Unpacking Anguish in Psychiatric Populations: Symptom Dimensions, Affective Correlates, and Evidence for Stronger Alignment with Depression

Unpacking Anguish in Psychiatric Populations: Symptom Dimensions, Affective Correlates, and Evidence for Stronger Alignment with Depression | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Unpacking Anguish in Psychiatric Populations: Symptom Dimensions, Affective Correlates, and Evidence for Stronger Alignment with Depression Fernando Filipe Paulos Vieira This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7639634/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Anguish is a subjectively intense affective state frequently observed in psychiatric practice, yet its diagnostic status remains uncertain. Objective This study investigated whether anguish is more closely associated with depressive or anxiety pathology by examining symptom patterns and psychiatric comorbidities in a clinical cohort. Methods One hundred outpatients (aged 17–77 years; M = 44.5) from general, anxiety, and affective disorder clinics at the University of São Paulo were classified into three groups: no anguish (n = 50), reported anguish (n = 35), and reported anguish with limited articulation (n = 15). Standardized instruments included the Brief Symptom Inventory, Defensive Style Questionnaire, Hospital Anxiety and Depression Scale, Hamilton Anxiety Rating Scale, State–Trait Anxiety Inventory, and the MINI International Neuropsychiatric Interview. Results Patients reporting anguish showed significantly higher somatisation, fears, depressed mood, gastrointestinal complaints, and neurovegetative symptoms. Anguish was markedly associated with depressive disorders, which were 3.6 times more likely to co-occur with anguish than anxiety disorders. Conclusions Anguish emerges as a distinct affective phenomenon more strongly aligned with depression than with anxiety. Its systematic assessment may improve diagnostic precision and inform more tailored interventions in psychiatric care. Psychiatry Anguish Depression Anxiety Comorbidity Psychiatric assessment Figures Figure 1 Figure 2 Introduction Negative life events can precipitate profound psychological distress, often accompanied by visceral sensations such as chest tightness, pain, or heaviness. Clinically, anguish—from the Latin angustia, denoting narrowing or constriction—has long been described by patients as agony, torment, or mental torture. These subjective experiences are frequently intertwined with somatic correlates: constriction in the chest or throat, pressure on the sternum, an inner void, suffocating sensations, or a diffuse sense of bodily compression. Phenomenologically, anguish differs from both fear and anxiety: whereas fear is object-directed and anxiety future-oriented, anguish conveys a present-tense, inescapable immersion in psychic pain, charged with existential immediacy [ 1 , 2 ]. Historically, the construct has occupied a liminal space between psychiatry and philosophy. In existentialist thought, notably in Kierkegaard and Heidegger, Angst is understood as a fundamental mood that discloses the contingency and finitude of existence—an ontological rather than a pathological experience [ 3 , 4 ]. In classical psychoanalysis, anguish (angoisse) was central to Freud’s early formulations of neurosis, later differentiated into signal anxiety and free-floating anxiety [ 5 ]. Lacan reframed it as a disruptive affect that emerges in the absence of a mediating signifier, representing a rupture in the symbolic order [ 6 ]. Yet these rich conceptualizations never translated into operational definitions within modern psychiatric nosology, leaving anguish absent from DSM-5 and ICD-11 classifications [ 7 , 8 ]. By contrast, constructs such as somatization have been clearly defined in contemporary psychiatry, with validated measurement tools and robust epidemiological evidence. Somatization refers to the manifestation of psychological distress through physical symptoms and is consistently linked to mood and anxiety disorders [ 9 – 11 ]. In non-cardiac chest pain, psychological factors—including somatization, catastrophic misinterpretation of bodily sensations, cardiac-specific anxiety, and depressive symptomatology—are major determinants of both symptom persistence and excessive healthcare utilization [ 12 , 13 ]. Somatic complaints are also more prevalent in depressive and somatoform disorders than in primary anxiety disorders [ 14 , 15 ]. From a phenomenological-clinical perspective, anguish may constitute a primary affective modality—an irreducible experiential category distinct from both anxiety and sadness. Patients often describe it as a narrowing of temporal and spatial horizons, an internal tightening that constricts both bodily sensation and the field of consciousness, coupled with an inability to project into the future or envision relief—an existential entrapment [ 16 ]. This resonates with phenomenological psychiatry’s emphasis on structural alterations of lived experience, particularly temporality, embodiment, and self–world relations, in affective disorders [ 17 ]. Neurobiologically, although direct studies on anguish are lacking, related affective states implicate overlapping