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ORIGINAL ARTICLE
Year : 2019  |  Volume : 28  |  Issue : 1  |  Page : 29-36  Table of Contents     

Correlates of worry and functional somatic symptoms in generalized anxiety disorder


1 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission27-Apr-2019
Date of Acceptance23-Oct-2019
Date of Web Publication11-Dec-2019

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipj.ipj_31_19

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   Abstract 


Background: Worry and functional somatic symptoms (FSS) are important clinical features of generalized anxiety disorder (GAD). Although there is literature on the prevalence of worry and FSS in GAD, there is limited data on psychological correlates of worry and somatic symptoms in patients with GAD. Objective: The purpose of this research was to evaluate the relationship of worry and FSS with somatosensory amplification, health anxiety (hypochondriasis), and alexithymia in patients with GAD. Methods: Forty patients with the diagnosis of GAD were assessed with Penn State Worry Questionnaire, Bradford Somatic Inventory (BSI), GAD-7 Scale, somatosensory amplification Scale (SSAS), Whiteley Index (WI), and Toronto Alexithymia Scale-20 Hindi version (TAS-H-20). Results: Worry had significant positive correlation with total scores of BSI, GAD-7 scale, TAS-H-20 subscale 1, SSAS, and WI. Younger age of onset was associated with higher FSS as assessed on BSI. BSI total score had positive correlation with total scores of GAD-7 scale, TAS-H-20 and its subscales, SSAS, WI, and with the severity grades of BSI and GAD. Conclusion: Worry and FSS are associated with somatosensory amplification and hypochondriasis. In addition, somatic symptoms are associated with alexithymia.

Keywords: Alexithymia, generalized anxiety disorder, health anxiety, hypochondriasis, somatic symptoms, somatosensory amplification, worry


How to cite this article:
Kumar V, Avasthi A, Grover S. Correlates of worry and functional somatic symptoms in generalized anxiety disorder. Ind Psychiatry J 2019;28:29-36

How to cite this URL:
Kumar V, Avasthi A, Grover S. Correlates of worry and functional somatic symptoms in generalized anxiety disorder. Ind Psychiatry J [serial online] 2019 [cited 2020 Jan 26];28:29-36. Available from: http://www.industrialpsychiatry.org/text.asp?2019/28/1/29/272687



The characteristic clinical features of generalized anxiety disorder (GAD) are excessive anxiety and worry about more than one life circumstance.[1] Worry is defined as a “chain of thoughts and images, negatively affect-laden and relatively uncontrollable; it represents an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes; consequently, worry relates closely to the fear process.”[2] Studies comparing the nature of worry in GAD and nonanxious controls suggest that the content of topics of worry is very similar in both groups; however, GAD patients worry more frequently, over longer periods, about more topics, and are less likely to recognize an external trigger for their worry; they also report that their worry is less controllable and leads to significant impairment.[3] Worry has also been found to be a dimensional construct associated with depression, anxiety, and stress symptoms to an equal degree, leading some researchers to suggest that worry is an important core transdiagnostic process that cuts across the current nosological diagnostic boundaries.[4] Considering worry as an important clinical manifestation of GAD, the researchers have distinguished worry from anxiety and have demonstrated a stronger directional relationship between worry-producing anxiety, rather than anxiety-producing worry.[2] The meta-cognitive theory of GAD contends that normal worry becomes pathological when worry itself constitutes the focus of worrying, or the “worry about worry” phenomenon.[5]

In addition, GAD is also characterized by feelings of threat, restlessness, irritability, sleep disturbance, tension, and autonomic symptoms such as palpitations, dry mouth, and sweating. These symptoms are recognized as part of the anxiety syndrome rather than independent complaints.[6] Various terms, including medically unexplained physical symptoms, somatic symptoms, and functional somatic symptoms (FSS), have been used to refer to these symptoms. FSS are considered as potential markers for an anxiety disorder.[7] Wittchen et al.[8] showed that only 13% of GAD patients seen in primary care present with anxiety as the primary complaint and in rest of the patients' pain, insomnia, and other FSS are the chief presentations. Some researchers have suggested that rather than the type of symptom, the number of somatic symptoms were strongest indicator of a mood or anxiety disorder.[9] A study compared the type of FSS in patients with GAD and depression and reported that muscle pains and aches are more prevalent in GAD compared to unipolar depression.[10] It was also noticed that the presence of comorbid depression increased the prevalence of painful physical symptoms further in patients with GAD.[11]

