Distinguishing between depression and anxiety: a proposal for an extension of the tripartite model

Dimensionality and Measurement Invariance of the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA) and Validity Comparison With Measures of Negative Emotionality

This study explored the factor structure of the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA) and measurement invariance between genders. We also measured concurrent and divergent validity of the STICSA as compared to the State-Trait Anxiety Inventory (STAI). A sample of 1064 (N Females = 855) participants completed questionnaires, including measures of anxiety, depression, stress, positive and negative affect. Confirmatory factor analyses supported the original factor structure of the STICSA, which was invariant between genders. Overall, the STICSA had superior concurrent and divergent validity as compared to the STAI. The somatic subscales were also significantly less correlated with depression, and positive and negative affect. Further, the somatic, as compared to cognitive anxiety STICSA subscales were less correlated with depression. This suggests that the STICSA, especially the somatic anxiety subscales, might hold the key to distinguishing between different types of anxiety, as well as between anxiety and depression.

Investigating the roles of age, sex, depression, and anxiety for valence and arousal ratings of words: a population-based study

BACKGROUND

The perception of the affective quality of stimuli with regard to valence and arousal has mostly been studied in laboratory experiments. Population-based research may complement such studies by accessing larger, older, better balanced, and more heterogeneous samples. Several characteristics, among them age, sex, depression, or anxiety, were found to be associated with affective quality perception. Here, we intended to transfer valence and arousal rating methods from experimental to population-based research. Our aim was to assess the feasibility of obtaining and determining the structure of valence and arousal ratings in the setting of the large observational BiDirect Study. Moreover, we explored the roles of age, sex, depression, and anxiety for valence and arousal ratings of words.

METHODS

704 participants provided valence and arousal ratings for 12 written nouns pre-categorized as unpleasant, neutral, or pleasant. Predictors of valence and arousal ratings (i.e. age, sex, depression, and anxiety) were analyzed for six outcomes that emerge by combining two affective dimensions with three words categories. Data were modeled with multiple linear regression. Relative predictor importance was quantified by model-explained variance decomposition.

RESULTS

Overall, average population-based ratings replicated those found in laboratory settings. The model did not reach statistical significance in the valence dimension. In the arousal dimension, the model explained 5.4% (unpleasant), 4.6% (neutral), and 3.5% (pleasant) of the variance. (Trend) effects of sex on arousal ratings were found in all word categories (unpleasant: increased arousal in women; neutral, pleasant: decreased arousal in women). Effects of age and anxiety (increased arousal) were restricted to the neutral words.

CONCLUSIONS

We report results of valence and arousal ratings of words in the setting of a large, observational, population-based study. Method transfer yielded acceptable data quality. The analyses demonstrated small effects of the selected predictors in the arousal dimension.

Parental psychological distress during pregnancy and the risk of childhood lower lung function and asthma: a population-based prospective cohort study

Background

Although maternal psychological distress during pregnancy is associated with increased risks of respiratory morbidity in preschool children, it is unknown whether this association persists into later childhood.

Objective

To examine the association between parental psychological distress during pregnancy and lung function and asthma in children of school age.

Methods

This study of 4231 children was embedded in a population-based prospective cohort. Parental psychological distress was assessed by the Brief Symptom Inventory during and 3 years after pregnancy, and in mothers also at 2 and 6 months after pregnancy. At age 10 years, lung function was obtained by spirometry and asthma by questionnaire.

Results

The prevalence of asthma was 5.9%. Maternal overall psychological distress during pregnancy was associated with a lower forced vital capacity (FVC) (z-score difference −0.10 (95% CI −0.20 to –0.01) per 1-unit increase), maternal depressive symptoms during pregnancy with a lower forced expiratory volume in the first second (FEV₁) and FVC (−0.13 (95% CI −0.24 to –0.01) and −0.13 (95% CI −0.24 to –0.02) when using clinical cut-offs) in their children. All maternal psychological distress measures during pregnancy were associated with an increased risk of asthma (range OR: 1.46 (95% CI 1.12 to 1.90) to 1.91 (95% CI 1.26 to 2.91)). Additional adjustment for paternal psychological distress during pregnancy and parental psychological distress after pregnancy did not materially change the associations. Paternal psychological distress during pregnancy was not associated with childhood respiratory morbidity.

Conclusion

Maternal, but not paternal, psychological distress during pregnancy is associated with an increased risk of asthma and partly lower lung function in children. This suggests intrauterine programming for the risk of later-life respiratory disease.

