Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2018 Jan 1.
Published in final edited form as: J Contextual Behav Sci. 2017 Jan;6(1):29–34. doi: 10.1016/j.jcbs.2016.11.002

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✰

Christopher R Berghoff a,*, Matthew T Tull a, David DiLillo b, Terri Messman-Moore c, Kim L Gratz a
PMCID: PMC5473660  NIHMSID: NIHMS834772  PMID: 28630827

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.

Keywords: Anxiety Disorders, Physical Health Symptoms, Experiential Avoidance

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 & 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, Mackenzie, Shooshtari, & Sareen, 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, Ormel, Demler, & Stang, 2003; McCauley, Katon, Russo, Richardson, & Lozano, 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, Kazmierczak, Power, & Sharp, 1994; Zaubler & 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, Strosahl, & Wilson, 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, Morina, & Priebe, 2009; Valdez & Lilly, 2012), social anxiety disorder (Kashdan, Breen, Afram, & Terhar, 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, 2006a; Levitt, Brown, Orsillo, & Barlow, 2004) has been found to increase subjective distress and physiological dysregulation (e.g., Campbell-Sills, Barlow, Brown, & Hofmann, 2006b; 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.

Method

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 Procedure for further details). Participants completed assessments at baseline (N = 151) and again four months later (n = 136). Participants were ethnically diverse (75.5% African American; 23.2% White; 2.0% Latina). Most participants were single (86.1%), full time students (70.2%), and identified as heterosexual (84.1%).

Materials

The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1996) was administered at baseline to assess for the presence of current DSM-IV Axis I disorders. Interviews were conducted by bachelors- or masters-level clinical assessors trained to reliability with the last author (κ ≥ .80). Discrepancies (found in fewer than 10% of cases) were discussed as a group and a consensus was reached. For the purposes of this study, a dichotomous anxiety disorder diagnosis variable was created, with participants meeting diagnostic criteria for any current anxiety disorder scored a 1 and those without any current anxiety disorder scored a 0.

The Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004) was used to assess EA. Participants respond to 9 items using a 7-point Likert-type scale (1 = never true to 7 = always true). AAQ total scores range from 9–63, with high scores indicating more EA. The AAQ has acceptable internal consistency (αs = .70-.86; Arch et al., 2012; Hayes et al., 2004) and demonstrates good concurrent validity with relevant constructs such as thought suppression and mental health symptoms (Hayes et al., 2004). The current study uses AAQ scores provided at the baseline assessment. Although internal consistency in the current sample was somewhat low (Cronbach’s α = .60), this is consistent with previous research using this measure (e.g., Andrew & Dulin, 2007).

The Cohen-Hoberman Inventory of Physical Symptoms—Revised (CHIPS-R; Campbell, Greeson, Bybee, & Raja, 2008) was used to assess physical health symptoms. Participants were presented with a list of 34 commonly experienced physical symptoms (e.g., “headaches,” “dizziness,” “stomach pain”) and asked to indicate how much each physical health problem had bothered or distressed them during the past four months (including the current day) on a scale from 0 (not at all) to 4 (extreme bother). Items are summed to create an overall index of physical health symptoms. The current study uses CHIPS-R scores at both the baseline and 4-month follow-up assessments. Internal consistency was good across both assessment waves (αs = .94–.96).

Procedure

All procedures received prior approval by the Institutional Review Boards of the participating institutions. Recruitment methods included both random sampling from the community and community advertisements. First, women within the targeted age range (18–25) were identified from a large commercially-sourced database. Randomly selected individuals from this list were sent a letter inviting them to participate in a longitudinal study of life experiences and adjustment. The recruitment letter contained a description of the project procedures, a post-paid response card to be mailed back by interested individuals, and an enclosed $1 monetary incentive intended to increase response rate (Helgeson, Voss, & Terpening, 2002). Women were also recruited through advertisements for a study on “women’s life experiences and adjustment” posted online and throughout the community (including coffee shops, churches, stores, hospitals, colleges, and clinics). All participants provided written informed consent.

At the baseline assessment, participants completed a diagnostic interview (including the SCID), as well as a series of self-report questionnaires and laboratory tasks. All questionnaires were administered online and completed on a computer in the laboratory. The second assessment (which occurred four months later) included online self-report questionnaires only, and could be completed either at home or in the laboratory. Participants were compensated $75 for the baseline assessment and $25 for the second assessment.

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. Specific phobia was the most frequent diagnosis (n = 25), followed by obsessive-compulsive disorder (n = 18), posttraumatic stress disorder (n = 17), social anxiety disorder (n = 14), panic disorder (n = 7), and agoraphobia without panic disorder (n = 6). Twenty-nine individuals (19%) received at least two separate DSM-IV anxiety disorder diagnoses. Heterosexual participants were less likely to have an anxiety disorder diagnosis (33%) than those who identified as lesbian, gay, or bisexual (70%; χ2(1) = 9.86, p = .002). No other significant differences in demographic characteristics were found between participants with and without an anxiety disorder diagnosis, all ps > .05.