circuits in the anterior insula, dorsal anterior cingulate cortex, and periaqueductal gray—regions engaged in interoception, threat appraisal, and autonomic regulation [ 18 , 19 ]. Functional neuroimaging research in depression and anxiety has demonstrated hyperactivation in these regions during tasks eliciting social pain, anticipatory stress, or breathlessness [ 20 , 21 ]. This suggests that anguish might represent a distinct interoceptive-affective signature, with specific autonomic and neural correlates. Clinically, the underrecognition of anguish has consequences for assessment, case formulation, and treatment. Without a standardized definition, clinicians may subsume it under anxiety, depression, or somatization, potentially overlooking nuances that could guide more precise interventions. Existential psychotherapies and phenomenologically informed approaches may address the meaning-laden dimensions of anguish, while psychopharmacological strategies targeting interoceptive hyperactivation could alleviate its somatic component [ 16 , 17 ]. In sum, anguish emerges as a neglected but potentially pivotal affective construct—at the intersection of phenomenology, clinical psychiatry, and neuroscience. Explicit integration of anguish into psychiatric research may clarify its prevalence, refine diagnostic categories, and inform interventions that target not only symptom clusters but also the embodied and existential dimensions of human suffering. Without such conceptual and empirical work, anguish risks remaining what it has long been: a vivid reality in the consulting room, yet a ghost in psychiatric classification systems. Methods We implemented an experimental, cross-sectional study using a non-probability (convenience) sampling strategy. Ethics approval was granted by the Research Ethics Committee of the Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, Brazil (CAAE: 37028419.2.0000.0068). Participants A total of 100 patients, aged between 17 and 77 years (M = 44.54), were recruited through a non-probability (convenience) sampling strategy from the general psychiatry, anxiety disorders, and adult mood disorders outpatient clinics of the Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, Brazil. Eligible participants were aged 17 years or older, capable of providing informed consent, and receiving or having previously received treatment in one of the participating clinics. All participants provided written informed consent prior to enrolment. For participants under the age of 18 years, written informed consent was also obtained from a parent, legal guardian, or close family member. Individuals presenting with acute psychosis, significant cognitive impairment, or unstable medical conditions that could interfere with study participation were excluded. Based on structured clinical interviews exploring their subjective experience of anguish, participants were categorised into three groups: those who denied ever experiencing anguish (n = 50), those who reported current or past anguish and were able to provide a detailed description of its phenomenology (n = 35), and those who reported anguish but were unable to adequately articulate its characteristics or distinguish it from other affective states (n = 15). Design and questionnaires This study employed an experimental, cross-sectional design with a non-probability (convenience) sampling approach. Data collection was conducted in a single session for each participant and included a structured clinical interview followed by a battery of self-report and clinician-administered instruments. Sociodemographic and clinical data were obtained during the initial interview. Psychopathological symptoms were assessed using the Brief Symptom Inventory (BSI), a 53-item self-report measure covering nine symptom dimensions, including somatization, depression, and anxiety [ 18 ]. The Brazilian Portuguese version demonstrated adequate internal consistency (Cronbach’s α = 0.71–0.85) and construct validity [ 19 ]. Defensive functioning was evaluated with the Defensive Style Questionnaire – 40 items (DSQ-40), which classifies defense mechanisms into mature, neurotic, and immature categories [ 20 ]. The Brazilian validation showed satisfactory reliability (α = 0.72–0.84) and factorial stability (21). Depressive and anxiety symptoms were measured with the Hospital Anxiety and Depression Scale (HADS), designed for the detection of mood and anxiety disorders in non-psychiatric populations [ 22 ]. Its Brazilian Portuguese version demonstrated good internal consistency (α = 0.77–0.87) and adequate sensitivity for screening purposes [ 23 ]. Generalized anxiety severity was assessed with the clinician-administered Hamilton Anxiety Rating Scale (HAM-A), which has shown high inter-rater reliability (intraclass correlation coefficient > 0.85) in Brazilian samples [ 24 , 25 ]. Situational and trait anxiety were measured with the State–Trait Anxiety Inventory (STAI) [ 26 ], whose Brazilian adaptation demonstrated strong internal consistency (α = 0.87–0.92) and convergent validity with other anxiety measures [ 27 ]. Psychiatric diagnoses and comorbidities were established with the Mini International Neuropsychiatric Interview (MINI), a