Although there is plenty of literature available on worry and FSS, the correlates of these in patients with GAD have not been studied in detail. Studies in other anxiety disorders like panic disorder suggest that psychopathology is influenced by various psychological constructs such as alexithymia, somatosensory amplification, and hypochondriacal worry.[12],[13],[14] The phenomenological expression of depression has quite an overlap with that of GAD, and the expression of somatic symptoms in depression correlates with psychological constructs such as alexithymia, hypochondriacal worry, and somatosensory amplification.[15],[16],[17] Understanding the role of these variables in the presentation of depressive disorder has accounted for the better understanding, diagnosis and treatment of the same.

However, the available literature on the assessment of these psychological constructs and their role in GAD has been minimal. The emotion dysregulation model of GAD states that poor understanding of emotions is one of the processes involved in emotions becoming dysfunctional in individuals with GAD.[18] In this context, it is very important to understand alexithymia, a psychological construct that measures feelings, description of feelings, and emotion. In the literature, we could come across only two studies, in which alexithymia has been assessed in patients with GAD and only one of these studies attempted to find its correlation with somatic symptoms of GAD.[19] Accordingly, the purpose of this research was to study the correlation of worry and FSS with somatosensory amplification, health anxiety (hypochondriasis) and alexithymia, in patients with GAD. Further, an attempt was made to evaluate the relationship between various correlates (FSS, somatosensory amplification, hypochondriasis, and alexithymia) among patients with GAD.


   Methods Top


Setting

This study was carried out in the outpatient clinic of a multispecialty teaching tertiary care hospital in North India. This study was approved by the Ethics Committee of the Institute and the patients were recruited after obtaining proper written informed consent. A cross-sectional design was employed.

As part of this study, patients were evaluated for worry, anxiety, FSS, depressive symptoms, hypochondriasis, somatosensory amplification, alexithymia, and quality of life. Data on prevalence of anxiety and FSS and data on correlation of anxiety and psychological correlates have been already published.[20],[21]

In this study, we included patients diagnosed with GAD as per the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (as per Mini-International Neuropsychiatric Interview).[22] The patients were aged between 18 and 60 years, educated beyond primary with proficiency in reading either English or Hindi. Patients with comorbid psychiatric disorders and with physical illnesses that could explain the anxiety were excluded from the study.

Worry was assessed using Penn State Worry Questionnaire (PSWQ),[23] FSS were assessed using Bradford Somatic Inventory (BSI),[24] and the severity of GAD was assessed with GAD-7 scale.[25] Somatosensory amplification scale (SSAS),[26] Whiteley Index (WI),[27] and Toronto Alexithymia Scale Hindi version (TAS-H)[28] were used for assessment of somatosensory amplification, hypochondriasis, and alexithymia, respectively.

Instruments

Penn State Worry Questionnaire

It is the most commonly used self-report measure to assess pathological worry in both clinical and nonclinical populations. It consists of 16 items, and each item is scored between 1 (not at all typical of me) and 5 (very typical of me).[23] The last five items are stated in a reversed fashion to reduce the effects of acquiescence. Higher PSWQ scores reflect greater levels of pathological worry. PSWQ has good psychometric properties with good reliability, validity, and internal consistency.[29] In this study, the scale was administered by the clinician to the participants.