Descriptive statistics of non-transformed scores and bivariate correlations among transformed scores are presented in Table 1. Consistent with the proxy risk factor model (Kraemer et al., 2001), anxiety disorder diagnosis and EA were positively correlated at the baseline assessment. As expected, baseline anxiety disorder diagnosis and EA were significantly positively correlated with physical health symptoms at both baseline and four months later. A hierarchical multiple regression analysis was conducted to examine the relations of baseline anxiety disorder diagnosis and EA to physical health symptoms four months later, when accounting for baseline physical health symptoms. Baseline physical health symptoms, anxiety disorder diagnosis, and EA were entered into the regression sequentially. Normal distribution of the residuals and homoscedasticity assumptions were confirmed through visual inspection. Table 2 presents the full regression model, including the intercept, unstandardized regression coefficients (B), standardized regression coefficients (β), semipartial correlations (sri2), and F, R2 and change in R2 for all steps of the regression.

Table 1.

Descriptive Statistics and Bivariate Relations among Anxiety Diagnosis, Physical Health Symptoms, and Experiential Avoidance

With Anxiety Diagnosis (n = 57) Without Anxiety Diagnosis (n = 94) Total Sample (n = 151) Bivariate Relations
Variable M (SD) M (SD) M (SD) 1 2 3
1. Anxiety Disorder Diagnosis - - - -
2. Baseline Health Symptoms 30.18 (25.60) 14.56 (15.47) 20.46 (21.23) .37** -
3. 4-Month Health Symptomsa 30.68 (30.15) 12.77 (14.21) 19.74 (23.44) .39** .72** -
4. Experiential Avoidance 35.88 (8.25) 30.80 (6.42) 32.72 (7.55) .33** .30** .38**
Open in a new tab

Note. Anxiety disorder diagnosis = baseline presence of an anxiety disorder diagnosis on the SCID (Absent = 0; Present = 1). Experiential avoidance assessed at baseline.

a

n = 136

**

p < .001

Table 2.

Hierarchical Regression Analysis Examining the Relations of Baseline Physical Health Symptoms, Anxiety Diagnosis, and Experiential Avoidance to Physical Health Symptoms Four Months Later

Variable B SE B β sri2 F R2 (ΔR2)
Step 1 147.39* .524 (.524)
Intercept  0.431 0.306
Baseline Physical Health  0.806 0.066 0.724 .524**
Symptoms Step 2 4.19* .538 (.015)
Intercept  0.397 0.303
Baseline Physical Health Symptoms  0.751 0.071 0.674
Anxiety Disorder Diagnosis  0.660 0.322 0.130 .014*
Step 3 4.54* .554 (.015)
Intercept  −0.831 0.650
Baseline Physical Health Symptoms  0.712 0.072 0.640
Anxiety Disorder Diagnosis  0.508 0.326 0.100
Experiential Avoidance  0.044 0.021 0.135 .016*
Open in a new tab

Note. SE = Standard error; sri2 = semipartial correlations; Baseline and 4-month physical health symptoms are square root transformed. Anxiety disorder diagnosis = baseline presence of an anxiety disorder diagnosis on the SCID (Absent = 0; Present = 1). Experiential avoidance assessed at baseline.

*

p < .05.

**

p < .001.

As predicted, baseline anxiety disorder diagnosis was significantly associated with later physical health symptoms when accounting for baseline physical health symptoms, with the inclusion of anxiety disorder diagnosis in the second step significantly improving the model (see Table 2). Likewise, the inclusion of baseline EA in the third step significantly improved the model, accounting for unique variance in later physical health symptoms above and beyond both baseline physical health symptoms and anxiety disorder diagnosis. Finally, anxiety disorder diagnosis did not remain significantly associated with four month physical health symptoms when EA was included in the model, t(132) = 1.56, p = .122, 95% CI [−.137, 1.153], consistent with the hypothesis that baseline EA would account for the relation between baseline anxiety disorder diagnosis and later physical health symptoms1.

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 (McCloughen, Foster, Husw-Thomas, & Delgado, 2012). The present study contributes to this limited evidence base by: (a) further clarifying the relation between anxiety disorders and future physical health symptoms, and (b) identifying EA as a behavioral process that accounts for this relation.