structured diagnostic interview administered by trained clinicians [ 28 ]. The Brazilian Portuguese version showed excellent diagnostic agreement with the Structured Clinical Interview for DSM (kappa > 0.80) [ 29 ]. All questionnaires were administered in their validated Brazilian Portuguese versions, and scoring procedures followed the guidelines established by the original developers. Data analysis All statistical analyses were conducted using R version 4.3.2 (R Core Team, Vienna, Austria). Two-tailed tests were applied, and the level of statistical significance was set at p < 0.05. Analyses were carried out in two sequential phases: descriptive and inferential. In the descriptive phase, four steps were undertaken. First, participants with and without anguish were compared on nominal and numerical variables using Pearson’s χ² test (or Fisher’s exact test when expected frequencies were < 5) and the Wilcoxon–Mann– Whitney test for non-normally distributed numerical variables. Second, sociodemographic characteristics were described for the overall sample and by group. Third, correspondence analysis was applied to visually explore associations between anguish and psychiatric diagnoses, including anxiety disorders, depressive disorders, and other psychiatric conditions. Fourth, comparative significance testing was performed for key study variables across groups defined by the presence of anguish, anxiety, and depression. The inferential phase comprised two steps. First, dimensionality reduction of selected questionnaire items was performed using Item Response Theory (IRT) to derive latent variables with optimal discriminatory capacity between participants with and without anguish. Second, binomial logistic regression models were used to identify independent predictors of anguish. Variable selection was based on a stepwise procedure minimising the Akaike information criterion (AIC). Model calibration was assessed using the Hosmer–Lemeshow goodness-of-fit test, and discriminative ability was quantified by the area under the receiver operating characteristic curve (AUC). Results Group comparisons In the comparison between participants with and without anguish, the only significant continuous variable was BSI Somatisation, with higher mean scores among the anguish group (M = 1.45, SD = 0.68) than the no-anguish group (M = 0.82, SD = 0.55; t (83) = 5.12, p < 0.001). Among nominal variables, the most significant were gender, education level, HAM-A Fears, HAM-A Depressed Mood, HAM-A Gastrointestinal Symptoms, and HAM-A Neurovegetative Symptoms. Sociodemographic analysis indicated that gender was the only demographic variable significantly associated with anguish, with women more frequently affected than men (χ² (1) = 4.17, p = 0.041). Correspondence analysis As shown in Figure 1, correspondence analysis of the MINI diagnostic categories (anxiety, depression, and other psychiatric disorders) demonstrated that participants with depression (D_Y) clustered more closely with those reporting anguish (Ang_Y) than with those presenting anxiety (A_Y), indicating a stronger association between anguish and depressive symptoms. In contrast, individuals without depression (D_N) were located proximally to those without anguish (Ang_N). This spatial pattern suggests that anguish may represent an important affective dimension overlapping with, but distinct from, anxiety in clinical populations. Questionnaire-based descriptive analyses Across the HAM-A and BSI domains, the variables most strongly linked to anguish were BSI Somatisation, HAM-A Depressed Mood, HAM-A Fears, HAM-A Gastrointestinal Symptoms, and HAM-A Neurovegetative Symptoms. Median scores for the anguish group were consistently higher; the Wilcoxon Mann–Whitney test confirmed statistical significance (p = 0.020). In the comparison between anguish and psychiatric diagnoses, BSI Somatisation was the only continuous variable significantly associated with a psychiatric diagnosis. Among nominal variables, Chi-square testing indicated HAM-A Fears was linked to anxiety, whereas HAM-A Neurovegetative Symptoms was linked to depression (Figure 1). Item Response Theory (IRT) and score reduction As summarised in Table 1, IRT was applied to the HAM-A and DSQ-40 to construct latent variables with potentially greater discriminatory power. For the HAM-A, two IRT-based scores were generated: the Hamilton IRT Score (all 13 items) and the Reduced Hamilton IRT Score (items with the strongest association to anguish: HAM-A Fears, Depressed Mood, Gastrointestinal Symptoms, and Neurovegetative Symptoms). Parallel sum-based scores (HAM-A Sum Score, Reduced Sum Score) were also calculated. Graphical comparisons indicated that IRT-derived scores demonstrated superior discriminatory capacity relative to sum scores. The DSQ-40 was analysed in its three latent dimensions (Neurotic, Immature, Mature), using both sum scores and IRT, with no meaningful association with anguish. Table 1 Significant HAM-A and BSI variables associated with anguish and their relationship to psychiatric diagnoses. Domain Association with Anguish Association with Psychiatric Diagnosis p-value (Anguish) p-value (Diagnosis) BSI Higher median Only 0.020 <0.05 Somatization in anguish