Bradford Somatic Inventory

BSI is a 46-item multiethnic inventory of functional somatic complaints associated with anxiety and depression.[24] Two items of BSI apply to men only. The BSI enquires about the functional somatic complaints during the previous month and if the patient has experienced a particular symptom, then further evaluation requires ascertainment as to whether, the symptom occurred on more or fewer than 15 days during the previous month (scoring 2 or 1, respectively). The severity grades of BSI are made based on the total score (a score >40 is considered to be the “high” range; 26–40, “middle” range; and 0–25, “low” range).

Generalized anxiety disorder-7 scale

It is a seven-item validated anxiety scale with higher scores indicating more severe anxiety.[25]

Somatosensory amplification scale

It is a five-point self-report questionnaire that assesses the sensitivity of persons to a range of normal bodily sensations and to neutral and noxious stimuli with higher scores indicating higher level of somatosensory amplification.[26] The scale has good psychometric properties in terms of test-retest reliability and internal consistency.[26]

Whiteley Index of hypochondriasis

This 14-item questionnaire evaluates health anxiety (hypochondriacal) attitudes and beliefs.[27] The cutoff score for health anxiety disorder or hypochondriasis is ≥7. The scale has good internal consistency and test-retest reliability.[30]

Toronto alexithymia scale-20

The 20-item self-report instrument is rated on a five-point scale with a score >60 is taken as an indicator of alexithymia.[31]. The scale comprises of three subscales, i.e., difficulty identifying feelings (DIF) and distinguishing them from bodily sensations (TAS-1), difficulty describing feeling (DDF) to others (TAS-2), externally oriented thinking (EOT) (TAS-3). The TAS-Hindi version (TAS-H-20) has adequate internal consistency and good test-retest reliability.[28]

Statistical analysis

Mean and standard deviation were calculated for the continuous variables. Discontinuous variables were analyzed as frequency and percentages. Associations between worry and other variables were studied by using Pearson's product-moment correlation and Spearman's rank-order correlation analysis.


   Results Top


The mean age of the sample was 42.37 standard deviation (SD-11.31) years. Majority of the patients were male (57.5%), married (82.5%), and from urban background (65%). The mean number of years of education was 11.87 (SD-3.93) years and the mean age of onset of GAD was 37.42 (SD-10.6; range 17–58) years and the mean duration of illness at the time of assessment was 58.6 (SD-53.4; range 10–236) months.

The total mean score for GAD-7 scale was 13.27 and majority of the patients (90%) scored more than 10 on GAD-7. More than half of the patients (55%) had moderate level of anxiety, about one-third of patients had severe anxiety (37.5%) and the rest had mild anxiety. The mean score on SSAS was 25.7 (range 12–41). The mean total score on WI was 7.75 (range 1–14). Half of the patients with GAD had WI score of >7 suggesting the presence of significant health anxiety (hypochondriasis). About two-fifth (42.5%) of patients with GAD, scored above the cutoff mark, for alexithymia (TAS-H20 >60). The mean score of the study sample on TAS-H-20 scale was 59.77. The mean scores were 21.50, 14.62, and 23.65 for subscale 1 (DIF), subscale 2 (DDF), and subscale 3 (EOT), respectively. [Table 1] summarizes the findings of PSWQ, BSI, GAD-7 scale, SSAS, WI, and TAS-H-20.
Table 1: Summary of scores on Penn State Worry Questionnaire, Bradford Somatic Inventory, generalized anxiety disorder scale, somatosensory amplification scale, Whiteley Index, and Toronto Alexithymia Scale-20

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On association analysis, few negative correlations were seen between various items of PSWQ and age of the patient and age of onset of GAD suggesting that younger patients and patients with younger age of onset worried more than the other patients. PSWQ total score had significant positive correlation with both BSI total score and BSI severity grade. Total BSI score and BSI severity had significant positive correlation with six items each of PSWQ. Of the PSWQ items that had significant correlation with BSI total score and BSI severity grade, five items were common. There were significant positive correlations of total GAD-7 scale score and GAD-7 severity with PSWQ total score. Furthermore, there were significant positive correlations between various items of GAD-7 tapping cognitions related to anxiety and PSWQ items. Items 2 and 3 of GAD_7 scale had positive correlation with about 7 items of PSWQ, whereas item 1 of GAD_7 scale had positive correlation with only one item of PSWQ.