In line with study hypotheses, the presence of an anxiety disorder predicted increased short-term (i.e., four-month) future physical health symptoms, above and beyond baseline physical health symptoms. This finding extends prior research on the relation of anxiety disorders to long-term negative health outcomes (e.g., Chen et al., 2009), suggesting that the relation of anxiety disorders to physical health problems may be evident in the short-term as well. These results highlight the potential utility of systematically assessing and/or screening for physical health symptoms following initial anxiety disorder diagnosis, as the impact of such disorders on physical health outcomes may be more immediate than previously thought. Systematically assessing and monitoring physical health symptoms among individuals with anxiety disorders may facilitate prevention or early intervention efforts aimed at reducing later physical health problems within this population. Nonetheless, it is important to note that we did not collect data on the age of onset or duration of participants’ current anxiety disorders; thus, the precise timing of the emergence of physical health problems vis-à-vis the onset of the anxiety disorder and the rate at which such problems occur cannot be determined. Identification of the first onset of anxiety-related pathology would help clarify the short- and long-term relations of clinical levels of anxiety to later physical health symptoms. Additionally, physical health symptoms were not examined as a predictor of future elevated anxiety, a relation with an evidentiary base (Chou, Huang, Goldstein, & Grant, 2013) that could account for at least a portion of the observed relation between anxiety disorder diagnosis and physical health symptoms in this study. Indeed, the likely bidirectional nature of the relation between physical health problems and anxiety complicates efforts to pinpoint the development of each, as well as to disentangle the processes that link anxiety diagnoses and physical health problems (Duric, Clayton, Leon, Yuan, 2016). Potential reciprocal relations between anxiety pathology and physical health symptoms remain an important area for future research.

As hypothesized, EA was uniquely related to future physical health symptoms (above and beyond anxiety disorder status), accounting for more unique variance in later physical health symptoms than anxiety disorder status alone. More importantly, anxiety disorder diagnostic status no longer predicted physical health symptoms once EA was added to the model (whereas the addition of anxiety disorder status to a model including EA did not reduce the strength of the relation of EA to physical health symptoms). These findings support our hypothesized model, suggesting that anxiety disorder diagnosis likely functions as a proxy risk factor (Kraemer et al., 2001) for EA when predicting future physical health symptoms. Though the relation between EA and anxiety disorder status is likely reciprocal, our results suggest that how one responds to internal and external stimuli (i.e., accepting vs. avoidant) may have a greater influence on health-related outcomes than anxiety disorder status per se. Particularly when the goal of treatment is to improve both anxiety and physical health symptoms, behavioral therapies that teach strategies for reducing unhelpful avoidant behavior may be more efficient than treatments that focus on the elimination of anxiety symptoms.

One important next step for future research in this area will be to examine the mediating role of EA in improvements in physical health outcomes over the course of treatments for anxiety disorders. For example, Acceptance and Commitment Therapy (ACT; Hayes et al., 2012) targets EA and is efficacious and effective for addressing anxiety disorders (Bluett, Homan, Morrison, Levin, & Twohig, 2014; Landy, Schneider, & Arch, 2015; Swain, Hancock, Hainsworth, & Bowman, 2013) and various physical health problems (A-Tjak et al., 2015), including chronic medical conditions (Dindo, 2015) and chronic pain (Hann & McCracken, 2014; Veehof, Oskam, Schreurs, & Bohlmeijer, 2011). ACT has been successfully disseminated through brief workshops (e.g., Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007; Lillis, Hayes, Bunting, & Masuda 2009; Sheppard, Forsyth, Hickling, & Bianchi, 2010) as well as group-based (McCracken, Sato, & Taylor, 2013) interventions. This makes ACT conducive to primary care settings (Dindo, 2015), which is often the only venue where individuals with elevated levels of anxiety access health care services (Regier et al., 1993). To the best of our knowledge, however, ACT has not been evaluated in samples with co-occurring anxiety disorders and physical health conditions. Future research examining the utility of ACT (or other interventions that target EA) for these co-occurring problems is needed. Early interventions aimed at targeting EA may help highly anxious patients learn more adaptive ways of responding to internal experiences, which, in turn, may prevent the development of physical health problems or improve recovery from and management of physical health problems that do occur.

Several limitations of the current study warrant discussion. First, the sample was composed of young adult women; thus, the extent to which these findings will generalize to men or more diverse age groups is unknown. Likewise, approximately 75% of the sample identified as African American. Although the racial makeup of our sample closely mirrored recent US census statistics of the geographical area (see U.S. Census Bureau, 2010), our results may not generalize to members of other racial or ethnic groups. Nonetheless, our findings highlight potential negative health consequences of anxiety disorders and EA among African Americans, a population with elevated rates of both mental and physical health problems (Centers for Disease Control and Prevention, 2012; 2013). In addition, this study assessed physical health symptoms (vs. physical health conditions or severe physical health problems) in a nonclinical community sample with a relatively low average level of reported symptoms. As such, our results may not extend to individuals with more serious physical health problems. Inclusion of patient populations in future research, particularly individuals with chronic physical health conditions, may clarify the relations of EA and anxiety disorders to major physical health problems.

Furthermore, although results provide support for the hypothesized proxy risk factor model and suggest that EA may be a global risk factor for later physical health symptoms relative to an anxiety disorder diagnosis, the effect size of the observed relation between EA and physical health symptoms was small and much of the variance in physical health symptoms remained unexplained. Future research is needed to examine other factors (e.g., adherence to treatment recommendations, early stressful life events, dysregulated central nervous system processes; see Bautista, Vera-Cala, Colombo, & Smith, 2012; Duric et al., 2016; Faravelli et al., 2012) that may relate to later physical health symptoms in young adults with and without anxiety disorders.