continuous group variable significantly linked HAM-A Higher median No significant 0.020 not significant Depressed in anguish association Mood group HAM-A Fears Higher median in anguish Linked to anxiety 0.020 <0.05 group; linked to anxiety HAM-A Higher median No significant 0.020 not significant Gastrointestinal in anguish association Symptoms group HAM-A Higher median Linked to 0.020 <0.05 Neurovegetative in anguish depression Symptoms group; linked to depression Logistic regression model As illustrated in Figure 2, a logistic regression excluding uncertain cases (n = 85) identified gender, Reduced Hamilton IRT Score, BSI Somatisation, BSI Hostility, BSI Obsession–Compulsion, age, and MINI Depression as predictors of anguish. Higher levels of somatisation were positively associated with anguish, with each 1-point increase in the BSI Somatisation score corresponding to a 9.4% increase in odds. Age exerted a protective effect, with each additional year reducing the odds by 4.6%. The Reduced Hamilton IRT Score emerged as the strongest predictor: each 1-point increase was linked to an 185% increase in odds, underscoring the substantial impact of symptom severity. In contrast, higher hostility scores were associated with a 15.5% reduction, and higher obsession–compulsion scores with a 12.6% reduction in the odds of anguish. Women had 2.76 times the odds of experiencing anguish compared with men, and those diagnosed with depression via the MINI had 3.64 times the odds, highlighting the amplifying effect of depressive comorbidity. Collectively, these results indicate a complex interplay of emotional, cognitive, demographic, and psychiatric factors in determining the likelihood of anguish. Discussion This study identified gender, reduced Hamilton TRI Score, BSI Somatization, BSI Hostility, BSI Obsession–Compulsion, age, and MINI Depression as significant predictors of anguish after excluding uncertain cases (n = 85). Taken together, these findings confirm the multidimensional nature of anguish, which integrates somatic, affective, and psychiatric components. This aligns with contemporary dimensional models of distress disorders that emphasise the convergence between mood and anxiety spectra [ 30 ]. Among all predictors, BSI Somatization emerged as the strongest continuous factor: each one-point increase corresponded to a 9.4% higher odds of anguish. This reinforces evidence that somatic symptom severity robustly predicts psychological burden and functional impairment, particularly in individuals with comorbid mood and anxiety disorders [ 31 , 32 ]. The centrality of somatic distress as both a driver of help-seeking and a determinant of disability underscores the view of anguish not merely as an affective state, but as an embodied form of suffering. Analysis of the Hamilton Anxiety Rating Scale (HAM-A) revealed four domains—Depressed Mood, Fears, Gastrointestinal Symptoms, and Neurovegetative Symptoms—significantly elevated in the anguish group. This pattern is consistent with observations that neurovegetative dysregulation (e.g., autonomic arousal, appetite, and sleep disturbances) and visceral anxiety manifestations underpin severe emotional distress [ 33 ]. Such domain–diagnosis associations support the hypothesis that anguish reflects overlapping affective and somatic circuits, potentially implicating both limbic–cortical networks and brainstem autonomic centres. Psychometric modelling through Item Response Theory (IRT) further demonstrated that the Reduced Hamilton IRT Score—derived from items most strongly linked to anguish—outperformed traditional sum scores in discriminatory capacity. IRT’s strengths, including enhanced measurement precision, interval-level scaling, and improved cross-study comparability, are well established [ 34 – 36 ]. The incorporation of IRT-based metrics into psychiatric assessment could pave the way for adaptive screening protocols, improving efficiency and diagnostic accuracy in clinical practice. From a sociodemographic perspective, female gender was associated with more than double the odds of reporting anguish, consistent with extensive epidemiological evidence of greater prevalence of internalising disorders among women [ 37 ]. Likewise, depression (MINI) conferred a threefold increase in the likelihood of anguish, highlighting the amplifying role of depressive comorbidity in both the intensity and persistence of distress [ 38 , 39 ]. By contrast, DSQ-40 defensive style dimensions—Mature, Neurotic, and Immature—showed no significant associations, suggesting that habitual defensive functioning may play a limited role in the immediate phenomenology of anguish, or that their effects are mediated by other affective or cognitive processes. Clinically, these results emphasise the value of combining symptom-specific psychometric tools with structured diagnostic interviews. Identifying core somatic and neurovegetative markers provides a potential pathway for earlier detection, particularly within primary care and consultation–liaison psychiatry. Future research should evaluate these predictors longitudinally to clarify causal pathways, investigate neurobiological correlates (e.g., insula–anterior cingulate connectivity, HPA axis reactivity), and