PSWQ total score had significant positive correlation with total TAS-H-20 score and total score of factor 1 (DIF) of TAS-H-20 but not with factors 2 and 3. In terms of correlations between items of PSWQ and TAS-H-20, there were significant positive correlations between six items of PSWQ and total score of factor-1 (DIF) of TAS-H-20. The presence of alexithymia (TAS-H-20 score >60) had no correlation with PSWQ total score. Significant positive correlation was noted between PSWQ total score and total score of SASS and WI, suggesting that those patients who have higher somatosensory amplification and hypochondriasis have more worries. Individuals with WI score >7 had positive correlation with total PSWQ score, suggesting that individuals with significant health anxiety (hypochondriasis) had higher scores on PSWQ. The correlation findings of worry are summarized in [Table 2].
Table 2: Correlation of worry with sociodemographic and clinical variables, functional somatic symptoms, generalized anxiety disorder severity, somatosensory amplification, health anxiety (hypochondriasis), and alexithymia

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FSS, as assessed with BSI, showed significant negative correlation with age of the patient and age of onset of illness. BSI total score and severity grade had significant positive correlation with total TAS-H-20 score and total score of all the three subscales of TAS-H-20. There was significant positive correlation between GAD-7 total score and BSI total score and BSI severity grades. GAD-7 severity grade had positive correlation only with BSI severity grade but not with BSI total score. Significant positive correlations were also seen between 5 out of the 7 items of GAD-7 and BSI total score and 5 out of 7 items of GAD-7 and BSI severity grade.

In terms of correlations between items of BSI and TAS-H-20, there were significant positive correlations between 6 items of BSI and total TAS-H-20 score, total scores of factor-1 (DIF) and factor-2 (DDF) of TAS-H-20. Total score of factor-3 (EOT) of TAS-H-20 had significant positive correlation with 4 items of BSI. The BSI total score and BSI severity grade also had positive correlation with the presence of alexithymia (TAS-H-20 score >60). There was significant positive correlation between BSI total score and severity grades with total score of SSAS and WI, suggesting that those patients who have higher somatosensory amplification and health anxiety (hypochondriacal worry) have more FSS. Individuals with WI score >7 had positive correlation with total BSI score and BSI severity grade, suggesting that individuals with significant health anxiety (hypochondriasis) had greater FSS. The correlation findings of FSS are summarized in [Table 3].
Table 3: Correlation of functional somatic symptoms with sociodemographic and clinical variables, worry, generalized anxiety disorder severity, somatosensory amplification, health anxiety (hypochondriasis), and alexithymia

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In addition, we did correlation analysis of GAD-7 scale total score and GAD-7 scale severity grades. As with BSI, age of the patient and age of onset of illness had negative correlation with both total GAD-7 scale score and GAD-7 severity grades. The total duration of illness had negative correlation with GAD-7 total score but not with GAD-7 severity grades. The severity of GAD-7 scale total score and GAD-7 severity grades had had positive correlation with SSAS total score, WI total score, presence of significant health anxiety (WI >7), TAS-H-20 total scores, and presence of alexithymia suggesting that the individuals with higher severity of GAD had greater scores on these psychological constructs. These findings are summarized in [Table 4].
Table 4: Correlation of generalized anxiety disorder-7 scale total score and severity with sociodemographic and clinical variables somatosensory amplification, health anxiety (hypochondriasis) and alexithymia

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   Discussion Top


The purpose of the current study was to study the correlations of worry and FSS with somatosensory amplification, health anxiety, and alexithymia in patients with GAD. In addition, an attempt was also made to study the relationship of severity of GAD with these constructs and with the sociodemographic and clinical variables.