There are also some limitations associated with our anxiety disorder and general assessment procedures. Although the use of an empirically supported structured diagnostic interview is a strength of this study, this interview was administered at baseline only. Thus, whether participants met criteria for a current anxiety disorder four months later, or the implications of this for the observed relations, remains unclear. The administration of structured diagnostic interviews at multiple time points over the course of a longitudinal study would provide a better understanding of the interrelations of anxiety disorders and physical health problems over time. In addition, our use of a dichotomous anxiety disorder variable may have limited our statistical power or influenced our findings relative to the use of a continuous assessment of anxiety pathology. Given past findings of a large-sized relation between our measure of EA and continuous measures of anxiety (e.g., Kashdan et al., 2006; see also Chawla & Ostafin, 2007; Hayes, Luoma, Bond, Masuda, & Lillis, 2006), use of a continuous assessment of anxiety in future research would facilitate examination of the predictive utility of EA relative to anxiety severity more broadly. The use of a self-report measure of physical health symptoms is also a limitation; future research should examine the relations reported herein in the context of medical diagnoses provided by physicians or captured through medical chart review. Furthermore, given that many factors in a person’s day may influence self-reports of EA and physical health symptoms, use of more intensive assessments (e.g., a daily diary design) may further clarify our findings and the precise interrelations among anxiety, EA, and physical health symptoms.

It is also important to note that we did not account for the presence of co-occurring anxiety disorders. Identification of the impact of EA on physical illness in individuals who experience multiple anxiety disorders is an important area for future research. Additionally, although the use of a prospective design allows us to clarify the temporal relations between both anxiety disorders and EA and later physical health symptoms, results cannot speak to the causal role of these factors in physical health problems. Replications of this research, as well as examinations of the relations reported herein over a longer course of time (e.g., 1 to 2 years), will increase confidence in the present findings. Finally, the low internal consistency of the AAQ warrants mention. Low reliability of this instrument has been found in a number of other studies (Bond et al., 2011). Nonetheless, the AAQ has demonstrated clinical and research utility across a variety of samples (see Hayes et al., 2006; Ruiz, 2010) and, in this study, provides valuable insight into a behavioral process that may underlie the relation between anxiety disorder diagnoses and physical health problems. Future studies attempting to replicate our findings would benefit from using more psychometrically sound measures of EA, such as the Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011) or behavioral measures (e.g., the Computerized Paced Auditory Serial Addition Task; Gratz, Bornovalova, Delany-Brumsey, Nick, & Lejuez, 2007).

This study represents an initial step in research aimed at alleviating the physical suffering experienced by some individuals with anxiety disorders. Our results highlight the role of EA as one possible factor accounting for the increased physical health symptoms associated with anxiety disorder status. As such, acceptance-based behavioral therapies such as ACT (which specifically targets EA) may be an efficient strategy for improving physical health outcomes among anxiety disordered populations. Further, although this study highlights one factor that may explain the heightened physical health problems observed among individuals with anxiety disorders, linkages between anxiety disorder status and physical health are undoubtedly complex. Thus, further work is needed to identify additional behavioral and physiological processes that may guide the development of effective complementary or alternative treatment strategies. Research along these lines has the potential to improve the overall wellbeing of individuals who experience anxiety disorders while also reducing healthcare burden associated with compromised physical health in this population.

Highlights.

  • Women (Mage = 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

Footnotes

✰

This research was supported by National Institute of Child Health and Human Development Grant R01 HD062226, awarded to the third author (DD).

