A systematic review of reviews on the prevalence of anxiety disorders in adult populations

Elevated Plus Maze for Assessment of Anxiety and Memory in Rodents

The elevated plus maze is the most widely used paradigm to evaluate anxiety-associated behavioral alterations in rodent models of central nervous system (CNS) disorders. Unconditioned aversive behavior for open and elevated areas is a measure of anxiety and can be assessed by the plus maze. Plus maze consists of perpendicularly arranged open arms and closed arms crossed in the middle with a central platform. Rodents are allowed to explore the maze between the open and closed arms. The number of entries and time spent in the open arms and the closed arms are used as indicators for the anxiety nature of the animals. Transfer latency is a memory indicator that measures the amount of time it takes to move an animal from an open arm to a closed arm. This chapter describes the pretest conditions, materials required, and protocol for the conductance and evaluating the results for the anxiety and cognition-related behavior in rodents.

Dietary Inflammatory Potential, Inflammation-Related Lifestyle Factors, and Incident Anxiety Disorders: A Prospective Cohort Study

It is unclear whether diet-associated inflammation is related to the development of anxiety disorders. We aimed to investigate the association between energy-adjusted dietary inflammatory index (E-DII) scores and the incidence of anxiety disorders, and explore the joint effects of E-DII scores with other inflammatory lifestyles in enhancing anxiety risk. In the UK Biobank Study of 96,679 participants, baseline E-DII scores were calculated from the average intake of at least two 24 h dietary recalls. Multivariable-adjusted Cox models were used to evaluate the associations between E-DII scores and the incidence of total anxiety disorders, and primary types and subtypes; additive and multiplicative interactions of a pro-inflammatory diet and seven inflammatory lifestyles were examined. After a median follow-up of 9.4 years, 2785 incident cases of anxiety disorders occurred. Consuming a pro-inflammatory diet was significantly associated with a higher risk of total anxiety disorders (HRQ4vsQ1 = 1.12, 95% CI = 1.00-1.25), and positive associations were consistently identified for primary types and subtypes of anxiety disorders, with HRs ranging from 1.08 to 1.52, and were present in women only. Both additive and multiplicative interactions of current smoking and a proinflammatory diet on total anxiety risk were identified. A proinflammatory diet was associated with a higher incidence of anxiety disorders, and current smoking may synergize with a proinflammatory diet to promote anxiety risk, particularly among women.

Effectiveness of electroacupuncture on anxiety: a systematic review and meta-analysis of randomized controlled trials

This systematic review and meta-analysis aimed to comprehensively evaluate the effectiveness of electroacupuncture (EA) for patients with anxiety. Randomized controlled trials (RCTs) on the treatment of anxiety by EA up to November 2022 were searched and collected from nine databases. Hamilton Anxiety Rating Scale (HAMA), self-rating anxiety scale (SAS), and adverse reactions were used as outcome indicators. The quality of relevant articles was evaluated using the Cochrane Collaboration's risk of bias tool. The quality of evidence for each outcome was classified as "low risk," "unclear risk," or "high risk." RevMan 5.0 was used for data analysis. A total of 633 articles were identified from nine electronic databases; 37 RCTs were included, which measured anxiety changes by using EA alone compared to the control group. For the main outcome, EA significantly reduced the HAMA score [Mean difference (MD):-1.13 (95% CI:-2.55-0.29), I2:80%], and the quality of evidence was moderate. EA significantly reduced the SAS score (MD:-3.47 (95% CI,-6.57--0.36), I2:88%), and the quality of evidence was moderate. Our meta-analysis shows that EA reduces HAMA and SAS. This study suggests that EA can relieve anxiety. For various uses, additional research is needed on its effect when combined with other treatments.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=345658, identifier (CRD42022345658).

Relation among, trait anxiety, intolerance to uncertainty and early maltreatment experiences on fear discrimination learning and avoidance generalization online task

BACKGROUND AND OBJECTIVES

Early aversive experiences, which have been associated with elevated anxiety and intolerance of uncertainty (IUS), may contribute negatively to fear conditioning learning. The aim of the present study was to analyze the relation among individual differences in childhood maltreatment experiences, trait anxiety, and IUS in adulthood; and to determine how these variables could affect fear learning discrimination and avoidance generalization.

METHODS

We adapted an avoidance procedure in an online fear learning task. Two pictures of different lamp colors (CS+) were first associated with two aversive images (US), while a third color was not (CS-). Next, clicking a button during one CS + could effectively avoid the US (CS + av), but not during the other (CS + unav). Finally, avoidance generalization was tested to lamp colors that were between CS- and CS + av (safety dimension) and CS + av and CS + unav (avoidability dimension). With a sample of 67 participants, we measured ratings of relief, expectancy, and anxiety, as well as button presses and individual differences (STAI, IUS and MAES).

RESULTS

Aversive early experiences were positively related to trait anxiety and intolerance of uncertainty. The results of the task further suggested that maltreatment experience contributes to be more attentive to aversive signals, which could be implicated in leading to difficulties in discrimination learning.

LIMITATIONS

Online experiments implies some loss of control over subjects and environment that can threaten internal validity. Likewise, the commitment of participants may be low.

CONCLUSIONS

Results suggest that early aversive experience and anxiety could contribute to the development of IUS, which likely contributes to the development of avoidance behavior.

A cognitive-behavioral skills building program improves mental health and enhances healthy lifestyle behaviors in nurses and other hospital employees

BACKGROUND

Mental health outcomes in nurses have historically indicated a greater prevalence of anxiety, depression, and suicide than the general population. It is vital to provide programming for healthcare workers to gain the necessary skills to reduce burnout and improve their mental and physical health.

AIMS

The aims of this study were to evaluate mental health outcomes and healthy lifestyle beliefs and behaviors among nurses and other hospital employees who completed MINDBODYSTRONG, a cognitive-behavioral skill building program.

METHODS

A pre-experimental, pre- and poststudy design was used to examine mental health and well-being outcomes among 100 hospital personnel who participated in MINDBODYSTRONG, a program designed to improve coping and resiliency and decrease stress, anxiety, and depressive symptoms. Outcomes measured included healthy lifestyle behaviors, healthy lifestyle beliefs, anxiety, depression, stress, and burnout.

RESULTS

One hundred hospital personnel, including 93 nurses, completed the pre- and post-survey. Among all participants, post- MINDBODYSTRONG scores for healthy lifestyle beliefs (p = .00; Cohen's d = 0.52) and healthy lifestyle behaviors (p = .00; Cohen's d = -0.74) increased significantly with medium effects, while depression (p = .00; Cohen's d = -0.51), anxiety (p = .00; Cohen's d = -0.54), stress (p = .00; Cohen's d = -0.33), and burnout (p = .00; Cohen's d = -0.37) decreased significantly with small and medium effects. The program produced even stronger positive effects on mental health outcomes for participants who started the study with higher levels of depression and anxiety.

LINKING EVIDENCE TO PRACTICE

Anxiety, depression, stress, and burnout decreased significantly postintervention. Participants also significantly improved their healthy lifestyle beliefs and behaviors with the MINDBODYSTRONG program. MINDBODYSTRONG is an effective program that reduces anxiety, depression, burnout, and stress and improves healthy lifestyle beliefs and behaviors in hospital-based clinicians. It is of utmost importance to provide evidence-based programs to improve mental resiliency and decrease stress, anxiety, burnout, and depressive symptoms, which will ultimately improve the safety and quality of health care.

Prevalence of mental disorders among older Australians: Contrasting evidence from the 2020-2021 National Study of Mental Health and Wellbeing among men and women and the Health In Men Data Linkage Study

OBJECTIVE

To determine the prevalence of common mental disorders among older Australians included in the Health In Men Data Linkage Study and compare those with the results of the 2020-2021 National Study of Mental Health and Wellbeing (NSMHW).

METHOD

We used longitudinal record linkage to estimate the prevalence of mental disorders from age 65 years in a random sample of 38173 Australian men aged 65-85 years living in the Perth metropolitan region. Outcome was the proportion of participants affected by depressive episodes or dysthymia, bipolar disorder, anxiety disorder, psychotic disorder and alcohol use disorder.

RESULTS

Prevalence estimates for participants aged 65-69, 70-74, 75-79, 80-84 and ≥85 years were 0.9%, 2.0%, 3.6%, 5.8% and 12.6% for depressive, 0.2%, 0.3%, 0.4%, 0.4% and 0.7% for bipolar, 0.1%, 0.5%, 1.3%, 2.2%, 6.9% for anxiety, 0.2%, 0.4%, 0.5%, 0.4% and 0.6% for psychotic and 1.2%, 1.7%, 2.1%, 2.2% and 4.2% for alcohol use disorders.

CONCLUSIONS

In contrast to the NSMHW, our data indicate that the prevalence of depressive and anxiety disorders increases with age, particularly among the older old. We conclude that the NSMHW should not be relied upon to guide planning or policies to address the mental health needs of older Australians.

The prevalence of anxiety in adult endocrinology outpatients: A systematic review and meta-analysis

INTRODUCTION

Anxiety disorders and anxiety symptoms are common mental disorders in the medically unwell and have significant impacts on patients' quality of life and engagement with psychiatric and medical services. Several systematic reviews have examined the prevalence of anxiety in specific endocrinology settings with estimates varying significantly from study to study. No meta-analysis has examined anxiety rates across the endocrinology outpatient setting. The aim of this meta-analysis is to provide endocrinologists with a precise estimate of the prevalence of anxiety - and impacting factors - in their outpatient clinics.

