Examining the interrelatedness of anxiety sensitivity, experiential avoidance, mindfulness, and chronic illness acceptance in persons with coronary artery disease and hypertension. Examining the interrelatedness of anxiety sensitivity, experiential avoidance, mindfulness, and chronic illness acceptance in persons with coronary artery disease and hypertension. John Forrette, M.A., Abbie Beacham, Ph.D., Matthew Maley, M.A. Xavier University, Cincinnati, OH Coronary artery disease (CAD) and hypertension (HT) are serious health concerns. According to the World Health Organization, cardiovascular diseases are the number one cause of death globally, accounting for 17.3 million deaths in 2008 [14]. Anxiety-related symptoms may be considered an independent risk factor for exacerbation of CAD/HT [5]. Anxiety sensitivity—fear of sensations associated with anxiety—has recently been associated with an increased risk of cardiovascular disease [12]. Experiential avoidance - the attempt to avoid difficult or aversive thoughts, feelings and sensations – may also be related to health behaviors that increase heart disease risk and accounts for poorer clinical outcomes [8]. Mindfulness involves an awareness of present moment experiences through an attitude of acceptance and openness. The aversive nature of anxiety problems and the fear and avoidance of anxiety related symptoms, may compromise some of the beneficial links between mindfulness, acceptance and desired health-related functional behavioral outcomes [4]. The purpose of the present study was to examine the relationships between Anxiety Sensitivity subscales (Physical, Cognitive, and Social) and mindfulness, chronic illness acceptance, and experiential avoidance in patients with CAD and HT in online chronic illness supports groups. INTRODUCTION RESULTS & DISCUSSION METHOD REFERENCES Participants and Procedure: Participants (N=580) were recruited from online support groups for chronic illness. A subsample (n=129; mean age=51.3, SD=12.6) of CAD/HT patients was primarily female (80.6%) and well educated (mean years=15.3, SD=2.7). Participants completed measures of anxiety sensitivity, mindfulness, chronic illness acceptance, and experiential avoidance as part of a larger survey study. Measures: Anxiety Sensitivity Index-3 (ASI-3): The ASI-3 is an 18- item self-report measure that assesses physical, cognitive, and social aspects of anxiety sensitivity [13]. Mindful Attention Awareness Scale (MAAS): The MAAS consists of 15 items designed to measure of a single-factor construct of mindfulness [3]. Each of the items is rated on a 6-point scale from 1 (almost always) to 6 (almost never). Chronic Illness Acceptance Questionnaire (CIAQ): The CIAQ was adapted from the Chronic Pain Acceptance Questionnaire (CPAQ) [9] by changing the word pain to illness. The CIAQ consists of 20 items rated on a 0 (“Never true”) to 6 (“Always true”) scale to produce a two-factor structure: Activity Engagement and Illness Willingness [1]. Acceptance and Action Questionnaire-II (AAQ-II): The 16 items are rated on a 1 (never true) to 7 (always true) scale and produce a one-factor total score of EA [2]. [1] Beacham, A.O., Linfield, K., Kinman, C.R. & Payne-Murphy, J. (Revision under review) The Chronic Illness Acceptance Questionnaire: Confirmatory Factor Analysis and Prediction of Perceived Disability in an Online Chronic Illness Support Group Sample. Journal of Contextual and Behavioral Science. [2] Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. C., Guenole, N., Orcutt, H. K., Waltz, T. and Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire – II: A revised measure of psychological flexibility and acceptance. Behavior Therapy, 42, [3] Brown, K.W. & Ryan, R.M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), [4] Consedine, N. S., & Butler, H. F. (2014). Mindfulness, health symptoms and healthcare utilization: Active facets and possible affective mediators. Psychology, Health & Medicine, 19(4), [5] Frasure-Smith, N., Lesperance, F. (2008). Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease. Arch Gen Psychiatry, 65, [6] Ginting, H., Näring, G., & Becker, E. S. (2013). Attentional bias and anxiety in individuals with coronary heart disease. Psychology & Health, 28(11), [7] Guck, T., Kinney, M., Anazia, G., & Williams, M. (2012). Relationship between acceptance of illness and functional outcomes following cardiac rehabilitation. Journal Of Cardiopulmonary Rehabilitation And Prevention, 32(4), [8] Hildebrandt, M.. J., & Hayes, S. C. (2012). The contributing role of negative affectivity and experiential avoidance to increased cardiovascular risk. Social & Personality Psychology Compass, 6(8), [9] McCracken, L. M., & Keogh, E. E. (2009). Acceptance, mindfulness, and values-based action may counteract fear and