1

The present model was also analyzed by entering EA in the second step and anxiety disorder diagnosis in the third step. EA remained a significant predictor of future physical health symptoms (ΔR2 = .032, p < .01), and inclusion of anxiety disorder diagnosis did not result in a significant improvement in the model (ΔR2 = .007, p > .05). In the parlance of the proxy risk factor model, EA dominated anxiety disorder diagnosis in the prediction of physical health symptoms (Kraemer et al., 2001). Full analyses are available by contacting the first author.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  1. A-Tjak JGL, Davis ML, Morina N, Powers MB, Smits JAJ, Emmelkamp PMG. A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics. 2015;84:30–36. doi: 10.1159/000365764. [DOI] [PubMed] [Google Scholar]
  2. Andrew DH, Dulin PL. The relationship between self-reported health and mental health problems among older adults in New Zealand: Experiential avoidance as a moderator. Aging & Mental Health. 2007;11:596–603. doi: 10.1080/13607860601086587. [DOI] [PubMed] [Google Scholar]
  3. Arch JJ, Eifert GH, Davies C, Vilardaga JCP, Rose RD, Craske MG. Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology. 2012;80:750–765. doi: 10.1037/a0028310. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Batten SV, Follette VM, Aban IB. Experiential avoidance and high-risk sexual behavior in survivors of child sexual abuse. Journal of Child Sexual Abuse. 2002;10:101–120. doi: 10.1300/J070v10n02_06. [DOI] [PubMed] [Google Scholar]
  5. Bautista LE, Vera–Cala LM, Colombo C, Smith P. Symptoms of depression and anxiety and adherence to antihypertensive medication. American Journal of Hypertension. 2012;25:505–511. doi: 10.1038/ajh.2011.256. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bluett EJ, Homan KJ, Morrison KL, Levin ME, Twohig MP. Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders. 2014;28:612–624. doi: 10.1016/j.janxdis.2014.06.008. [DOI] [PubMed] [Google Scholar]
  7. Bond FW, Hayes SC, Baer RA, Carpenter KC, Guenole N, … Zettle RD. Preliminary psychometric properties of the Acceptance and Action Questionnaire II: A revised measure of psychological flexibility and acceptance. Behavior Therapy. 2011;42:676–688. doi: 10.1016/j.beth.2011.03.007. [DOI] [PubMed] [Google Scholar]
  8. Campbell R, Greeson MR, Bybee D, Raja S. The co-occurrence of childhood sexual abuse, adult sexual assault, intimate partner violence, and sexual harassment: A meditational model of posttraumatic stress disorder and physical health outcomes. Journal of Consulting and Clinical Psychology. 2008;76:194–207. doi: 10.1037/0022-006X.76.2.194. [DOI] [PubMed] [Google Scholar]
  9. Campbell-Sills L, Barlow DH, Brown TA, Hofmann SG. Acceptability and suppression of negative emotion in anxiety and mood disorders. Emotion. 2006a;6:587–595. doi: 10.1037/1528-3542.6.4.587. [DOI] [PubMed] [Google Scholar]
  10. Campbell-Sills L, Barlow DH, Brown TA, Hofmann SG. Effects of suppression and acceptance on emotional responses of individuals with anxiety and mood disorders. Behaviour Research and Therapy. 2006b;44:1251–1263. doi: 10.1016/j.brat.2005.10.001. [DOI] [PubMed] [Google Scholar]
  11. Centers for Disease Control and Prevention. Summary health statistics for US adults: National health interview survey, 2010. 2012 Retrieved from http://www.cdc.gov/nchs/data/series/sr_10/sr10_252.pdf.
  12. Centers for Disease Control and Prevention. CDC health disparities and inequalities report – United States, 2013. Morbidity and Mortality Weekly Report. 2013;62(3) Retrieved from http://www.cdc.gov/mmwr/pdf/other/su6203.pdf. [Google Scholar]
  13. Chavira DA, Garland AF, Daley S, Hough R. The impact of medical comorbidity on mental health and functional health outcomes among children with anxiety disorders. Journal of Developmental & Behavioral Pediatrics. 2008;29:394–402. doi: 10.1097/DBP.0b013e3181836a5b. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Chawla N, Ostafin B. Experiential avoidance as a functional dimensional approach to psychopathology: An empirical review. Journal of Clinical Psychology. 2007;63:871–890. doi: 10.1002/jclp.20400. [DOI] [PubMed] [Google Scholar]
  15. Chen H, Cohen P, Crawford TN, Kasen S, Guan B, Gorden K. Impact of early adolescent psychiatric and personality disorder on long-term physical health: A 20-year longitudinal follow-up study. Psychological Medicine. 2009;39:865–874. doi: 10.1017/S0033291708004182. [DOI] [PubMed] [Google Scholar]