Hsp90 and FKBP51: complex regulators of psychiatric diseases

Mood disorders affect nearly a quarter of the world's population. Therefore, understanding the molecular mechanisms underlying these conditions is of great importance. FK-506 binding protein 5 (FKBP5) encodes the FKBP51 protein, a heat shock protein 90 kDa (Hsp90) co-chaperone, and is a risk factor for several affective disorders. FKBP51, in coordination with Hsp90, regulates glucocorticoid receptor (GR) activity via a short negative feedback loop. This signalling pathway rapidly restores homeostasis in the hypothalamic-pituitary-adrenal (HPA) axis following stress. Expression of FKBP5 increases with age through reduced DNA methylation. High levels of FKBP51 are linked to GR resistance and reduced stress coping behaviour. Moreover, common allelic variants in the FKBP5 gene are associated with increased risk of developing affective disorders like anxiety, depression and post-traumatic stress disorder (PTSD). This review highlights the current understanding of the Hsp90 co-chaperone, FKBP5, in disease from both human and animal studies. In addition, FKBP5 genetic implications in the clinic involving life stress exposure, gender differences and treatment outcomes are discussed.This article is part of the theme issue 'Heat shock proteins as modulators and therapeutic targets of chronic disease: an integrated perspective'.

Sleep Quality and Emotion Regulation Interact to Predict Anxiety in Veterans with PTSD

Posttraumatic stress disorder (PTSD) is a debilitating and common consequence of military service. PTSD is associated with increased incidence of mood disturbances (e.g., anxiety). Additionally, veterans with PTSD often have poor-quality sleep and poor emotion regulation ability. We sought to assess whether such sleep and emotion regulation deficits contribute to mood disturbances. In 144 veterans, using a double moderation model, we tested the relationship between PTSD and anxiety and examined whether sleep quality and emotion regulation interact to moderate this relationship. We found that PTSD predicts higher anxiety in veterans with poor and average sleep quality who utilize maladaptive emotion regulation strategies. However, there was no relationship between PTSD and anxiety in individuals with good sleep quality, regardless of emotion regulation. Similarly, there was no relationship between PTSD and anxiety in individuals with better emotion regulation, regardless of sleep quality. Results were unchanged when controlling for history of traumatic brain injury (TBI), despite the fact that those with both PTSD and TBI had the poorest emotion regulation overall. Taken together, these results suggest that good-quality sleep may be protective against poor emotion regulation in veterans with PTSD. Sleep may therefore be a target for therapeutic intervention in veterans with PTSD and heightened anxiety.

Fear and distress disorders as predictors of heart disease: A temporal perspective

OBJECTIVE

Few studies have been able to contrast associations of anxiety and depression with heart disease. These disorders can be grouped in fear and distress disorders. Aim of this study was to study the association between fear and distress disorders with subsequent heart disease, taking into account the temporal order of disorders.

METHODS

Twenty household surveys were conducted in 18 countries (n=53791; person years=2,212,430). The Composite International Diagnostic Interview assessed lifetime prevalence and age at onset of disorders, and respondents were categorized into categories based on the presence and timing of fear and distress disorders. Heart disease was indicated by self-report of physician-diagnosed heart disease or self-report of heart attack, together with year of onset. Survival analyses estimated associations between disorder categories and heart disease.

RESULTS

Most respondents with fear or distress disorders had either pure distress or pure fear (8.5% and 7.7% of total sample), while fear preceded distress in the large majority of respondents with comorbid fear and distress (3.8% of total sample). Compared to the "no fear or distress disorder" category, respondents with pure fear disorder had the highest odds of subsequent heart disease (OR:1.8; 95%CI:1.5-2.2; p<0.001) and compared to respondents with pure distress disorder, these respondents were at a significantly increased risk of heart disease (OR:1.3; 95%CI:1.0-1.6; p=0.020).

CONCLUSION

This novel analytic approach indicates that the risk of subsequent self-reported heart disease associated with pure fear disorder is significantly larger than the risk associated with distress disorder. These results should be confirmed in prospective studies using objective measures of heart disease.

Two-year course of anxiety disorders: different across disorders or dimensions?

OBJECTIVE

This study compares diagnostic and symptom course trajectories across different anxiety disorders, and examines the role of anxiety arousal vs. avoidance behaviour symptoms in course prediction.

METHOD

Data were from 834 subjects with a current anxiety disorder from the Netherlands Study of Depression and Anxiety (NESDA) who were re-interviewed after 2 years. DSM-IV-based diagnostic interviews and Life Chart Interviews (LCI) were used to assess the diagnostic and symptom course trajectory over 2 years. Anxiety arousal and avoidance behaviour symptoms were measured with LCI, Beck Anxiety Inventory and Fear Questionnaire.