avoidance of emotions in chronic pain: An analysis of anxiety sensitivity. Journal Of Pain, 10(4), [10] McCracken, L.M., Vowles, K.E., & Eccleston, C. (2004). Acceptance of chronic pain: Component analysis and a revised assessment method. Pain, 107, [11] Roemer, L., Williston, S., Eustis, E., & Orsillo, S. (2013). Mindfulness and acceptance-based behavioral therapies for anxiety disorders. Current Psychiatry Reports, 15(11), [12] Seldenrijk, A., van Hout, H., van Marwijk, H., de Groot, E., Gort, J., Rustemeijer, C., Diamant, M., Penninx, B. (2013). Sensitivity to depression or anxiety and subclinical cardiovascular disease. Journal of Affective Disorders, 146(1), [13] Taylor, S., Zvolensky, M.J., Cox, B.J., Deacon, B., Heimber, R.G., Ledley, D.R., et al. (2007). Robust dimensions of anxiety sensitivity: Development and initial validation of the anxiety sensitivity index-3. Psychological Assessment, 19(2), [14] World Health Organization (2011). Global status report on noncommunicable diseases Geneva, Switzerland: World Health Organization. Bivariate correlations were notably strong across variables in the predicted direction. There was a strong, positive relationship between each ASI subscale and EA and inverse relationship between ASI subscales and mindfulness. CI Acceptance- willingness was likewise inversely related to each ASI subscale. See Table 1. When examined more closely, ASI items most closely resembling cardiac symptoms tended to be strongly associated with experiential avoidance and mindfulness in hypothesized directions. Contrary to a priori hypotheses, correlations with CI Acceptance subscales were not as strong. See Table 2. Although CAD/HT patients tended to have higher levels of each type of anxiety sensitivity compared to individuals with others in the study sample, on most of the measures, CAD/HT participants tended to have lower scores overall when compared to other samples of clinical or normative samples. Table 3. The results may have further research and clinical implications for patients with CAD/HT. Overall, these results suggest that anxiety sensitivity in CAD/HT patients may be related to a tendency to avoid activities that elicit internal events or symptoms that are associated with cardiac symptoms. This is particularly evident in the strong correlations between ASI subscales and AAQ-II, MAAS and CIAQ-Willingness scores. Given that all of these constructs are indicative of a desire to “not experience” cognitive, emotional and/or physical symptoms or sensations, an effective treatment approach in this population might be to target mindfulness and acceptance. These approaches have been shown to be associated with positive outcomes for individuals with heart disease [6]. Acceptance-based behavioral therapies may be especially helpful in the enhancing willingness to experience negative emotions and bodily sensations, and help the individual more readily engage in valued health related activities (e.g., physical exercise) [11] to ultimately improve functional health outcomes [8]. Table 1. Bivariate correlations of Anxiety Sensitivity subscales and ACT-related variables in CHD/HTN patients ASI Physical Concerns ASI Cognitive Concerns ASI Social Concerns MAAS Total Score AAQ-II Total Score CIAQ- Activity Engagement CIAQ - Willingness ASI Physical.593***.568***-.391***.511*** ** ASI Cognitive.641***-.582***.629***-.281**-.262** ASI Social -.429***.584*** ** MAAS Total Score -.613***.197*.143 AAQ-II Total Score -.371***-.283** CIAQ- Activity Engagement.200* NOTE: ***Denotes p <.001; **Denotes p <.01; *Denotes p <.05 Table 3. Comparison of means between study sample and other clinical samples. Measure Study Sample Mean (SD) Comparison Sample Mean (SD) p-value ASI Physical Concerns 7.12 (5.49)11.0 (6.9) [9].000 ASI Cognitive Concerns 4.13 (5.56)7.4 (4.0) [9].000 ASI Social Concerns 7.10 (5.47)4.8 (2.9) [9].000 ASI Total Score (14.21)23.2 (12.1) [9].000 MAAS Total Score 4.21 (1.11)4.1 (0.89) [9].267 AAQ-II Total Score (9.96)21.41 (7.97) [2].000 CIAQ- Activity Engagement (12.25)46.9 (7.1) [7].000 CIAQ - Willingness (9.04)23.3 (9.3) [7].685 Table 2. Selected cardiac symptom related ASI Items and bivariate correlations AAQ-IIMAASCIAQ AECIAQ W It scares me when my heart beats rapidly..385***-.307*** ** When my stomach is upset, I worry that I might be seriously ill..373***-.254*** * When my chest feels tight, I get scared that I won’t be able to breathe properly..346***-.248** * When I feel pain in my chest, I worry that I’m going to have a heart attack..399***-.251** ** When I notice me heart skipping a beat, I worry that there is something seriously wrong with me..419***-.339*** ** When my throat feels tight, I worry that I could choke to death..360***-.364*** * NOTE: ***Denotes p <.001; **Denotes p <.01; *Denotes p <.05