  16. Chou SP, Huang B, Goldstein R, Grant BF. Temporal associations between physical disorders – Results from the wave 2 national epidemiologic survey on alcohol and related conditions (NESARC) Comprehensive Psychiatry. 2013;54:627–638. doi: 10.1016/j.comppsych.2012.12.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Dindo L. One-day acceptance and commitment training workshops in medical populations. Current Opinion in Psychology. 2015;2:38–42. doi: 10.1016/j.copsyc.2015.01.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Duric V, Clayton S, Leong ML, Yuan LL. Comorbidity factors and brain mechanisms linking chronic stress and systemic illness. Neural Plasticity. 2016;2016:5460732. doi: 10.1155/2016/5460732. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. El-Gabalawy R, Mackenzie CS, Shooshtari S, Sareen J. Comorbid physical health conditions and anxiety disorders: A population-based exploration of prevalence and health outcomes among older adults. General Hospital Psychiatry. 2011;33:556–564. doi: 10.1016/j.genhosppsych.2011.07.005. [DOI] [PubMed] [Google Scholar]
  20. Faravelli C, Lo Sauro C, Godini L, Lelli L, Benni L, Pietrini F, … Ricca V. Childhood stressful events, HPA axis and anxiety disorders. World Journal of Psychiatry. 2012;2:13–25. doi: 10.5498/wjp.v2.i1.13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Feldman JM, Siddique MI, Morales E, Kaminski B, Lu S, Lehrer PM. Psychiatric disorders and asthma outcomes among high-risk inner-city patients. Psychosomatic Medicine. 2005;67:989–996. doi: 10.1097/01.psy.0000188556.97979.13. [DOI] [PubMed] [Google Scholar]
  22. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical interview for DSM-IV axis I disorders, clinician version (SCID-CV) Washington, D.C: American Psychiatric Press, Inc; 1996. [Google Scholar]
  23. Gili M, Comas A, García-García M, Monzón S, Antoni S, Roca M. Comorbidity between common mental disorders and chronic somatic diseases in primary care patients. General Hospital Psychiatry. 2010;32:240–245. doi: 10.1016/j.genhosppsych.2010.01.013. [DOI] [PubMed] [Google Scholar]
  24. Gillanders S, Wild M, Deighan C, Gillanders D. Emotion regulation, affect, psychosocial functioning, and well-being in hemodialysis patients. American Journal of Kidney Diseases. 2008;51:651–662. doi: 10.1053/j.ajkd.2007.12.023. [DOI] [PubMed] [Google Scholar]
  25. Gratz KL, Bornovalova MA, Delany-Brumsey A, Nick B, Lejuez CW. A laboratory-based study of the relationship between childhood abuse and experiential avoidance among inner-city substance users: The role of emotional non-acceptance. Behavior Therapy. 2007;38:256–268. doi: 10.1016/j.beth.2006.08.006. [DOI] [PubMed] [Google Scholar]
  26. Gregg JA, Callaghan GM, Hayes SC, Glenn-Lawson JL. Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology. 2007;75:336–343. doi: 10.1037/0022-006X.75.2.336. [DOI] [PubMed] [Google Scholar]
  27. Gross JJ, Levenson RW. Hiding feelings: The acute effects of inhibiting negative and positive emotion. Journal of Abnormal Psychology. 1997;106:95–103. doi: 10.1037/0021-843X.106.1.95. [DOI] [PubMed] [Google Scholar]
  28. Hann KEJ, McCracken LM. A systematic review of randomized controlled trials of acceptance and commitment therapy for adults with chronic pain: Outcome domains, design quality, and efficacy. Journal of Contextual Behavioral Science. 2014;3:217–227. doi: 10.1016/j.jcbs.2014.10.001. [DOI] [Google Scholar]
  29. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy. 2006;44:1–25. doi: 10.1016/j.brat.2005.06.006. [DOI] [PubMed] [Google Scholar]
  30. Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: The process and practice of mindful change. 2. New York: Guilford Press; 2012. [Google Scholar]
  31. Hayes SC, Strosahl KD, Wilson KG, Bissett RT, Pistorello J, Toarmino D, … McCurry SM. Measuring experiential avoidance: A preliminary test of a working model. The Psychological Record. 2004;54:553–578. [Google Scholar]
  32. Helgeson JG, Voss KE, Terpening WD. Determinants of mail-survey response: Survey design factors and respondent factors. Psychology & Marketing. 2002;19:303–328. doi: 10.1002/mar.1054. [DOI] [Google Scholar]
  33. Jain A, Lolak S. Psychiatric aspects of chronic lung disease. Current Psychiatry Reports. 2009;11:219–225. doi: 10.1007/s11920-009-0034-9. [DOI] [PubMed] [Google Scholar]
  34. Kashdan TB, Barrios V, Forsyth JP, Steger MF. Experiential avoidance as a generalized psychological vulnerability: Comparisons with coping and emotion regulation strategies. Behaviour Research and Therapy. 2006;44:1301–1320. doi: 10.1016/j.brat.2005.10.003. [DOI] [PubMed] [Google Scholar]
  35. Kashdan TB, Breen WE, Afram A, Terhar D. Experiential avoidance in idiographic, autobiographical memories: Construct validity and links to social anxiety, depressive, and anger symptoms. Journal of Anxiety Disorders. 2010;24:528–534. doi: 10.1016/j.janxdis.2010.03.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Kashdan TB, Morina N, Priebe S. Post-traumatic stress disorder, social anxiety disorder, and depression in survivors of the Kosovo War: Experiential avoidance as a contributor to distress and quality of life. Journal of Anxiety Disorders. 2009;23:185–196. doi: 10.1016/j.janxdis.2008.06.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Kashdan TB, Zvolensky MJ, McLeish AC. Anxiety sensitivity and affect regulatory strategies: Individual and interactive risk factors for anxiety-related symptoms. Journal of Anxiety Disorders. 2008;22:429–440. doi: 10.1016/j.janxdis.2007.03.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Kariuki-Nyuthe C, Stein DJ. Anxiety and related disorders and physical illness. Key Issues in Mental health. 2015;179:81–87. doi: 10.1159/000365538. [DOI] [Google Scholar]