METHOD

PubMed, Embase, Cochrane and PsycINFO databases and Google Scholar were searched to identify studies that assessed anxiety prevalence in endocrinology outpatients published up to 23 January 2023. This was part of a larger systematic review search of anxiety prevalence in common medical outpatient clinics. Data characteristics were extracted independently by two investigators. Studies of patients 16 years and older and representative of the clinic were included. The point prevalence of anxiety or anxiety symptoms was measured using validated self-report questionnaires or structured interviews. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Pooled estimates were analysed under the random-effects model and subgroup analyses on relevant variables were conducted under a mixed-effects model. Heterogeneity was assessed using the I2 statistic.

RESULTS

Fifty-nine studies with a total of 25,176 participants across 37 countries were included in this study. The overall pooled prevalence of anxiety or anxiety symptoms was 25·1% (95%CI 21·4-29·2; 6372/25,176; n = 59). Subgroup analyses revealed no difference in prevalence between outpatients with diabetes mellitus compared to other grouped endocrine disorders. Generalized Anxiety Disorder (GAD) was the most frequent clinical diagnosis 11·7% (95%CI 8·1-16·7; I2=87·93%; 443/4604; n = 17), while panic disorder was significantly higher in the non-diabetes group 9·5% (95%CI 5·9-14·9; I2=57·28%; 56/588; n = 8), compared to the diabetes group 5·2% (95%CI 3·7-7·3; I2=32·18%; 184/3669; n = 6). Estimates of prevalence were higher when assessed with a self-report scale 32·4% (95%CI 25·6-40·0; I2=96·06%; 1565/4675; n = 21) compared to diagnostic interview 17·6% (95%CI 12·2-24·7; I2=94·39%; 636/5168; n = 21). Outpatients in developing countries had higher rates of anxiety than those in developed countries. Female diabetes patients reported higher rates of anxiety compared to males.

CONCLUSION

Our study provides evidence that anxiety occurs frequently amongst endocrinology outpatients and at a higher rate than is estimated in the general population. Given the impact anxiety has on patient outcomes, it is important that effective management strategies be developed to support endocrinologists in identifying and treating these conditions in their outpatient clinics.

Shaping Memories Via Stress: A Synaptic Engram Perspective

Stress modulates the activity of various memory systems and can thereby guide behavioral interaction with the environment in an adaptive or maladaptive manner. At the cellular level, a large body of evidence indicates that (nor)adrenaline and glucocorticoid release induced by acute stress exposure affects synapse function and synaptic plasticity, which are critical substrates for learning and memory. Recent evidence suggests that memories are supported in the brain by sparsely distributed neurons within networks, termed engram cell ensembles. While the physiological and molecular effects of stress on the synapse are increasingly well characterized, how these synaptic modifications shape the multiscale dynamics of engram cell ensembles is still poorly understood. In this review, we discuss and integrate recent information on how acute stress affects synapse function and how this may alter engram cell ensembles and their synaptic connectivity to shape memory strength and memory precision. We provide a mechanistic framework of a synaptic engram under stress and put forward outstanding questions that address knowledge gaps in our understanding of the mechanisms that underlie stress-induced memory modulation.

Global Prevalence of Anxiety in Adult Cardiology Outpatients: A Systematic Review and Meta-analysis

Anxiety and anxiety disorders are associated with adverse cardiovascular outcomes, and reduced quality of life. Despite this, no comprehensive study on the global prevalence of anxiety symptoms and disorders among adult cardiology outpatients exists. This systematic review and meta-analysis aims to provide cardiologists with a precise estimate of the prevalence of anxiety in their outpatient clinics. PubMed, Embase, Cochrane and PsycINFO databases and Google Scholar were searched from database inception to January 23, 2023. Data characteristics were extracted independently by 2 investigators. Ninety-three studies, n = 36,687 participants across 31 countries, were included. Global prevalence of anxiety symptoms/disorders was 28.9% (95%CI 25.7-32.4; 8927/36, 687; I2 = 97.33; n = 93). The highest rates were found in patients presenting with hypertension, 43.6%. Subgroup analyses revealed higher prevalence estimates when using self-report screening compared to gold-standard diagnostic interview. When using diagnostic interview, the highest rates were reported in outpatients with undifferentiated chest pain/palpitations, 19·0%. Panic disorder was the most frequent diagnosis 15.3%, and rates were significantly higher in patients with undifferentiated chest pain/palpitations compared to ischemic heart disease. Higher rates of anxiety were found in studies of outpatients from developing countries, and female outpatients tended to have higher rates compared to males. Anxiety occurred frequently among cardiology outpatients and at a higher rate than estimated in the general population. Given the impact anxiety has on patient outcomes, it is important that effective identification and management strategies be developed to support cardiologists in identifying and treating these conditions in their clinics.

Yoga-based interventions may reduce anxiety symptoms in anxiety disorders and depression symptoms in depressive disorders: a systematic review with meta-analysis and meta-regression

OBJECTIVE

To summarise the effect of mind-body exercises on anxiety and depression symptoms in adults with anxiety or depressive disorders.

DESIGN

Systematic review with meta-analysis and meta-regression.

DATA SOURCES

Five electronic databases were searched from inception to July 2022. Manual searches were conducted to explore clinical trial protocols, secondary analyses of clinical trials and related systematic reviews.

ELIGIBILITY CRITERIA

Randomised clinical trials evaluating qigong, tai chi or yoga styles with anxiety or depression symptoms as the outcomes were included. No intervention, waitlist or active controls were considered as control groups. The risk of bias and the certainty of the evidence were assessed. Meta-analyses, meta-regressions and sensitivity analyses were performed.

RESULTS

23 studies, comprising 22 different samples (n=1420), were included. Overall, meta-analyses showed yoga interventions were superior to controls in reducing anxiety symptoms in anxiety disorders. Furthermore, yoga-based interventions decreased depression symptoms in depressive disorders after conducting sensitivity analyses. No differences between groups were found in the rest of the comparisons. However, the certainty of the evidence was judged as very low for all outcomes due to concerns of high risk of bias, indirectness of the evidence, inconsistency and imprecision of the results. In addition, there was marked heterogeneity among yoga-based interventions and self-reported tools used to evaluate the outcomes of interest.

CONCLUSION

Although yoga-based interventions may help to improve mental health in adults diagnosed with anxiety or depressive disorders, methodological improvements are needed to advance the quality of clinical trials in this field.

PROSPERO REGISTRATION NUMBER

CRD42022347673.

Anxiety in Parkinson's Patients: What's Timing Got to Do with It?

Background: Parkinson's Disease (PD) affects over 10 million people worldwide. Many PD patients experience comorbid anxiety disorders, which have been correlated with reduced quality of life and can manifest at any time during the course of PD, including prior to motor symptom onset. Purpose: Prior work has demonstrated that patients diagnosed with depression following a PD diagnosis are less likely to receive depression treatment, but no such study has been conducted for anxiety. Research Design: A cross-sectional analysis of secondary electronhic health record data was conducted. Study Sample: Data was obtained through Optum® de-identified Electronic Health Record dataset, using ICD-9 and ICD-10 diagnosis codes to determine PD status and comparing index date of anxiety and PD diagnoses to classify patients by relative time of diagnosis. Data Analysis: Multivariate logistic regression was performed to assess factors associated with receipt of mental health treatment. Results: Of PD patients with anxiety, 52% documented a diagnosis of anxiety prior to PD. Overall, 69% documented some treatment, with 79% of those diagnosed with anxiety prior to PD receiving some treatment compared to 59% of those diagnosed with anxiety on or after PD (P < 0.001). Conclusion: Patients with PD and subsequent anxiety diagnoses are less likely to receive treatment. Further study could explore reasons for variations in mental health care within the context of an existing PD diagnosis.

Sexual differentiation of neural mechanisms of stress sensitivity during puberty

Anxiety disorders are a major public health concern and current treatments are inadequate for many individuals. Anxiety is more common in women than men and this difference arises during puberty. Sex differences in physiological stress responses may contribute to this variability. During puberty, gonadal hormones shape brain structure and function, but the extent to which these changes affect stress sensitivity is unknown. We examined how pubertal androgens shape behavioral and neural responses to social stress in California mice (Peromyscus californicus), a model species for studying sex differences in stress responses. In adults, social defeat reduces social approach and increases social vigilance in females but not males. We show this sex difference is absent in juveniles, and that prepubertal castration sensitizes adult males to social defeat. Adult gonadectomy does not alter behavioral responses to defeat, indicating that gonadal hormones act during puberty to program behavioral responses to stress in adulthood. Calcium imaging in the medioventral bed nucleus of the stria terminalis (BNST) showed that social threats increased neural activity and that prepubertal castration generalized these responses to less threatening social contexts. These results support recent hypotheses that the BNST responds to immediate threats. Prepubertal treatment with the nonaromatizable androgen dihydrotestosterone acts in males and females to reduce the effects of defeat on social approach and vigilance in adults. These data indicate that activation of androgen receptors during puberty is critical for programming behavioral responses to stress in adulthood.