RESULTS

Prognosis varied across disorders, with favourable remittance rates of 72.5% for panic disorder without agoraphobia and 69.7% for generalized anxiety disorder; gradually declining to 53.5% for social phobia and 52.7% for panic disorder with agoraphobia. Only 42.9% of those with multiple anxiety disorder remitted, and this group showed a more chronic course than pure anxiety disorders. Both baseline duration and severity were course predictors. Avoidance behaviour symptoms predicted the outcome better than anxiety arousal symptoms.

CONCLUSIONS

These data suggest that the specific anxiety disorders such as recognized by DSM-IV are useful in predicting the outcome and that this may be determined largely by the relative severity of avoidance behaviour that patients have developed.

Different gene sets contribute to different symptom dimensions of depression and anxiety

Although many genetic association studies have been carried out, it remains unclear which genes contribute to depression. This may be due to heterogeneity of the DSM-IV category of depression. Specific symptom-dimensions provide a more homogenous phenotype. Furthermore, as effects of individual genes are small, analysis of genetic data at the pathway-level provides more power to detect associations and yield valuable biological insight. In 1,398 individuals with a Major Depressive Disorder, the symptom dimensions of the tripartite model of anxiety and depression, General Distress, Anhedonic Depression, and Anxious Arousal, were measured with the Mood and Anxiety Symptoms Questionnaire (30-item Dutch adaptation; MASQ-D30). Association of these symptom dimensions with candidate gene sets and gene sets from two public pathway databases was tested using the Global test. One pathway was associated with General Distress, and concerned molecules expressed in the endoplasmatic reticulum lumen. Seven pathways were associated with Anhedonic Depression. Important themes were neurodevelopment, neurodegeneration, and cytoskeleton. Furthermore, three gene sets associated with Anxious Arousal regarded development, morphology, and genetic recombination. The individual pathways explained up to 1.7% of the variance. These data demonstrate mechanisms that influence the specific dimensions. Moreover, they show the value of using dimensional phenotypes on one hand and gene sets on the other hand.

Distinguishing symptom dimensions of depression and anxiety: an integrative approach

BACKGROUND

Clark and Watson developed the tripartite model in which a symptom dimension of 'negative affect' covers common psychological distress that is typically seen in anxious and depressed patients. The 'positive affect' and 'somatic arousal' dimensions cover more specific symptoms. Although the model has met much support, it does not cover all relevant anxiety symptoms and its negative affect dimension is rather unspecific. Therefore, we aimed to extend the tripartite model in order to describe more specific symptom patterns with unidimensional measurement scales.

METHOD

1333 outpatients provided self report data. To develop an extended factor model, exploratory factor analysis (EFA) was conducted in one part of the data (n=578). Confirmatory factor analysis (CFA) was conducted in the second part (n=755), to assess model-fit and comparison with other models. Rasch analyses were done to investigate the unidimensionality of the factors.

RESULTS

EFA resulted in a 6-factor model: feelings of worthlessness, fatigue, somatic arousal, anxious apprehension, phobic fear and tension. CFA in the second sample showed that a 6-factor model with a hierarchical common severity factor fits the data better than alternative 1- and 3-factor models. Rasch analyses showed that each of the factors and the total of factors can be regarded as unidimensional measurement scales.

LIMITATIONS

The model is based on a restricted symptom-pool: more dimensions are likely to exist.

CONCLUSION

The extended tripartite model describes the clinical state of patients more specifically. This is relevant for both clinical practice and research.

Symptom dimensions as predictors of the two-year course of depressive and anxiety disorders

BACKGROUND

Because of the heterogeneity of known predictive factors, course-predictions for depression and anxiety are often unspecific. Therefore, it was investigated whether symptom-dimensions could be used as more specific course-predictors, on top of already known predictors, such as diagnosis and overall severity.

METHODS

A sample of 992 subjects with depressive and/or anxiety disorders was followed in a 2-year prospective cohort study. Dimensions of the tripartite model (general distress, anhedonic depression and anxious arousal) were assessed at baseline. Diagnostic and course information were assessed at baseline and 2-year follow-up.

RESULTS

Dimensional scores at baseline predicted diagnosis after two years and course-trajectories during follow-up. Increased general distress at baseline was associated with comorbid depression-anxiety at follow-up, increased anhedonic depression was associated with single depression and anxious arousal was associated with (comorbid) panic disorders at follow-up. Baseline general distress was associated with an unfavorable course in all patients. All associations were independent and added prognostic information on top of diagnosis and other predictive factors at baseline.

LIMITATIONS

Only prevalent patients were included at baseline and only three dimensions were measured

CONCLUSIONS

Symptom dimensions predict the future 2-year course of depression and anxiety. Importantly, the dimensions yield predictive information on top of diagnosis and other prognostic factors at baseline.