  39. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry. 2005;62:593–602. doi: 10.1001/archpsyc.62.6.593. [DOI] [PubMed] [Google Scholar]
  40. Kessler RC, Ormel J, Demler O, Stang PE. Comorbid mental disorders account for the role impairment of commonly occurring chronic physical disorders: Results from the national comorbidity survey. Journal of Occupational and Environmental Medicine, 45. 2003:1257–1266. doi: 10.1097/01.jom.0000100000.70011.bb. [DOI] [PubMed] [Google Scholar]
  41. Kraemer HC, Stice E, Kazdin A, Offord D, Kupfer D. How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors. The American Journal of Psychiatry. 2001;158:848–856. doi: 10.1176/appi.ajp.158.6.848. [DOI] [PubMed] [Google Scholar]
  42. Landy LN, Schneider RL, Arch JJ. Acceptance and commitment therapy for the treatment of anxiety disorders: a concise review. Current Opinion in Psychology. 2015;2:70–74. doi: 10.1016/j.copsyc.2014.11.004. [DOI] [Google Scholar]
  43. Levitt JT, Brown TA, Orsillo SM, Barlow DH. The effects of acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide challenge in patients with panic disorder. Behavior Therapy. 2004;35:747–766. doi: 10.1016/S0005-7894(04)80018-2. [DOI] [Google Scholar]
  44. Lillis J, Hayes SC, Bunting K, Masuda A. Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine. 2009;37:58–69. doi: 10.1007/s12160-009-9083-x. [DOI] [PubMed] [Google Scholar]
  45. Marcks BA, Woods DW. A comparison of thought suppression to an acceptance-based technique in the management of personal intrusive thoughts: A controlled evaluation. Behaviour Research and Therapy. 2005;43:433–445. doi: 10.1016/j.brat.2004.03.005. [DOI] [PubMed] [Google Scholar]
  46. McCauley E, Katon W, Russo J, Richardson L, Lozano P. Impact of anxiety and depression on functional impairment in adolescents with asthma. General Hospital Psychiatry. 2007;29:214–222. doi: 10.1016/j.genhosppsych.2007.02.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. McCloughen A, Foster K, Huws-Thomas M, Delgado C. Physical health and wellbeing of emerging and young adults with mental illness: An integrative review of international literature. International Journal of Mental Health Nursing. 2012;21:274–288. doi: 10.1111/j.1447-0349.2011.00796.x. [DOI] [PubMed] [Google Scholar]
  48. McCracken LM, Sato A, Taylor GJ. A trial of a brief group-based form of acceptance and commitment therapy (ACT) for chronic pain in general practice: Pilot outcomes and process results. The Journal of Pain. 2013;14:1398–1406. doi: 10.1016/j.jpain.2013.06.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. McLean CP, Asnaani A, Litz BT, Hofmann SG. Gender differences in anxiety disorders: Prevalence, course of illness, comorbidity and burden of illness. Journal of Psychiatric Research. 2011;45:1027–1035. doi: 10.1016/j.jpsychires.2011.03.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Merikangas KR, Ames M, Cui L, Stang PE, Ustun B, Von Korff M, Kessler RC. The impact of comorbidity of mental and physical conditions on role disability in the US adult household population. Archives of General Psychiatry. 2007;64:1180–1188. doi: 10.1001/archpsyc.64.10.1180. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Milot E, Morissette-Thomas V, Li Q, Fried LP, Ferrucci L, Cohen AA. Trajectories of physiological dysregulation predicts mortality and health outcomes in a consistent manner across three populations. Mechanisms of Ageing and Development. 2014;141/142:56–63. doi: 10.1016/j.mad.2014.10.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Niles AN, Dour HJ, Stanton AL, Roy-Byrne PP, Stein MB, Sullivan G, … Craske MG. Anxiety and depressive symptoms and medical illness among adults with anxiety disorders. Journal of Psychosomatic Research. 2015;78:109–115. doi: 10.1016/j.jpsychores.2014.11.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Oh K, Cho S, Chung YK, Kim J, Chu MK. Combination of anxiety and depression is associated with an increased headache frequency in migraineurs: A population-based study. BMC Neurology. 2014;14:238. doi: 10.1186/s12883-014-0238-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Player MS, Peterson LE. Anxiety disorders, hypertension, and cardiovascular risk: A review. The International Journal of Psychiatry in Medicine. 2011;41:365–377. doi: 10.2190/PM.41.4.f. [DOI] [PubMed] [Google Scholar]
  55. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system: Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry. 1993;50:85–94. doi: 10.1001/archpsyc.1993.01820140007001. [DOI] [PubMed] [Google Scholar]