Looking Beyond the Chair: Psycho-Perceptual Predictors of Sexual Distress and Sexual Satisfaction in Individuals with Spinal Cord Injury

Despite a large body of biomedical research, little is known about the psychological and perceptual predictors of sexual satisfaction (SS) and sexual distress (SD) post spinal cord injury (SCI). Guided by a bio-psycho-perceptual framework, this cross-sectional research aimed at assessing SS and SD in a large SCI sample using validated patient-reported outcome measures (PROM). Significant correlates and predictors of SS and SD were also identified. Ninety-one men and women with SCI completed PROMs of SS and SD, as well as psychological (mood, sexual and body esteem) and perceptual (interoceptive awareness, trait mindfulness, sexual mindfulness) factors. Neurological profiles were also assessed, along with experience of orgasm. Correlates of SS and SD were first identified using Pearson's correlations, then multiple hierarchical regression models were computed to isolate predictors. Orgasm experience and psychological factors emerged as moderate correlates of both SS and SD, while neurological factors did not. Interoceptive awareness and trait mindfulness showed weak associations with SD and none with SS. Among the tested predictors, experience of orgasm emerged as the strongest for SS (β = -.29, p < .01), followed by mood, which predicted SS and SD. Sexual and body esteem was predictive of SD only. In sexually active participants, sexual mindfulness predicted both SS (β = 0.55, p < .001) and SD (β = -0.56, p < .001) above and beyond all other variables. This study reveals unique aspects of SS and SD postinjury and supports further consideration of psychological and perceptual dimensions of SCI sexuality in rehabilitation research.

Psychometric Properties of the Persian Version of Social Anxiety Scale for Social Media Users (SAS-SMU)

Objective: Social anxiety refers to an excessive concern or fear about social situations. It seems that social media, which has become one of the most popular and effective tools for communication today, can be one of the contexts of social anxiety. Due to the lack of a Persian instrument to assess social anxiety in the context of social networks, the current study was undertaken to analyze the psychometric criteria of the Iranian version of the Social Anxiety Scale for Social Media Users (SAS-SMU). The SAS-SMU is a 21-item questionnaire designed by Alkis and colleagues (2017) to measure social anxiety emerging from the social media platforms. Method : In this study, a total of 842 participants within the age range of 11 to 82 years old (mean age 33.11 ± 12.134), 59% female) answered the questions in an online survey. The original version of the scale was translated into Persian using the back translation procedure. All participants completed a Demographic Questionnaire, the SAS-SMU, and the Beck Anxiety Inventory. In order to analyze the collected data, internal and external consistency, factor analysis, construct validity, and confirmatory factor analysis (CFA) were examined. A significance level of less than 0.05 was considered to determine statistical significance. Results: Four subscales were obtained from the exploratory factor analysis (SCA, PCA, IA, and SEA), which were confirmed by the confirmatory factor analysis. Cronbach's alpha for internal consistency was found to be 0.931 for the total scale and 0.920, 0.846, 0.901, 0.828 for SCA, PCA, IA, and SEA, respectively. In addition, the test-retest scores of 30 participants (interval: between 2 to 3 weeks) for all four subscales (SCA = 0.641, PCA = 0.773, IA = 0.688, SEA = 0.727) indicated acceptable stability of the questionnaire over time. Conclusion: This study validates the Persian version of the SAS-SMU for use in studies in the field of psychological problems related to social media and online communications.

Is Increasing Diet Diversity of Animal-Source Foods Related to Better Health-Related Quality of Life among Chinese Men and Women?

Diet plays a crucial role in regulating individuals' lifestyles and is closely related to health. The intake of animal-sourced foods (ASF) provides the human body with high-quality protein and various micronutrients. This study aimed to investigate whether the diversity of animal foods has a positive impact on the health-related quality of life (HRQoL) among residents. The data came from the Shaanxi baseline survey of the Northwest Chinese Regional Ethnic Cohort Study, which recruited more than 100 thousand participants aged 35 to 74 from five provinces between June 2018 and May 2019. A total of 39,997 participants in Shaanxi (mean age: 50 years; 64% women) were finally included in this current study. The animal source food diet diversity score (ASFDDS) was established based on the frequency of consuming pork, mutton, beef, poultry, seafood, eggs, pure milk, and yogurt. The physical component score (PCS) and mental component score (MCS), ranging from 0 to 100 on the 12-Item Short Form Survey (SF-12), were used to assess participants' HRQoL. Better PCS/MCS was defined as scores higher than the 90th percentile. The results showed that men had a higher intake of ASF and ASFDDS than women. After adjusting for potential confounders, compared with those who never or rarely consumed animal foods, the likelihood of having better PCS and MCS increased by 16% (OR = 1.16, 95%CI: 1.01-1.34) and 24% (OR = 1.24, 95%CI: 1.03-1.448), respectively, in men with an ASFDDS ≥ 2. In women, a 34% increase (OR = l.34, 95%CI: 116-l.54) likelihood for better PCS was observed for an ASFDDS ≥ 2, but no association was observed for MCS. Increasing each specific animal source's food intake was associated with better PCS after adjusting for all covariates. However, for MCS, positive associations were only observed in seafood consumption among men and eggs among women. Restricted cubic splines showed a substantial dose-response association between intake frequency of animal-source foods and PCS, both in men and women. The study suggests that a diverse intake of animal-sourced foods can potentially improve the HRQoL of Chinese adults.

Changes in anxiety in the general population over a six-year period

BACKGROUND

Anxiety is a frequent condition in patients and in the general population. The aim of this study was to investigate changes in anxiety over time and to test several psychometric properties of the Generalized Anxiety Disorder Screener (GAD-7) from a longitudinal perspective.

METHODS

The GAD-7 was included in an examination with two waves, six years apart. The study sample (n = 5355) was comprised of representatively selected adults from the general population with a mean age of 57.3 (SD = 12.3) years.

RESULTS

During the 6-year time interval, anxiety increased significantly from 3.28 ± 3.16 (t1) to 3.66 ± 3.46 (t2). Confirmatory factor analyses proved the longitudinal measurement invariance of the GAD-7. Reliability of the GAD-7 was established both for the cross-sectional and the longitudinal perspective. The test-retest correlation was r = 0.53, and there were no substantial sex or age differences in these coefficients of temporal stability. The mean changes in anxiety were similar for males and females, and there was no linear age trend in the changes measured by the GAD-7. Changes in anxiety over the 6-year period were correlated with changes in satisfaction with life (r = -0.30), bodily complaints (r = 0.31), and the mental component of quality of life (r = -0.48).

CONCLUSION

The GAD-7 is a suitable instrument for measuring changes in anxiety. Age and gender have only minor significance when interpreting change scores.

Anxiety in Response to Sustaining Spinal Cord Injuries and Disorders: When Should Clinicians Be Concerned?

OBJECTIVE

To recommend a cut-off score for the brief 2-item Generalized Anxiety Disorder (GAD-2) measure for persons with spinal cord injuries/disorders (PwSCI/D) and to estimate anxiety occurrence within this population using the full 7-item Generalized Anxiety Disorder (GAD-7).

DESIGN

Multicenter retrospective analyses.

SETTING

One inpatient rehabilitation center and 2 community sites for PwSCI/D.

PARTICIPANTS

PwSCI/D 18 years or older (N=909) were included for analysis using retrospectively collected GAD-2 and GAD-7 data.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Occurrence of anxiety symptoms were compared using cut-off scores of ≥8 and ≥10 on the GAD-7. A cut-off score recommendation for the GAD-2 was determined using ROC curve, and sensitivity and specificity analyses.

RESULTS

Occurrence of anxiety symptoms was 21% using a GAD-7 cut-off of ≥8 and 15% using a cut-off of ≥10. Analyses indicated optimal sensitivity for a GAD-2 score of ≥2 when a GAD-7 cut-off of ≥8 was used.

CONCLUSIONS

Anxiety occurrence is elevated among PwSCI/D compared with the general population. For PwSCI/D, it is recommended that a cut-off score of ≥2 is used for the GAD-2 to maximize sensitivity and that a threshold of ≥8 is used for the GAD-7 to ensure the maximum number of individuals presenting with symptoms of anxiety are recognized for diagnostic interview. Study limitations are discussed.

The Association of Cytomegalovirus and Allostatic Load by Country of Birth and Length of Time in the United States

BACKGROUND

Cytomegalovirus (CMV) is a highly prevalent virus with a worldwide distribution. It typically remains dormant in most individuals until reactivation. Immunocompromised states are known to be potential causes for CMV reactivation. Current research has shown a link in the decline of immigrant health among those living in the US for an extended period, though the impact of CMV on this is not clear.

METHODS

This study investigated the association between country of birth, duration of US residency, allostatic load, and latent cytomegalovirus infection (CMV IgG) in a sample of US adults aged 20-49. The data utilized for our analysis was obtained from the National Health and Nutrition Examination Survey (NHANES) conducted between 2001 and 2004. Allostatic load, an index measuring the cumulative physiological strain on the body as it strives to regain stability in the presence of chronic stress, provided a valuable approach to assess stress within the context of CMV exposure. Logistic regression modeling was employed to estimate odds ratios and confidence intervals for the analysis. The chi-square test of association and Cramer's V statistic were used to assess the correlation among categorical variables, while Pearson's correlation coefficient was applied to evaluate the relationship between continuous variables. The results revealed that individuals born outside the US and those with less than 20 years of residency in the US exhibited significantly higher proportions of positive CMV IgG compared to individuals born in the US. Specifically, individuals born outside the US had more than triple the odds of CMV IgG when adjusting for the AL index (OR = 3.69, p-value = 0.0063). A similar trend was observed when examining AL risk based on the duration of US residency. Furthermore, age and sex were identified as significant predictors (p-value < 0.05) of AL risk, considering the individual's country of birth. In summary, the findings of this study significantly enhance our comprehension of the intricate interplay between cytomegalovirus (CMV) and allostatic load (AL). The investigation sheds light on how CMV and AL interact within specific demographic contexts, providing valuable insights into the underlying risk factors for CMV infection.