assess whether IRT-enhanced tools can translate into tangible improvements in patient outcomes. Conclusion This study identifies key somatic, affective, and psychiatric predictors of anguish, with BSI Somatisation and the Reduced Hamilton IRT Score as the strongest markers. The results support viewing anguish as an embodied distress state and highlight gender and depressive comorbidity as important amplifiers. These insights may inform targeted detection and intervention, warranting further longitudinal and neurobiological research. Declarations Acknowledgments The author gratefully acknowledge Professor Julia Maria Pavan Soler and colleagues for their expert guidance and support in the statistical analysis. The author also thank all participants and collaborating institutions for their contribution to this research. Declaration of Conflicting Interests The author declare that there are no potential conflicts of interest with respect to the research, authorship, or publication of this article. Funding The author(s) declare that no financial support was received for the research, authorship, or publication of this article. References López-Ibor JJ (1950) Anguish and anxiety in psychiatry. Actas Luso Esp Neurol Psiquiatr Cienc Afines Roberts M, Taylor G (2021) Phenomenology of anguish: clinical perspectives. J Affect Disord 295:432–439 Kierkegaard S (1844) The concept of anxiety. Reitzel, Copenhagen Heidegger M (1927) Sein und Zeit. Niemeyer, Tübingen Freud S (1926) Inhibitions, symptoms and anxiety. Hogarth, London Lacan J, Seminar (1962) X: Anxiety. Seuil, Paris American Psychiatric Association (2022) Diagnostic and statistical manual of mental disorders, 5th edn. 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07:54:25","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75117,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7639634/v1/afc49da5ccb480ca167d6989.html"},{"id":91962130,"identity":"2db37dec-4b6c-44af-827b-3ee9ee8de6a8","added_by":"auto","created_at":"2025-09-23 07:54:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":129456,"visible":true,"origin":"","legend":"\u003cp\u003eCorrespondence Analysis of Depression, Anxiety, and Anguish Categories\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7639634/v1/7d0c7355e9701831f4a397ab.png"},{"id":91962186,"identity":"abf540a7-7e30-4951-8ca8-8e9131e00941","added_by":"auto","created_at":"2025-09-23 07:54:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":121042,"visible":true,"origin":"","legend":"\u003cp\u003ePredictors of Anguish Identified by Logistic Regression\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7639634/v1/24a72879c6486c4ac1365866.png"},{"id":91963276,"identity":"d4700d93-6e12-421b-ba03-1154ca4ac721","added_by":"auto","created_at":"2025-09-23 08:02:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":689032,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7639634/v1/3f2aba00-0652-4c79-9700-5d7bfb191723.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eUnpacking Anguish in Psychiatric Populations: Symptom Dimensions, Affective Correlates, and Evidence for Stronger Alignment with Depression\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNegative life events can precipitate profound psychological distress, often accompanied by visceral sensations such as chest tightness, pain, or heaviness. Clinically, anguish\u0026mdash;from the Latin angustia, denoting narrowing or constriction\u0026mdash;has long been described by patients as agony, torment, or mental torture. These subjective experiences are frequently intertwined with somatic correlates: constriction in the chest or throat, pressure on the sternum, an inner void, suffocating sensations, or a diffuse sense of bodily compression. Phenomenologically, anguish differs from both fear and anxiety: whereas fear is object-directed and anxiety future-oriented, anguish conveys a present-tense, inescapable immersion in psychic pain, charged with existential immediacy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHistorically, the construct has occupied a liminal space between psychiatry and philosophy. In existentialist thought, notably in Kierkegaard and Heidegger, Angst is understood as a fundamental mood that discloses the contingency and finitude of existence\u0026mdash;an ontological rather than a pathological experience [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In classical psychoanalysis, anguish (angoisse) was central to Freud\u0026rsquo;s early formulations of neurosis, later differentiated into signal anxiety and free-floating anxiety [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Lacan reframed it as a disruptive affect that emerges in the absence of a mediating signifier, representing a rupture in the symbolic order [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Yet these rich conceptualizations never translated into operational definitions within modern psychiatric nosology, leaving anguish absent from DSM-5 and ICD-11 classifications [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBy contrast, constructs such as somatization have been clearly defined in contemporary psychiatry, with validated measurement tools and robust epidemiological evidence. Somatization