Relationship between worry, somatic symptoms and severity of anxiety

In the present study, worry was measured PSWQ and FSS were evaluated using BSI and severity of anxiety was measured by using GAD. The PSWQ score correlated positively with both BSI score and BSI severity grades. DSM-5 conceptualizes the clinical manifestations of GAD with focus on worry as the central feature of the GAD.[1] Considering worry as an important clinical manifestation of GAD, the researchers have demonstrated a stronger directional relationship between worry-producing anxiety and somatic symptoms, rather than anxiety-producing worry.[2],[31] The finding of our study provides further evidence that worry and FSS are related to each other in patients of GAD, although our study is not powered and designed to comment on the impact of worry and FSS on each other.

Spitzer et al.[25] found that the first three items of GAD-7 scale capture the two core criteria (A and B) of DSM-IV (same as DSM 5) that are related to worry in the definition of GAD. Similarly, in our study, items 2 and 3 of GAD-7 scale had positive correlation with about 7 items of PSWQ, whereas item 1 of GAD-7 scale had positive correlation with only one item of PSWQ. Interestingly, item 7 of GAD-7 scale had positive correlation with five items of PSWQ. The total PSWQ scores and total BSI score correlated positively with GAD-7 scale total score and GAD-7 severity. It shows that that GAD-7 item (total score of GAD-7 scale) as a construct together also have good correlations with worry as measured with PSWQ. These findings suggest that there is an overlap between the items of the PSWQ and GAD-7 scale, although the latter comprises of fewer items. In their study, Spitzer et al.[25] found increasing scores on GAD-7 scale to positively correlate with general amount of difficulty patients attribute to their symptoms, but the relationship of GAD-7 scale items and total score with somatic symptoms was not evaluated.[25] In our study, GAD-7 total score positively correlated with BSI total score and BSI severity. Five items each of GAD-7 scale correlated positively with BSI total score and BSI severity and four items were common to both of them (item numbers 3, 4, 6, and 7 of GAD-7 scale). These findings put together suggest that worry and FSS correlate strongly with each other and both of them correlate positively with the anxiety measurement in GAD-7 scale. Hence, the correlates of various worries, FSS, and severity of anxiety as measured with GAD-7 are discussed together in subsequent sections to have a better conceptualization of relationship of symptoms and the factors that influence the same.

Sociodemographic and clinical correlates of worry, functional somatic symptoms, and severity of anxiety

In the present study, no significant correlations emerged between most of the sociodemographic variables and the level of anxiety, worry, and FSS. Lack of any correlation between the certain sociodemographic variables probably suggests that GAD manifests similarly across gender, socioeconomic background, and locality. Younger patients had higher total BSI score and higher GAD-7 total score. This suggests that GAD is more severe in younger patients and as the age progresses the illness becomes less severe. However, it is important to note that it is also quite possible that the older patients were on treatment for longer duration and hence had less severe anxiety, as negative correlation was seen between the duration of treatment and severity of illness as assessed on GAD-7. Correlation analysis suggested those with longer duration of illness has less severe illness, in terms of GAD-7 total score. However, it is to be understood that in the present study most of the patients were receiving selective serotonin reuptake inhibitors, and the relationship of severity of illness and duration of illness possibly reflects effectiveness of these medications in the management of symptoms of GAD.

Relationship of worry, functional somatic symptoms, and severity of anxiety with alexithymia

Alexithymia is understood as a personality construct derived from clinical observations of patients with psychosomatic diseases, characterized by difficulty in distinguishing between emotions and bodily sensations.[32] According to the concept of alexithymia, patients presenting with predominant somatic complaints as a manifestation of psychological distress lack the linguistic skills to articulate emotional experience. In the present study, there was significant positive correlation of GAD-7 total score with total TAS-H-20 score. Similarly, those who had alexithymia (TAS-H-20 score >60) had higher GAD-7 total score. Our findings support the general notion that alexithymia is quite prevalent in patients of anxiety disorders.[12],[33],[34] There was significant correlation of BSI total score of BSI severity grades with total score of TAS-H-20, 3 factors of alexithymia scale (TAS-H DIF, DDF, and EOT) and overall patients who had alexithymia had more somatic symptoms score as assessed on BSI total score. These correlations suggest that patients correlated have higher severity of anxiety and greater FSS. These findings of our study are similar to the only such study available in the literature on the correlations of FSS with alexithymia.[19] In addition, studies in patients with depression, psychiatric outpatients, and medical outpatients suggest that alexithymia predicts the presence of FSS.[15],[35],[36] Hence, when we look at these findings of the present study in the background of existing literature, it can be said that irrespective of the diagnostic categories identified by the nosological system, FSS is predicted by alexithymia.