Concurrent validity of the anxiety symptom-scale compared to two well-being scales: results from the Lolland-Falster health study

OBJECTIVE

To examine the concurrent validity of the Anxiety Symptom-scale against two well-being scales, the Cantril Ladder (CL) and World Health Organization Well-Being Index (WHO-5), to test the algorithm defining anxiety against these scales, and identify cut-off points for the Anxiety Symptom-scale sum score.

SUBJECTS

14,405 adult respondents completing all psychometric questions in the Lolland Falster Health Study.

METHOD

Receiver operating characteristic analyses comparing Anxiety Symptom-scale WHO-5 and CL.

RESULTS

2.5% of respondents had an anxiety disorder (3% female and 2% male) according to the Anxiety Symptom-scale algorithm. The area under the curve (AUC) was 0.87 for CL and 0.90 for WHO-5 (using inverse scores), indicating high concordance with anxiety disorder as identified by the scale. A score solely ≥2 on item 10 is a relevant cut off to low wellbeing. Anxiety disorder covers a broad range on the scale's sum score, with 3 to 4 indicating low well-being in this population sample and a sensitivity of 0.85 - 0.99 against CL and WHO-5.

CONCLUSION

The Anxiety Symptom-scale is a sensitive and valid instrument for the identification of patients in low well-being with symptoms of anxiety. A score ≥2 on the functional impact (Item 10) of all symptoms is a relevant indicator of anxiety associated with low well-being in this sample. A higher Anxiety Symptom-scale sum score is coherent with lower well-being, though without specific cut-off points. Further validation of the Anxiety Symptom-scale in a clinical setting is recommended.

Assessment of depression and anxiety in young and old with a question-based computational language approach

Middle aged adults experience depression and anxiety differently than younger adults. Age may affect life circumstances, depending on accessibility of social connections, jobs, physical health, etc, as these factors influence the prevalence and symptomatology. Depression and anxiety are typically measured using rating scales; however, recent research suggests that such symptoms can be assessed by open-ended questions that are analysed by question-based computational language assessments (QCLA). Here, we study middle aged and younger adults' responses about their mental health using open-ended questions and rating scales about their mental health. We then analyse their responses with computational methods based on natural language processing (NLP). The results demonstrate that: (1) middle aged adults describe their mental health differently compared to younger adults; (2) where, for example, middle aged adults emphasise depression and loneliness whereas young adults list anxiety and financial concerns; (3) different semantic models are warranted for younger and middle aged adults; (4) compared to young participants, the middle aged participants described their mental health more accurately with words; (5) middle-aged adults have better mental health than younger adults as measured by semantic measures. In conclusion, NLP combined with machine learning methods may provide new opportunities to identify, model, and describe mental health in middle aged and younger adults and could possibly be applied to the older adults in future research. These semantic measures may provide ecological validity and aid the assessment of mental health.

Efficacy and safety of non-pharmacological therapy under the guidance of TCM theory in the treatment of anxiety in patients with myocardial infarction: A protocol for systematic review and meta-analysis

BACKGROUND

With the increasing pressures of modern life and work, combined with a growing older population, the incidence of comorbid anxiety and myocardial infarction (MI) is increasing. Anxiety increases the risk of adverse cardiovascular events in patients with MI and significantly affects their quality of life. However, there is an ongoing controversy regarding the pharmacological treatment of anxiety in patients with MI. The concomitant use of commonly prescribed selective serotonin reuptake inhibitors (SSRIs) and antiplatelet medications such as aspirin and clopidogrel may increase the risk of bleeding. Conventional exercise-based rehabilitation therapies have shown limited success in alleviating anxiety symptoms. Fortunately, non-pharmacological therapies based on traditional Chinese medicine (TCM) theory, such as acupuncture, massage, and qigong, have demonstrated promising efficacy in treating MI and comorbid anxiety. These therapies have been widely used in community and tertiary hospital settings in China to provide new treatment options for patients with anxiety and MI. However, current studies on non-pharmacological TCM-based therapies have predominantly featured small sample sizes. This study aims to comprehensively analyze and explore the effectiveness and safety of these therapies in treating anxiety in patients with MI.

METHOD

We will systematically search six English and four Chinese databases by employing a pre-defined search strategy and adhering to the unique rules and regulations of each database to identify studies that fulfilled our inclusion criteria, to qualify for inclusion, patients must be diagnosed with both MI and anxiety, and they must have undergone non-pharmacological TCM therapies, such as acupuncture, massage, or qigong, whereas the control group received standard treatments. The primary outcome measure will be alterations in anxiety scores, as assessed using anxiety scales, with secondary outcomes encompassing the evaluations of cardiopulmonary function and quality of life. We will utilize RevMan 5.3 to conduct a meta-analysis of the collected data, and subgroup analyses will be executed based on distinct types of non-pharmacological TCM therapies and outcome measures.

RESULTS

A narrative summary and quantitative analysis of the existing evidence on the treatment of anxiety patients with MI using non-pharmacological therapies guided by Traditional Chinese Medicine theory.

CONCLUSION

This systematic review will investigate whether non-pharmacological interventions guided by TCM theory are effective and safe for anxiety in patients with MI, and provide evidence-based support for their clinical application.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022378391.

Sex, anxiety and the interplay with physiological variables of stress: a clinical study of patients about to undergo bronchoscopy

Women often report more anxiety than men, but there are divergent results regarding the putative correlation between physiological variables, such as cortisol, blood pressure and heart rate and the experienced emotional states. The aim of the present study was to evaluate sex differences in anxiety, and the relation to serum cortisol, blood pressure and heart rate. We used data from two pooled studies with participants from the same population (N = 405) facing a real-life stressor, bronchoscopy, as part of examination for lung cancer. At admission, blood pressure and heart rate were recorded, and a blood sample was taken for analysis of serum cortisol. Participants then completed Spielberger's State Trait Anxiety Inventory (STAI). Patients had elevated anxiety measured with STAI state compared to relevant age and sex stratified norm scores. Women had significantly higher STAI state score than men (M = 44.9, SD = 13.2 vs M = 36.2, SD = 10.7; t(403) = 7.25, p < 0.001). Mean serum cortisol, systolic blood pressure and heart rate showed no significant sex difference. There was a weak but significant correlation between state anxiety and heart rate and cortisol but none between blood pressure and anxiety. This study adds an important confirmation of sex differences in anxiety in a real-life setting, where women report significantly more anxiety than men do. However, the physiological markers only show a weak link with experienced anxiety, and exhibit no sex differences.

mGluR5 in hippocampal CA1 pyramidal neurons mediates stress-induced anxiety-like behavior

Pharmacological manipulation of mGluR5 has showed that mGluR5 is implicated in the pathophysiology of anxiety and mGluR5 has been proposed as a potential drug target for anxiety disorders. Nevertheless, the mechanism underlying the mGluR5 involvement in stress-induced anxiety-like behavior remains largely unknown. Here, we found that chronic restraint stress induced anxiety-like behavior and decreased the expression of mGluR5 in hippocampal CA1. Specific knockdown of mGluR5 in hippocampal CA1 pyramidal neurons produced anxiety-like behavior. Furthermore, both chronic restraint stress and mGluR5 knockdown impaired inhibitory synaptic inputs in hippocampal CA1 pyramidal neurons. Notably, positive allosteric modulator of mGluR5 rescued stress-induced anxiety-like behavior and restored the inhibitory synaptic inputs. These findings point to an essential role for mGluR5 in hippocampal CA1 pyramidal neurons in mediating stress-induced anxiety-like behavior.

Psychometric Properties and Factorial Structure of Postpartum-Specific Anxiety Scale (PSAS) Within Arabic Language in a Palestinian Context

BACKGROUND

The Postpartum-Specific Anxiety Scale (PSAS) is an international measure designed to evaluate anxiety experienced by mothers in the postpartum period from one day to six months; the scale was translated into Arabic and validated within Palestinian context to test postpartum anxiety among Palestinian women.

AIMS

The current study aimed to test the psychometric properties and the factorial structure within the Arabic language in a Palestinian context using confirmatory factor analysis (CFA). The sample of this study consisted of 475 Palestinian women recruited from health centers in the West Banks of Palestine using a convenience sample. 61% were of ages 20-30 years and 39% percent ages 31-40 years.

FINDINGS

The PSAS showed good validity and reliability indicators in assessing postpartum anxiety within Palestinian context. Results of CFA showed a stable construct of a four-factor structure in assessing postpartum anxiety among Palestinian mothers: (1) competence and attachment anxieties, (2) infant safety and welfare anxieties, (3) practical baby care anxieties and (4) psychosocial adjustment to motherhood, which is consisting with the original four-factor structure of the scale.

CONCLUSIONS

The PSAS showed good validity indicators within Palestinian context. Therefore, it is recommended to conduct similar studies with clinical and non-clinical groups in the Palestinian society. The PSAS can be a useful measure to assess anxiety levels among women during the postpartum months; which will enable mental health providers to provide psychological interventions for mothers whose anxiety levels are high.