  56. Roemer L, Salters K, Raffa SD, Orsillo SM. Fear and avoidance of internal experiences in GAD: Preliminary tests of a conceptual model. Cognitive Therapy and Research. 2005;29:71–88. doi: 10.107/s10608-005-1650-2. [DOI] [Google Scholar]
  57. Roy-Byrne PP, Davidson KW, Kessler RC, Asmundson GJG, Goodwin RD, Kubzansky L, … Stein MB. Anxiety disorders and comorbid medical illness. General Hospital Psychiatry. 2008;30:208–225. doi: 10.1016/j.genhosppsych.2007.12.006. [DOI] [PubMed] [Google Scholar]
  58. Ruiz FJ. A review of acceptance and commitment therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies. International Journal of Psychology and Psychological Therapy. 2010;10:125–162. [Google Scholar]
  59. Sanna L, Stuart AL, Pasco JA, Kotowicz MA, Berk M, Girardi P, … Williams LJ. Physical comorbidities in men with mood and anxiety disorders: A population-based study. BMC Medicine. 2013;11:110. doi: 10.1186/1741-7015-11-110. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Sareen J, Jacobi F, Cox BJ, Belik S, Clara I, Stein MB. Disability and poor quality of life associated with comorbid anxiety disorders and physical conditions. Archive of Internal Medicine. 2006;166:2109–2116. doi: 10.1001/archinte.166.19.2109. [DOI] [PubMed] [Google Scholar]
  61. Scott KM, Bruffaerts R, Tsang A, Ormel J, Alonso J, Angermeyer MC, … Von Korff M. Depression-anxiety relationships with chronic physical conditions: Results from the world mental health surveys. Journal of Affective Disorders. 2007;103:113–120. doi: 10.1016/j.jad.2007.01.015. [DOI] [PubMed] [Google Scholar]
  62. Scott KM, Von Korff M, Alonso J, Angermeyer MC, Bromet E, Fayyad J, … Williams D. Mental-physical co-morbidity and its relationship with disability: Results from the world mental health surveys. Psychological Medicine. 2009;39:33–43. doi: 10.1017/S0033291708003188. [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Scott KM, Von Korff M, Angermeyer MC, Benjet C, Bruffaerts R, de Girolamo G, … Kessler RC. The association of childhood adversities and early onset mental disorders with adult onset chronic physical conditions. Archives of General Psychiatry. 2011;68:838–844. doi: 10.1001/archgenpsychiatry.2011.77. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Sheppard SC, Forsyth JP, Hickling EJ, Bianchi J. A novel application of acceptance and commitment therapy for psychosocial problems associated with multiple sclerosis: Results from a half-day workshop intervention. International Journal of MS Care. 2010;12:200–206. doi: 10.7224/1537-2073-12.4.200. [DOI] [Google Scholar]
  65. Simpson RJ, Kazmierczak T, Power KG, Sharp DM. Controlled comparison of the characteristics of patients with panic disorder. British Journal of General Practice. 1994;44:352–356. [PMC free article] [PubMed] [Google Scholar]
  66. Stein DJ, Scott K, Haro Abad JM, Aguilar-Gaxiola S, Alonso J, Angermeyer M, … Lara C. Early childhood adversity and later hypertension: Data from the world mental health survey. Annals of Clinical Psychiatry. 2010;22:19–28. [PMC free article] [PubMed] [Google Scholar]
  67. Stewart SH, Zvolensky MJ, Eifert GH. The relations of anxiety sensitivity, experiential avoidance, and alexithymic coping to young adults’ motivations for drinking. Behavior Modification. 2002;26:274–296. doi: 10.1177/0145445502026002007. [DOI] [PubMed] [Google Scholar]
  68. Swain J, Hancock K, Hainsworth C, Bowman J. Acceptance and commitment therapy in the treatment of anxiety: A systematic review. Clinical Psychology Review. 2013;33:965–978. doi: 10.1016/j.cpr.2013.07.002. [DOI] [PubMed] [Google Scholar]
  69. Tull MT, Roemer L. Emotion regulation difficulties associated with the experience of uncued panic attacks: Evidence of experiential avoidance, emotional nonacceptance, and decreased emotional clarity. Behavior Therapy. 2008;38:378–391. doi: 10.1016/j.beth.2006.10.006. [DOI] [PubMed] [Google Scholar]
  70. U.S. Census Bureau. Hinds county Mississippi QuickFacts from the US Census Bureau. 2010 http://www.census.gov/quickfacts/table/PST045215/28049/accessible#headnote-a.
  71. Valdez CE, Lilly MM. Thought control: Is it ability, strategies, or both that predicts posttraumatic symptomatology in victims of interpersonal trauma? Journal of Psychopathology and Behavioral Assessment. 2012;34:531–541. doi: 10.1007/s10862-012-9300-y. [DOI] [Google Scholar]
  72. Veehof MM, Oskam M, Schreurs KMG, Bohlmeijer ET. Acceptance-based interventions for the treatment of chronic pain: A systematic review and meta-analysis. Pain. 2011;152:533–542. doi: 10.1016/j.pain.2010.11.002. [DOI] [PubMed] [Google Scholar]
  73. Wegner DM, Shortt JW, Blake AW, Page MS. The suppression of exciting thoughts. Journal of Personality and Social Psychology. 1990;58:409–418. doi: 10.1037/0022-3514.58.3.409. [DOI] [PubMed] [Google Scholar]
  74. Zaubler TS, Katon W. Panic disorder in the general medical setting. Journal of Psychosomatic Research. 1998;44:25–42. doi: 10.1016/S0022-3999(97)00134-7. [DOI] [PubMed] [Google Scholar]

RESOURCES