The emotion dysregulation model of GAD states poor understanding of emotions is one of the processes involved in emotions becoming dysfunctional in individuals with GAD.[36] Mennin et al.[18] measured mean scores of TAS-H DIF and DDF items as measurements of poor understanding of emotions in patients with GAD and healthy controls. They found mean values of items of TAS-H DIF (3.07) and DDF (3.17) to be significantly higher in patients with GAD when compared to healthy controls. The mean values of these measures in our patients – TAS-H DIF (2.97) and DDF (3.06) are similar to the findings of the above-mentioned study. In the present study, although the total score of PSWQ correlated positively with alexithymia scores, it did not have significant correlation with the presence or absence of alexithymia. Further it was seen that the positive correlation between worry was present only for the TAS DIF and not for other two factors that is DDF (TAS-H DIF) and (TAS-H EOT). In discriminant function analysis, Mennin et al.[18] found TAS DIF to correlate strongly with emotional dysregulation in patients with GAD, which may explain the positive correlation of PSWQ scores only with TAS-H DIF total scores in our patients.[18] Hence, from the findings of the present study, it can be considered that the correlation of worry with alexithymia can be specific to the TAS factor 1 (TAS-H DIF), unlike in depression where all the subscales of TAS were noted to correlate with depressive symptoms.[35]

Relationship of worry, functional somatic symptoms, and severity of anxiety with somatosensory amplification and health anxiety (hypochondriacal worry)

The findings of the present study suggest that patients of GAD have higher propensity for somatosensory amplification and health anxiety (hypochondriacal worry), and this psychological construct along with other constructs determines the clinical manifestation of GAD in the form of anxiety, worry, and somatic symptoms. As with alexithymia, studies in patients of depression, psychiatric outpatients, and medical outpatients suggest that somatosensory amplification predicts the presence of FSS.[15],[16],[35],[36] Hence, it can be said that irrespective of the diagnostic categories, FSS is predicted by constructs such as somatosensory amplification, health anxiety (hypochondriacal worry), and alexithymia.


   Conclusion Top


Findings of the present study suggest that worry and FSS have significant correlation with each other in patients with GAD and both of them correlate with severity grades of GAD. Younger age of onset of GAD is associated with greater FSS and higher severity of GAD. More FSS are seen in patients of GAD, who have alexithymia. In contrast, only TAS-H-20 total score and TAS-H-DIF were found to have correlation with worry. Somatosensory amplification and health anxiety (hypochondriacal worry) correlated strongly with worry, FSS, and severity of GAD, suggesting that these constructs have significant role in the manifestation of the psychopathology of GAD.

Findings of the present study suggest that severity of FSS and worry in GAD are related to somatosensory amplification and health anxiety (hypochondriacal worry) as in other psychiatric disorders. Alexithymia has positive correlation with FSS, whereas the correlation of alexithymia with worry seems to be related specifically to TAS-H DIF factor.

This study lacked the healthy control group, which is the major limitation of this study. The sample size was small and consisted of 40 consecutive outpatients between the ages of 18 and 60 years attending a general hospital psychiatric unit. The results of this study, therefore, cannot be generalized to other patient populations. Although in the literature the incidence of GAD is higher in females, in our study males' outnumbered females. The above-mentioned limitations must be kept in mind while interpreting the results of this study.

Future research should overcome the limitations of this study. The replication of our study findings in much larger sample size derived from the general population across different age groups is required before any definitive conclusions can be drawn on the correlates of worry and FSS in patients with GAD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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