Group-based active artistic interventions for adults with primary anxiety and depression: a systematic review

OBJECTIVES

This systematic review examined the potential benefit of all group-based performing arts interventions for primary anxiety and/or depression.

SETTING

Scholarly literature from any country or countries globally.

DATA SOURCES

Three key bibliographic databases, Google Scholar and relevant citation chasing.

PRIMARY AND SECONDARY OUTCOME MEASURES

Depression and/or anxiety symptom severity, well-being, quality of life, functional communication or social participation.

RESULTS

Database searches returned a total of 63 678 records, of which 56 059 remained following dededuplication. From these database searches, a total of 153 records proceeded to full-text screening. These were supplemented by 18 additional unique full-text screening records from Google Scholar searches and citation chasing (12% of total). From a total of 171 records at the full-text screening stage, 12 publications (7%) were eligible for inclusion in this systematic review, each reporting on a separate study. Published from 2004 to 2021, these studies involved a total of 669 participants with anxiety and/or depression from nine countries and covered five broad artistic modalities: dance, music therapy, art therapy, martial arts and theatre. Dance was the most studied artistic modality (five studies), while there were three studies on art therapy, two on music therapy and one each on martial arts and theatre. The evidence was clearest for a benefit of arts therapies on depression and/or anxiety symptoms.

CONCLUSIONS

This systematic review addresses all group-based active arts interventions in a focused population of primary anxiety and/or depression. The evidence suggests that the arts may be a useful therapeutic medium in this population. However, a substantial limitation of the evidence base is the lack of studies directly comparing different artistic modalities. Moreover, not all artistic modalities were assessed for all outcome domains. Therefore, it is not currently possible to determine which artistic modalities are most beneficial for which specific outcomes.

Inappropriate Medications Use and Polypharmacy among Older Adults with Anxiety Disorder

BACKGROUND

Elderly with mental health conditions usually use multiple medications, which predisposes them to inappropriate use of medications, which is defined as medications that should be avoided due to their risk; this outweighs their benefit given that safer alternatives are available. This study aimed to examine potentially inappropriate medication use among older patients with anxiety disorder.

METHODS

This study used a cross-sectional retrospective study design using twelve months of data extracted from the Electronic Health Record (EHR) database for older adults diagnosed with anxiety disorder and treated in the ambulatory care setting. Potentially inappropriate medications (PIMs) use was evaluated using the 2019 Beers criteria. Descriptive statistics were used to describe the sample. Pearson's chi-square tests (for categorical variables) and t-tests (for continuous variables) were utilized to measure the differences in independent variables between patients with and without PIMs. Binary logistic regression was used to examine the associations between PIMs use and identify potential factors for PIMs use among older adults with anxiety disorder. Analyses were performed using the Statistical Analysis Software version 9.4 (SAS^® 9.4).

RESULTS

The study sample includes 371 older adults (age ≥ 65 years) with anxiety disorder; their average age was (72.1 ± 5.8) years. PIMs use was highly prevalent among older adults with anxiety (66.6%). About 35.6% of the study sample used one PIM, 22.6% used two PIMs, and 8.4% used three PIMs. The most frequently prescribed PIMs were NSAIDs and gastrointestinal agents. The adjusted regression analysis found that PIMs use was less likely among men than women. In addition, PIMs use was more likely among women with diabetes, cancer, and polypharmacy.

CONCLUSIONS

Future studies on strategies and interventions rationing PIMs use in older adults with anxiety disorder are necessary given the high prevalence of PIMs and polypharmacy within this population.

Remotely and collaboratively evaluating a campus-based therapy dog program during the COVID-19 pandemic

The COVID-19 pandemic adversely affected the wellbeing of university students and adults in general, emphasizing the need for mental health programming that was compliant with physical distancing mandates. The present evaluation investigated mental health and social connection within the context of COVID-19 by remotely evaluating a virtual animal-assisted activity at the University of Saskatchewan - PAWS Your Stress. The purpose of this article is to outline our evaluation methods and findings, while calling specific attention to the collaborative strategies that were implemented within a remote, time-sensitive context. The evaluation findings revealed that remote animal-assisted programming can facilitate connections with humans and animals, and promote multiple mental health benefits, despite the lack of physical interaction with the animals. Our lessons learned indicate that remote program logic modelling workshops are feasible when suited to audience demographics. Further, our experience suggests that the Most Significant Change technique (a qualitative, participatory, storytelling method that elicits outcome data) can be useful in time-restricted evaluations, and the necessity of central steps in the process may vary depending on evaluation goals. This project has implications for future evaluation work, by demonstrating the effective use of remote methods that allowed for successful stakeholder collaboration.

Impaired fear memory in a rat model of the Brain-Derived Neurotrophic Factor Val66Met polymorphism is reversed by chronic exercise

The brain-derived neurotrophic factor (BDNF) Val66Met polymorphism is associated with reduced activity-dependent BDNF release in the brain and has been implicated in fear and anxiety disorders, including post-traumatic stress disorder. Exercise has been shown to have benefits in affective disorders but the role of BDNF Val66Met remains unclear. Male and female BDNF Val66Met rats were housed in automated running-wheel cages from weaning while controls were housed in standard cages. During adulthood, all rats underwent standard three-day fear conditioning testing, with three tone/shock pairings on day 1 (acquisition), and extinction learning and memory (40 tones/session) on day 2 and day 3. Expression of BDNF and stress-related genes were measured in the frontal cortex. Extinction testing on day 2 revealed significantly lower freezing in response to initial cue exposure in control Met/Met rats, reflecting impaired fear memory. This deficit was reversed in both male and female Met/Met rats exposed to exercise. There were no genotype effects on acquisition or extinction of fear, however chronic exercise increased freezing in all groups at every stage of testing. Exercise furthermore led to increased expression of Bdnf in the prefrontal cortex of females and its isoforms in both sexes, as well as increased expression of FK506 binding protein 51 (Fkpb5) in females and decreased expression of Serum/glucocorticoid-regulated kinase (Sgk1) in males independent of genotype. These results show that the Met/Met genotype of the Val66Met polymorphism affects fear memory, and that chronic exercise selectively reverses this genotype effect. Chronic exercise also led to an overall increase in freezing in all genotypes which may contribute to results.

The impact of insomnia on anxiety and depression: a longitudinal study of non-clinical young Chinese adult males

Insomnia, anxiety, and depression commonly co-occured and were closely related. Most of the prior studies were cross-sectional, with a poor ability to infer causality. Longitudinal study was needed to classify the relationships. The present study conducted a longitudinal study of non-clinical young Chinese males to investigate whether insomnia predicted the likelihood of future anxiety and depression, and vice versa. Convenient sampling method was applied, and 288 participants was recruited from Shanghai in October 2017 with Athens Insomnia Scale (AIS), Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9). 120 of them were re-tested in June 2018. The drop-out rate was 58.33%. Correlation analyses and cross-lagged analysis showed that AIS global score was significantly positively related with scores of depression and anxiety at baseline and follow-up. Insomnia was a predictive factor of anxiety, but it can't predict depression. In sum, insomnia may be an important cause of anxiety, while no predictive relationship was found between insomnia and depression.

Association between breast nodules, anxiety, depression and metabolic risk factors in a Chinese cohort

Background

The relationship between anxiety, depression, and metabolic parameters and the incidence of breast nodules is unclear. This study aims to investigate the association between female breast nodules and anxiety, depression and metabolic factors.

Methods

This cross-sectional study recruited 857 individuals with biological indicators and breast ultrasound data from the Daping hospital from April 2021 to February 2022. Serum samples were used to measure fasting blood glucose, uric acid, triglycerides, total cholesterol, urea nitrogen, alanine transaminase, aspartate transaminase, albumin, high-density lipoprotein, low-density lipoprotein. Self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to assess the level of anxiety and depression.

Result

The positive rate of breast nodules in women aged 40 to 49 years old was significantly higher than that of other age women. The proportion of participants aged 40-49 years old in the group with breast nodules was significantly higher than that in the group without breast nodules (34.6% vs. 16.9%, p<0.001). Breast nodules in postmenopausal women were significantly lower than those in premenopausal women (26.4% vs. 73.6%, p = 0.026). The SAS scores of women with breast nodules were higher than those of the no-nodules group (40.99 ± 8.45 vs. 38.94 ± 6.89, p<0.001), same as the SDS scores (41.97 ± 10.33 vs. 38.91 ± 7.60, p < 0.001). The number of women suffering from anxiety in the group of breast nodules was significantly higher than that in control (13.8% vs. 4.5%, p < 0.001), and the number of depression in the group of breast nodules was also significantly higher than that of in control (14.4% vs. 4.5%, p < 0.001). Women with breast nodules showed a slightly lower uric acid level than those without breast nodules (290.11 ± 65.32 vs. 301.43 ± 65.93 umol/L, p = 0.016). Multivariable logistic regression analysis showed that age, menopausal status, anxiety and depression status were significantly associated with the presence of breast nodules, but there was no significant difference in uric acid.

Conclusion

Our findings offer insight into the occurrence of depression and anxiety in the breast nodules of Chinese women. Anxiety and depression status, age and menopausal status may be the independent risk factors for the occurrence of breast nodules.

