2005, Simpson et al., 1994, Zaubler and Katon, 1998). The occurrence of physical health symptoms among individuals with an anxiety diagnosis results in considerable strain on the medical health system and represents a significant public health burden.
Despite the importance of research in this area, few studies have examined the prospective effects of anxiety disorders in young adulthood on general physical health symptoms. Moreover, although preliminary evidence indicates that the presence (vs. absence) of an anxiety diagnosis in adolescence is associated with more self-reported pain, physical illness, and poor physical health up to 20 years later (Chen et al., 2009), no studies have examined the behavioral processes that may account for poor physical health among individuals with anxiety disorders. Thus, the precise nature and strength of the relation of anxiety disorders to future physical health problems remains unclear. In particular, it is possible that anxiety disorders are a proxy risk factor for some key behavioral process or mechanism that relates to physical health problems (see Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001). A proxy risk factor model is considered applicable when the temporal precedence of two correlated putative risk factors for some outcome is not clear, and when one risk factor (i.e., the proxy risk factor) is only (or primarily) related to an outcome due to their shared association with a stronger, or more dominant, global risk factor for that outcome. Identification of global risk factors for physical health problems would facilitate the development of more efficient and targeted interventions aimed at improving the health of populations with elevated anxiety (Kraemer et al., 2001).
One process that warrants examination in this regard is experiential avoidance (EA), defined as rigid behavioral attempts to alter the form, frequency, or intensity of unwanted private events (i.e., thoughts, emotions, and physical sensations) when such behavior impedes valued living (Hayes et al., 2004, Hayes et al., 2012). Evidence suggests that self-reported EA is strongly linked to both anxiety (e.g., Kashdan, Zvolensky, & McLeish, 2008; Tull & Roemer, 2008) and specific anxiety-related disorders, including posttraumatic stress disorder (Kashdan et al., 2009, Valdez and Lilly, 2012), social anxiety disorder (Kashdan et al., 2010, Kashdan et al., 2009), and generalized anxiety disorder (Roemer, Salters, Raffa, & Orsillo, 2005). Moreover, behavioral expressions of EA in the context of anxiety disorders (such as emotional and thought suppression and risky behaviors) are associated with negative health consequences. For example, the suppression of thoughts and emotions (an avoidance-oriented strategy common among people with anxiety; Campbell-Sills, Barlow, Brown, & Hofmann, 2006b; Levitt, Brown, Orsillo, & Barlow, 2004) has been found to increase subjective distress and physiological dysregulation (e.g., Campbell-Sills, Barlow, Brown, & Hofmann, 2006a; Gillanders, Wild, Deighan, & Gillanders, 2008; Gross & Levenson, 1997; Marcks & Woods, 2005; Wegner, Shortt, Blake, & Page, 1990) – the latter of which predicts poor future physical health (Milot et al., 2014). EA is also linked to a variety of risky behaviors (e.g., substance use: Stewart, Zvolensky, & Eifert, 2002; risky sexual behaviors: Batten, Follette, & Aban, 2002) that may, themselves, have negative health consequences. Taken together, and consistent with evidence that EA operates as a general psychological vulnerability factor (Kashdan, Barrios, Forsyth, & Steger, 2006), this body of research suggests that EA may be a global risk factor for physical health problems among individuals with anxiety disorders, with the presence of an anxiety disorder diagnosis serving as a proxy for EA in the risk for later physical health symptoms.
Based on the above theory and research, we tested a proxy risk factor model of the interrelations of anxiety disorder diagnosis, EA, and physical health symptoms among young adult women, wherein EA would supersede anxiety disorder diagnosis in the prediction of future physical health symptoms (see Kraemer et al., 2001). We hypothesized that the presence of an anxiety disorder diagnosis would predict greater physical health symptoms four months later after controlling for baseline health symptoms. Consistent with a proxy risk factor model, however, we also predicted that baseline EA would fully account for the relation between anxiety disorders and future physical health symptoms. If these hypotheses are supported, such findings have the potential to inform the development of targeted treatments that both ease individual suffering and reduce the healthcare costs associated with anxiety disorders.
Section snippets
Participants
Participants were drawn from a large prospective study of emotion dysregulation and sexual revictimization among young adult women in the community. Eligible individuals included all females aged 18–25 who lived in the recruitment catchment areas; there were no other exclusion criteria. One hundred and fifty-one women (Mage =21.75, SDage =2.02) were recruited from the community in a metropolitan area of the Southern United States without consideration of sexual victimization status (see
Results
Analyses were conducted using SPSS Statistics 22.0.0.2 for Mac. Inspection of histograms and skewness and kurtosis statistics indicated that CHIPS-R scores were positively skewed and leptokurtic. Square-root transformations reduced skewness and kurtosis to non-significant levels. AAQ scores approximated a normal univariate distribution. No outliers were identified following transformation.
Fifty-seven participants (38%) were diagnosed with a DSM-IV anxiety disorder based upon the SCID interview.
Discussion
Young adults with anxiety disorders are at risk for poor long-term outcomes as a result of physical health problems (Chen et al., 2009). Although most anxiety disorders emerge by early adulthood (Kessler et al., 2005) and there is some evidence that early-onset anxiety disorders are related to later physical health conditions (e.g., Scott et al., 2011; Stein et al., 2010), research examining physical health problems among young (vs. older-aged) adults with an anxiety disorder is sparse (
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This research was supported by National Institute of Child Health and Human Development Grant R01 HD062226, awarded to the third author (DD).