The role of experiential avoidance in the relation between anxiety disorder diagnoses and future physical health symptoms in a community sample of young adult women

Highlights

• Women (M_age =21.75) assessed at baseline (N =151) and 4-months later (n =136).

• Baseline anxiety disorder diagnosis related to baseline experiential avoidance (EA).

• Anxiety disorder diagnosis related to physical health symptoms four months later.

• EA fully accounted for the relation of anxiety disorders to physical health symptoms.

• Anxiety disorders may be a proxy for EA in the risk for physical health problems.

Abstract

Individuals diagnosed with an anxiety disorder report more physical health problems than those without an anxiety disorder. Few studies have examined the relation of anxiety disorders to later physical health symptoms, or the processes that may explain this relation. One process of interest is experiential avoidance (EA), which is commonly reported in populations characterized by high anxiety and often leads to health-compromising behaviors. The present study examined the relations between anxiety disorder diagnostic status, EA, and physical health symptoms in a community sample of young adult women. Results revealed a significant association between an anxiety disorder diagnosis and physical health problems four months later. Furthermore, levels of EA accounted for this relation. Findings highlight the potential utility of targeting EA as a method for improving health outcomes among individuals with anxiety disorders.

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.