Analysis of the prevalence and influencing factors of anxiety and depression in the Chinese population: A cross-sectional survey

To explore the prevalence and influencing factors of anxiety and depression symptoms among Chinese people in 2021. Investigation teams were recruited in 120 cities across the country. Based on the data from "the Seventh National Population Census in 2021″, quota sampling was conducted on the residents of these cities to obtain samples that conformed to population characteristics. Next, baseline information on research objects was collected, and the questionnaire survey was conducted through the online questionnaire Wenjuanxing platform. The Patient Health Questionnaire-9 (PHQ-9) rating scale was used to evaluate the mental state of the subjects. The correlation between baseline information and different PHQ-9 risk intervals was analyzed using the Chi-square test and Logit model. The impact of relevant risk factors on PHQ-9 scores was analyzed using the decision tree. The Chi-square test results revealed that place of residence (p = 0.438) and obesity (p = 0.443) was not significantly correlated with PHQ-9 risk intervals. According to Logit model analysis, age (p = 0.001, 95%CI 0.84-0.96), marital status (p < 0.001, 95%CI 0.71-0.89), drinking (p < 0.001, 95%CI 1.07-1.18), diabetes or hypertension (p = 0.001, 95%CI 1.11-1.47), health care (p < 0.001, 95%CI 0.53-0.66), economic welfare (p = 0.022, 95%CI 0.85-0.99), COVID-19 vaccine (p < 0.001, 95%CI 1.28-1.72), and HPV vaccine (p < 0.001, 95%CI 0.46-0.57) were potential influencing factors of PHQ-9 risk intervals. Decision tree analysis results showed that the grouping strategy in the PHQ-9 two-side groups had a better classification effect on the questionnaire population according to the PHQ-9 score characteristics. The prevalence rate of moderate to severe depression among Chinese people was about 8.29%. Age, marital status, drinking, diabetes or hypertension, health care, economic well, COVID-19 vaccine, and HPV vaccine were potential influencing factors of anxiety and depression symptoms in Chinese people.

miR-483-5p offsets functional and behavioural effects of stress in male mice through synapse-targeted repression of Pgap2 in the basolateral amygdala

Severe psychological trauma triggers genetic, biochemical and morphological changes in amygdala neurons, which underpin the development of stress-induced behavioural abnormalities, such as high levels of anxiety. miRNAs are small, non-coding RNA fragments that orchestrate complex neuronal responses by simultaneous transcriptional/translational repression of multiple target genes. Here we show that miR-483-5p in the amygdala of male mice counterbalances the structural, functional and behavioural consequences of stress to promote a reduction in anxiety-like behaviour. Upon stress, miR-483-5p is upregulated in the synaptic compartment of amygdala neurons and directly represses three stress-associated genes: Pgap2, Gpx3 and Macf1. Upregulation of miR-483-5p leads to selective contraction of distal parts of the dendritic arbour and conversion of immature filopodia into mature, mushroom-like dendritic spines. Consistent with its role in reducing the stress response, upregulation of miR-483-5p in the basolateral amygdala produces a reduction in anxiety-like behaviour. Stress-induced neuromorphological and behavioural effects of miR-483-5p can be recapitulated by shRNA mediated suppression of Pgap2 and prevented by simultaneous overexpression of miR-483-5p-resistant Pgap2. Our results demonstrate that miR-483-5p is sufficient to confer a reduction in anxiety-like behaviour and point to miR-483-5p-mediated repression of Pgap2 as a critical cellular event offsetting the functional and behavioural consequences of psychological stress.

Anxiolytic-like Effects and Quantitative EEG Profile of Palmitone Induces Responses Like Buspirone Rather Than Diazepam as Clinical Drugs

Anxiety is a mental disorder with a growing worldwide incidence due to the SARS-CoV-2 virus pandemic. Pharmacological therapy includes drugs such as benzodiazepines (BDZs) or azapirones like buspirone (BUSP) or analogs, which unfortunately produce severe adverse effects or no immediate response, respectively. Medicinal plants or their bioactive metabolites are a shared global alternative to treat anxiety. Palmitone is one active compound isolated from Annona species due to its tranquilizing activity. However, its influence on neural activity and possible mechanism of action are unknown. In this study, an electroencephalographic (EEG) spectral power analysis was used to corroborate its depressant activity in comparison with the anxiolytic-like effects of reference drugs such as diazepam (DZP, 1 mg/kg) and BUSP (4 mg/kg) or 8-OH-DPAT (1 mg/kg), alone or in the presence of the GABA_A (picrotoxin, PTX, 1 mg/kg) or serotonin 5-HT_1A receptor antagonists (WAY100634, WAY, 1 mg/kg). The anxiolytic-like activity was assayed using the behavioral response of mice employing open-field, hole-board, and plus-maze tests. EEG activity was registered in both the frontal and parietal cortex, performing a 10 min baseline and 30 min recording after the treatments. As a result, anxiety-like behavior was significantly decreased in mice administered with palmitone, DZP, BUSP, or 8-OH-DPAT. The effect of palmitone was equivalent to that produced by 5-HT_1A receptor agonists but 50% less effective than DZP. The presence of PTX and WAY prevented the anxiolytic-like response of DZP and 8-OH-DPAT, respectively. Whereas only the antagonist of the 5-HT_1A receptor (WAY) inhibited the palmitone effects. Palmitone and BUSP exhibited similar changes in the relative power bands after the spectral power analysis. This response was different to the changes induced by DZP. In conclusion, brain electrical activity was associated with the anxiolytic-like effects of palmitone implying a serotoninergic rather than a GABAergic mechanism of action.

Association between obstructive sleep apnea and risk for post-stroke anxiety: A Chinese hospital-based study in noncardiogenic ischemic stroke patients

OBJECTIVE

This study explored the role of obstructive sleep apnea (OSA) in post stroke anxiety (PSA) in noncardiogenic ischemic stroke patients.

METHODS

180 patients with noncardiogenic ischemic stroke were consecutively enrolled from January 2019 to December 2019. All patients underwent polysomnography (PSG) to assess for OSA. OSA severity was identified based on the apnea hypopnea index (AHI), i.e., no OSA (AHI <5), mild OSA (5 = AHI <15), and moderate to severe OSA (AHI ≥15). Neuropsychological assessments were performed at acute phase and 6 months later to evaluate anxiety (Chinese version of the Zung self-rating anxiety scale [SAS], and Beck Anxiety Inventory [BAI]), depression (Patient Health Questionnaire-9, [PHQ-9]), and cognition (Mini-mental state examination, [MMSE], and Montreal Cognitive Assessment, [MOCA]). Clinical diagnoses of PSA were made based on interviews and the anxiety scales. The correlations between PSA and OSA were investigated in Logistic regression analysis.

RESULTS

The prevalence of acute-phase and 6-month PSA were 27 (15%) and 52 (28.9%) respectively. Moderate to severe OSA and post-stroke depression (PSD) were the influencing factors of acute-phase PSA. 6-Month PSA was not associated with OSA but was associated with acute-phase anxiety, education status and MOCA. Logistic regression analysis including respiratory and sleeping parameters showed that AHI and micro-arousal index contributed to acute-phase PSA.

CONCLUSIONS

Acute-phase PSA was associated with OSA severity, potentially through OSA-caused sleep discontinuity. While 6-month PSA was associated with acute-phase anxiety, highlighting the need for integration of screening for and management of OSA and PSA at acute phase.

Homework, sleep insufficiency and adolescent neurobehavioral problems: Shanghai Adolescent Cohort

BACKGROUND

The prospective associations between homework burdens and adolescent neurobehavioral problems, and whether sleep-durations mediated and sex modified such associations remained unclear.

METHODS

Using Shanghai-Adolescent-Cohort study, 609 middle-school students were recruited and investigations took place at Grade 6, 7 and 9. Information on homework burdens (defined by homework completion-time and self-perceived homework difficulty), bedtime/wake-up-time and neurobehavioral problems was collected. Two patterns of comprehensive homework burdens ('high' vs. 'low') were identified by latent-class-analysis and two distinct neurobehavioral trajectories ('increased-risk' vs. 'low-risk') were formed by latent-class-mixture-modeling.

RESULTS

Among the 6th-9th graders, the prevalence-rates of sleep-insufficiency and late-bedtime ranged from 44.0 %-55.0 % and 40.3 %-91.6 %, respectively. High homework burdens were concurrently associated with increased-risks of neurobehavioral problems (IRRs: 1.345-1.688, P < 0.05) at each grade, and such associations were mediated by reduced sleep durations (IRRs for indirect-effects: 1.105-1.251, P < 0.05). High homework burden at the 6th-grade (ORs: 2.014-2.168, P < 0.05) or high long-term (grade 6-9) homework burden (ORs: 1.876-1.925, P < 0.05) significantly predicted increased-risk trajectories of anxiety/depression and total-problems, with stronger associations among girls than among boys. The longitudinal associations between long-term homework burdens and increased-risk trajectories of neurobehavioral problems were mediated by reduced sleep-durations (ORs for indirect-effects: 1.189-1.278, P < 0.05), with stronger mediation-effects among girls.

LIMITATIONS

This study was restricted to Shanghai adolescents.

CONCLUSIONS

High homework burden had both short-term and long-term associations with adolescent neurobehavioral problems, with stronger associations among girls, and sleep-insufficiency may mediate such associations in a sex-specific manner. Approaches targeting appropriate homework-load/difficulty and sleep restoration may help prevent adolescent neurobehavioral problems.

Association between gut microbiota and anxiety symptoms: A large population-based study examining sex differences

BACKGROUND

This study aimed to examine the association between anxiety symptoms and gut microbial composition and to infer their functional pathways.