Auditory affective norms for German: testing the influence of depression and anxiety on valence and arousal ratings

Background

The study of emotional speech perception and emotional prosody necessitates stimuli with reliable affective norms. However, ratings may be affected by the participants' current emotional state as increased anxiety and depression have been shown to yield altered neural responding to emotional stimuli. Therefore, the present study had two aims, first to provide a database of emotional speech stimuli and second to probe the influence of depression and anxiety on the affective ratings.

Methodology/Principal Findings

We selected 120 words from the Leipzig Affective Norms for German database (LANG), which includes visual ratings of positive, negative, and neutral word stimuli. These words were spoken by a male and a female native speaker of German with the respective emotional prosody, creating a total set of 240 auditory emotional stimuli. The recordings were rated again by an independent sample of subjects for valence and arousal, yielding groups of highly arousing negative or positive stimuli and neutral stimuli low in arousal. These ratings were correlated with participants' emotional state measured with the Depression Anxiety Stress Scales (DASS). Higher depression scores were related to more negative valence of negative and positive, but not neutral words. Anxiety scores correlated with increased arousal and more negative valence of negative words.

Conclusions/Significance

These results underscore the importance of representatively distributed depression and anxiety scores in participants of affective rating studies. The LANG-audition database, which provides well-controlled, short-duration auditory word stimuli for the experimental investigation of emotional speech is available in Supporting Information S1.

Symptom dimensions of depression and anxiety and the metabolic syndrome

OBJECTIVE

To investigate the association between depression and anxiety symptoms and the metabolic syndrome (MetSyn), using a dimensional approach. The association between depression and anxiety, on the one hand, and the MetSyn as a cluster or its individual components, on the other hand, is equivocal. The categorical nature of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition might partly explain the inconsistent findings.

METHODS

In 2,433 Netherlands Study of Depression and Anxiety participants (mean age, 42.3 years; 33.1% male), three symptoms dimensions-lack of positive affect (PA, depression specific); negative affect (NA, aspecific); and somatic arousal (SA, anxiety specific)-were assessed by a shortened adaptation of the Mood and Anxiety Symptom Questionnaire. The association between symptom dimensions and MetSyn components (waist circumference, triglycerides, high-density lipoprotein cholesterol, glucose, and mean blood pressure) was analyzed, using linear regression analysis.

RESULTS

The occurrence rate of the MetSyn was 20.1% (n = 490). SA, but not PA and NA, was strongly associated with four out of five MetSyn components, especially waist circumference, triglycerides, and blood pressure (β = 0.046, p = .01; β = 0.077, p < .001; and β = 0.069, p < .001, respectively), and with the total number of MetSyn components (β = 0.098, p < .001).

CONCLUSIONS

Our results demonstrate a strong association of most of the MetSyn components with the SA dimension, but not with the NA and PA scales.

Dimensions of depression and anxiety and the hypothalamo-pituitary-adrenal axis

BACKGROUND

Results on the association between depression and the hypothalamo-pituitary-adrenal (HPA) axis have been inconsistent, possibly due to heterogeneity of the DSM-IV category of depression. Specific symptom-dimensions could be used as a more homogenous phenotype in HPA-axis research.

METHODS

Subjects (n = 1029) with a lifetime depression and/or anxiety disorder from the NESDA study (Netherlands Study of Depression and Anxiety) (mean age: 43.0 ± 12.7 years, 67.4% women) provided seven saliva samples to yield the cortisol awakening response (CAR), evening cortisol, and dexamethasone suppression data. The dimensions of the tripartite model (General Distress, Anhedonic Depression, and Anxious Arousal) were measured with the 30-item adapted Mood and Anxiety Symptoms Questionnaire (MASQ-D30) and analyzed in association with the cortisol measures with linear and nonlinear regression.

RESULTS

Median (interquartile range) scores of General Distress, Anhedonic Depression, and Anxious Arousal were 20 (14-27), 36 (28-44), and 15 (12-19), respectively, indicating large variability. Nonlinear associations with the shape of an inverted U were found between General Distress, Anhedonic Depression, and Anxious Arousal on one hand and total morning secretion and the dynamic of the CAR by contrast. Both high and low severity levels were associated with a lower CAR, compared with intermediate levels of severity. Most of the associations remained significant when adjusted for covariates and the presence of DSM-IV diagnoses.

CONCLUSIONS

Nonlinear associations were found between the CAR and the dimensions of the tripartite model. This could explain previous inconsistent findings regarding HPA-axis activity in depressed patients and illustrates the added value of symptom-dimensions for HPA-axis research.