METHODS

In total, 605 participants were included in this study. Participants were categorized into anxious and non-anxious groups according to their Beck Anxiety Inventory scores, and their fecal microbiota was profiled using 16S ribosomal RNA gene sequencing. The microbial diversity and taxonomic profiles of the participants with anxiety symptoms were analyzed using generalized linear models. The function of the gut microbiota was inferred by comparing 16S rRNA data between the anxious and non-anxious groups.

RESULTS

The gut microbiome of the anxious group showed lower alpha diversity than that of the non-anxious group, and there were prominent differences in the community structure of the gut microbiota between the two groups. Male participants with anxiety had lower relative abundances of the family Oscillospiraceae, fibrolytic bacteria including those of the family Monoglobaceae, and short-chain fatty acid-producing bacteria such as those of the genus Lachnospiraceae_NK4A136 than those without anxiety symptoms. Female participants with anxiety symptoms had a lower relative abundance of the genus Prevotella than those without anxiety symptoms.

LIMITATION

The direction of causality between anxiety symptoms and the gut microbiota was unclear owing to the cross-sectional design of the study.

CONCLUSION

Our results elucidate the association between anxiety symptoms and gut microbiota and provide insights for developing interventions to treat anxiety symptoms.

The patients' experience of neuroimaging of primary brain tumors: a cross-sectional survey study

PURPOSE

To gain insight into how patients with primary brain tumors experience MRI, follow-up protocols, and gadolinium-based contrast agent (GBCA) use.

METHODS

Primary brain tumor patients answered a survey after their MRI exam. Questions were analyzed to determine trends in patients' experience regarding the scan itself, follow-up frequency, and the use of GBCAs. Subgroup analysis was performed on sex, lesion grade, age, and the number of scans. Subgroup comparison was made using the Pearson chi-square test and the Mann-Whitney U-test for categorical and ordinal questions, respectively.

RESULTS

Of the 100 patients, 93 had a histopathologically confirmed diagnosis, and seven were considered to have a slow-growing low-grade tumor after multidisciplinary assessment and follow-up. 61/100 patients were male, with a mean age ± standard deviation of 44 ± 14 years and 46 ± 13 years for the females. Fifty-nine patients had low-grade tumors. Patients consistently underestimated the number of their previous scans. 92% of primary brain tumor patients did not experience the MRI as bothering and 78% would not change the number of follow-up MRIs. 63% of the patients would prefer GBCA-free MRI scans if diagnostically equally accurate. Women found the MRI and receiving intravenous cannulas significantly more uncomfortable than men (p = 0.003). Age, diagnosis, and the number of previous scans had no relevant impact on the patient experience.

CONCLUSION

Patients with primary brain tumors experienced current neuro-oncological MRI practice as positive. Especially women would, however, prefer GBCA-free imaging if diagnostically equally accurate. Patient knowledge of GBCAs was limited, indicating improvable patient information.

A Gender-Based Point of View in Pediatric Neurology

While the significance of gender has only recently been recognized, gender assigned at birth has long been understood to have a significant influence on a number of illnesses. Due to the paucity of data in this regard in pediatrics, the purpose of this narrative review is to frame the most recent knowledge about the role of gender assigned at birth in the neurological development and neuropsychiatric disorders among young people. Literature analysis showed that gender disparities exist in neurologic and neuropsychiatric disorders among the pediatric population and supported the fact that new guidelines should take this into account. However, there is an urgent need for specific studies focused on gender role among children and adolescents in order to better understand how this can relate to diagnosis, development and treatment of different neurologic and neuropsychiatric diseases. Moreover, further efforts should be directed to identify unique risks linked to gender disorders and gender dysphoria as well as taking into account a gender point of view when approaching a pediatric patient.

Prevalence and Odds of Depressive and Anxiety Disorders and Symptoms in Children and Adults With Alopecia Areata: A Systematic Review and Meta-analysis

Importance

Two recent meta-analyses reported a high prevalence of both anxiety and depression in patients with alopecia areata (AA), as well as a positive association of AA with anxiety and depression, without distinguishing between disorders and symptoms. Yet, depression and anxiety can manifest either as symptoms identified in questionnaires or as specific diagnoses defined by Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision criteria.

Objective

To perform a large meta-analysis separating the prevalence of depressive and anxiety disorders from that of depressive and anxiety symptoms in patients with AA.

Data Sources

PubMed, ScienceDirect, the Cochrane Library, Embase, and PsycINFO databases were searched from inception through August 1, 2020.

Study Selection

Studies that contained data on the prevalence of depressive or anxiety disorders or symptoms were included.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines were used. Pooled prevalence was calculated with a random effects model meta-analysis that took into account between- and within-study variability. Meta-regressions were used to study the association between variations in prevalence and study characteristics.

Main Outcomes and Measures

The prevalence of depressive and anxiety disorders and symptoms in patients with AA.

Results

Thirty-seven articles (29 on depression and 26 on anxiety) that met the inclusion criteria were identified. By distinguishing between disorders and symptoms, the prevalence of both depressive disorders (9%) and unspecified anxiety disorders (13%) in patients with AA was shown to be greater than that in the general population. The prevalence and odds ratio (OR) of depressive disorders (prevalence, 9%; OR, 1.38) and anxiety disorders of which each category had been specifically studied (prevalence, 7%-17%; OR, 1.51-1.69) were markedly lower than that of depressive symptoms (prevalence, 37%; OR, 2.70) and anxiety symptoms (prevalence, 34%; OR, 3.07). Meta-regressions showed that variations in prevalence were mainly associated with methodological differences between studies.

Conclusions and Relevance

In this systematic review and meta-analysis, the separate analyses showed that 7% to 17% of patients with AA had depressive or anxiety disorders that require psychiatric care, including specific medication. Additionally, more than one-third of patients had symptoms that are warning signs and that need monitoring because they can develop into disorders.

Efficacy of the myofascial approach as a manual therapy technique in patients with clinical anxiety: A randomized controlled clinical trial

BACKGROUND

To analyze the efficacy of the myofascial approach in patients with clinical anxiety and to study its relationship with associated symptoms.

METHODS

Randomized placebo-controlled clinical trial. Thirty-six adult patients with clinical anxiety were randomized to receive the myofascial treatment (n = 18) or placebo (n = 18). The patients and the evaluators were blinded to this assignation. The treatment consisted of four myofascial sessions of 40 min each for four weeks. The placebo intervention consisted of four sessions of simulated myofascial intervention of the same duration and frequency as the treatment. Follow-up was at one, three and six months. The primary outcome was clinical anxiety measured using the STAI (State-Trait Anxiety Inventory). Secondary outcomes were central sensitization, general health, somatization, depression, and pain.

RESULTS

There were significant differences in the behavior of the groups over time for clinical anxiety (STAI Trait-Anxiety) (p < 0.001), central sensitization (p = 0.005) and somatization (p = 0.008) in favor of the myofascial group, with a large effect size for anxiety and a medium effect size for central sensitization and somatization. Regarding clinical anxiety, after the intervention a mean difference was observed with respect to the baseline of 19.98 points in the myofascial group (p < 0.001) and 5.95 in the placebo group (p = 0.22). The intention-to-treat principle was used. There were no adverse events or side effects in either group.

CONCLUSIONS

The myofascial approach is effective in improving anxiety levels and associated central sensitization processes in patients with clinical anxiety and this improvement is maintained over time.

CLINICAL TRIAL REGISTRATION

NCT04826302.

'Feel like going crazy': Mental health discourses in an online support group for mothers during COVID-19

COVID-19 has become a mental health pandemic. The impact on vulnerable demographic groups has been particularly severe. This paper focuses on women in employment in Hong Kong who have had to balance remote work and online schooling for over 2 years. Using semi-ethnography and theme-oriented discourse analysis, we examine 200 threads that concern members' mental health on a popular Facebook support group for mothers. We demonstrate that mental health messages are typically framed as 'troubles talk'. Other support group members actively align with a trouble-teller through 'caring responses', namely expressions of empathy and sympathy. These are realized through assessments of the trouble-teller's experience, reports of similar experiences; expressions of compassion and advice-giving. Mental health talk online is heavily mitigated, nevertheless the medium provides a space for expressing mental health troubles and providing informal psychosocial support. We advocate the importance of microanalytic discourse studies for mental health research to get insights into people's lived experiences during the pandemic.

Fear of COVID-19 is associated with trust, subjective numeracy, and differentially with loneliness in older versus younger adults

Introduction

The emotional impacts of the COVID-19 pandemic and resulting public health emergency are only beginning to be understood.

Methods

We assessed the contributions of emotional and cognitive factors and age-related comorbidities to greater COVID-19 fear in a community dwelling sample of 142 younger (Mage = 19.63, SDage = 2.59) and 157 older (Mage = 72.01, SDage = 7.06) adults, between July 2020 and July 2021. We hypothesized that individuals with increased loneliness, depression, and/or decreased subjective numeracy (SN) and interpersonal trust would experience more COVID-19 fear. We also predicted that females and older adults would experience more COVID-19 fear given that age-related comorbidities are associated with increased illness severity.

Results

Results showed that the extent of loneliness in older adults was more strongly related to fear of COVID-19 than it was in younger adults (β = 0.197, p = 0.016), and poorer SN was associated with increased COVID-19 fear in both age groups (β = -0.138, p = 0.016). Further, higher interpersonal mistrust was associated with increased COVID-19 fear (β = 0.136, p = 0.039), as was identifying as female (β = 0.137, p = 0.013).

Discussion

Given that self-described poor numeracy was a marker for greater COVID-19 fear, investigators and policy makers might consider mitigation opportunities addressing data literacy requirements imposed by the media. Further, outreach to mitigate loneliness, particularly of the elderly, might effectively lessen the negative psychological impact of this ongoing public health crisis.

Preventing anxiety in the children of anxious parents - feasibility of a brief, online, group intervention for parents of one- to three-year-olds

BACKGROUND

The evidence suggests an increased risk of developing anxiety problems in children of anxious parents. The current study explored the feasibility and acceptability of an intervention with anxious parents of young children, to inform the possibility of further trials.

METHODS

Participants were recruited through primary and secondary care psychological services and social media. Participants who had a current or recent anxiety disorder and a child aged 12-47 months were included. Assessments of parental and child outcomes occurred at baseline, after the intervention (week-2) and follow-up (week-8). The intervention was delivered in a small group format, in two sessions, one week apart, using videoconferencing.

RESULTS

Out of 32 participants, 30 (94%) attended the full intervention. All found the intervention acceptable and reported it as useful and relevant. There was a reduction in parental depression (MD = 2.63, 95%CI 1.01-4.26), anxiety (MD = 3.93, 95%CI 2.49-5.37) and stress (MD = 4.60, 95% CI 3.02-6.18) and increases in parenting confidence.

CONCLUSIONS

The online group intervention was feasible and acceptable. There were moderate to large effects on parental mental health and no adverse effects on children (decline on outcome measures). This indicates that intervening early in parenting with anxious parents is possible and warrants further investigation to establish prevention efficacy with a larger, controlled trial.

Unravelling the dorsal periaqueductal grey matter NMDA receptors relevance in the nitric oxide-mediated panic‑like behaviour and defensive antinociception organised by the anterior hypothalamus of male mice

RATIONALE

Previous studies suggested that the dorsal column of the periaqueductal grey matter (dPAG) can be a target of neural pathways from hypothalamic nuclei involved in triggering fear-related defensive responses. In turn, evidence is provided suggesting that microinjection of the nitric oxide (NO) donor SIN-1 into the anterior hypothalamus (AH) of mice evokes panic-like behaviours and fear-induced antinociception. However, it is unknown whether the dPAG of mice mediates these latter defensive responses organised by AH neurons.

OBJECTIVES

This study was designed to examine the role of dPAG in mediating SIN-1-evoked fear-induced defensive behavioural and antinociceptive responses organised in the AH of mice.

METHODS

First, neural tract tracing was performed to characterise the AH-dPAG pathways. Then, using neuropharmacological approaches, we evaluated the effects of dPAG pretreatment with either the non-selective synaptic blocker cobalt chloride (CoCl₂; 1 mM/0.1 μL) or the competitive N-methyl-D-aspartate (NMDA) receptor antagonist LY235959 (0.1 nmol/0.1 μL) on defensive behaviours and antinociception induced by microinjections of SIN-1 in the AH of male C57BL/6 mice.

RESULTS

AlexaFluor488-conjugated dextran-labelled axonal fibres from AH neurons were identified in both dorsomedial and dorsolateral PAG columns. Furthermore, we showed that pre-treatment of the dPAG with either CoCl₂ or LY235959 inhibited freezing and impaired oriented escape and antinociception induced by infusions of SIN-1 into the AH.

CONCLUSIONS

These findings suggest that the panic-like freezing and oriented escape defensive behaviours, and fear-induced antinociception elicited by intra-AH microinjections of SIN-1 depend on the activation of dPAG NMDA receptors.

Prevalence of anxiety disorders and association to socioeconomic position. Results from the Lolland Falster Health Study

PURPOSE

The purpose of this study is to describe the prevalence of anxiety disorders in a general population and the association to socioeconomic position (SEP), which has not been described in a Danish context before.

MATERIAL AND METHODS

We present data on anxiety symptoms from respondents in the rural-provincial Lolland-Falster population Health Study (LOFUS). Analyses of the questionnaire responses to the Anxiety Symptom Scale were done by descriptive statistics and logistic regression analyses adjusted for sex and age.

RESULTS

14,834 LOFUS respondents who completed the Anxiety Symptom Scale were included; According to the original algorithm 371 (2.5%) had an anxiety disorder. The adjusted odds ratios (aOR) for anxiety disorder were strongly associated to SEP. We found aOR for anxiety to be: 3.8 (confidence interval (CI 95%) 2.54 - 5.92) for respondents with no postsecondary education compared to those with 3+ years of postsecondary education; 11.9 (CI 8.89 - 16.01) for respondents temporarily out of a job compared to those working; 9.4 (CI 6.06 - 14.51) for those experiencing constant financial strain compared to those not experiencing financial strain. Relaxing the criteria for anxiety to item 10 > 1, the prevalence raised to 3.9%. The association was unchanged related to education; however, the aOR dropped to 9 and 8 respectively, for being temporally out of job, or in financial strain every month- when doing same comparisons.

CONCLUSIONS

The 14-day prevalence of anxiety disorder seems low but strongly associated to SEP especially for individuals temporarily out of a job or experiencing financial strain.

Effects of a blended design of closed-book and open-book examinations on dental students' anxiety and performance

BACKGROUND

While closed-book examinations (CBEs) have traditionally been implemented in dental education, open-book examinations (OBEs) are being introduced for the purpose of acquiring higher levels of knowledge and promoting long-term memory. This study examines whether it is effective to use a blended assessment of CBEs and OBEs for dental students to reduce test anxiety and enhance academic performance.

METHODS

Using a quasi-experimental research method, a blended assessment that combined CBEs in class and OBEs online was designed for a dental course. In 2020, when the pandemic was at its peak, student assessment was ineffective, and the 2020 cohort was omitted for our study; instead, two cohorts of predoctoral dental students (N = 178) enrolled in Restorative Dentistry in the spring semesters of 2019 and 2021 were included in the study. These students were informed about the experimental design, and they provided written consent for data collection, thereby voluntarily participating in the survey. Their self-perceived responses to open-ended survey questions on assessment methods were qualitatively analyzed.

RESULTS

There was no significant difference in test anxiety between the CBEs and OBEs at the p-values of 0.001 in all items. Traditional and blended assessment showed a similar trend of lower scores in midterm exams compared to higher scores in final exams, thus discriminating against students' performances. In particular, a low-achieving group was better predicted by a blended assessment. An analysis of the students' self-perceived responses produced highly topical themes, including exam burden, learning effects, and fairness issues.

CONCLUSIONS

This study confirmed the feasibility of blended assessment that can be implemented in online and in-person educational environments. Moreover, it can be used as the groundwork to develop new models of assessment in dental education.

How does gender and work location impact perceived worker stress during COVID-19? Findings from King County, WA

Using an online survey, we explored workplace determinants of perceived stress during COVID-19 in n=2910 county government workers, and differences in perceived stress by gender and work arrangement (work from home v. do not work from home). We explored relationships with descriptive statistics and linear regression. Access to health and safety resources, increased workplace safety climate, support for work-life balance, and increased access to sick leave were related to lower stress; dependent care stress and female gender were related to higher stress. Among those working from home, higher stress related to an increase in workload and erosion of work/life boundaries. Findings show how the workplace impacts stress, differential determinants by gender/work arrangement, and areas to intervene to improve employee health and well-being.

Prevalence of Antenatal Anxiety in European Women: A Literature Review

The presence of anxiety during pregnancy is associated with adverse consequences for both mothers and their babies. The aim of this study was to review the prevalence of anxiety in European pregnant women in order to find out which countries have published the most studies in respect to the presence of anxiety during pregnancy, which countries are the most and least prevalent in terms of anxiety within pregnant women, and which are the most common tools used to assess anxiety during this stage. As such, a literature review was conducted regarding the studies that were published in the last twenty years in the PsycInfo, Medline, and SCOPUS databases. Thirty-eight studies were selected for the purposes of this review. The prevalence of anxiety in pregnancy and generalized anxiety disorder (GAD) varies considerably between studies. The European countries that have carried out the most research on this issue are Spain, Italy, and the United Kingdom. The most widely used assessment instrument is the State Trait Anxiety Inventory (STAI). The lowest prevalence rate of anxiety, using the STAI-E, was found in Poland, 7.7%, and the highest was found in Italy, 36.5%. The prevalence of GAD ranges from 0.3% to 10.8%. This indicates that anxiety in pregnant women is a very relevant mental health problem. It is therefore important to detect and intervene early in order to promote the well-being of both mothers and children.

Effects of the COVID-19 pandemic on nurses’ psychological well being in an emergency room

ABSTRACT Objectives: to assess the level of anxiety of nurses in an emergency room in view of the new Coronavirus and describe the relationship between the degrees of anxiety and their sociodemographic variables. Methods: quantitative descriptive-correlational study with a sample of 60 nurses. A questionnaire was used as a data collection instrument based on the Hamilton Anxiety Assessment Scale. Results: the nurses’ average anxiety is mild. A statistically significant relationship was found between anxiety and the variables “sex” and “children”, with women having higher levels of anxiety than men, and nurses who do not have children showing mild, moderate, or severe anxiety. Conclusions: COVID-19 triggers anxiety in nurses, sometimes at pathological levels. Being female and not having children increase the anxiety experienced. Sex can be considered the determining factor for the level of anxiety experienced.