refers to the manifestation of psychological distress through physical symptoms and is consistently linked to mood and anxiety disorders [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In non-cardiac chest pain, psychological factors\u0026mdash;including somatization, catastrophic misinterpretation of bodily sensations, cardiac-specific anxiety, and depressive symptomatology\u0026mdash;are major determinants of both symptom persistence and excessive healthcare utilization [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Somatic complaints are also more prevalent in depressive and somatoform disorders than in primary anxiety disorders [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFrom a phenomenological-clinical perspective, anguish may constitute a primary affective modality\u0026mdash;an irreducible experiential category distinct from both anxiety and sadness. Patients often describe it as a narrowing of temporal and spatial horizons, an internal tightening that constricts both bodily sensation and the field of consciousness, coupled with an inability to project into the future or envision relief\u0026mdash;an existential entrapment [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This resonates with phenomenological psychiatry\u0026rsquo;s emphasis on structural alterations of lived experience, particularly temporality, embodiment, and self\u0026ndash;world relations, in affective disorders [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNeurobiologically, although direct studies on anguish are lacking, related affective states implicate overlapping circuits in the anterior insula, dorsal anterior cingulate cortex, and periaqueductal gray\u0026mdash;regions engaged in interoception, threat appraisal, and autonomic regulation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Functional neuroimaging research in depression and anxiety has demonstrated hyperactivation in these regions during tasks eliciting social pain, anticipatory stress, or breathlessness [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This suggests that anguish might represent a distinct interoceptive-affective signature, with specific autonomic and neural correlates.\u003c/p\u003e\u003cp\u003eClinically, the underrecognition of anguish has consequences for assessment, case formulation, and treatment. Without a standardized definition, clinicians may subsume it under anxiety, depression, or somatization, potentially overlooking nuances that could guide more precise interventions. Existential psychotherapies and phenomenologically informed approaches may address the meaning-laden dimensions of anguish, while psychopharmacological strategies targeting interoceptive hyperactivation could alleviate its somatic component [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn sum, anguish emerges as a neglected but potentially pivotal affective construct\u0026mdash;at the intersection of phenomenology, clinical psychiatry, and neuroscience. Explicit integration of anguish into psychiatric research may clarify its prevalence, refine diagnostic categories, and inform interventions that target not only symptom clusters but also the embodied and existential dimensions of human suffering. Without such conceptual and empirical work, anguish risks remaining what it has long been: a vivid reality in the consulting room, yet a ghost in psychiatric classification systems.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe implemented an experimental, cross-sectional study using a non-probability (convenience) sampling strategy. Ethics approval was granted by the Research Ethics Committee of the Department and Institute of Psychiatry, Faculty of Medicine, University of S\u0026atilde;o Paulo, Brazil (CAAE: 37028419.2.0000.0068).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eA total of 100 patients, aged between 17 and 77 years (M\u0026thinsp;=\u0026thinsp;44.54), were recruited through a non-probability (convenience) sampling strategy from the general psychiatry, anxiety disorders, and adult mood disorders outpatient clinics of the Department and Institute of Psychiatry, Faculty of Medicine, University of S\u0026atilde;o Paulo, Brazil. Eligible participants were aged 17 years or older, capable of providing informed consent, and receiving or having previously received treatment in one of the participating clinics. All participants provided written informed consent prior to enrolment. For participants under the age of 18 years, written informed consent was also obtained from a parent, legal guardian, or close family member. Individuals presenting with acute psychosis, significant cognitive impairment, or unstable medical conditions that could interfere with study participation were excluded. Based on structured clinical interviews exploring their subjective experience of anguish, participants were categorised into three groups: those who denied ever experiencing anguish (n\u0026thinsp;=\u0026thinsp;50), those who reported current or past anguish and were able to provide a detailed description of its phenomenology (n\u0026thinsp;=\u0026thinsp;35), and those who reported anguish but were unable to adequately articulate its characteristics or distinguish it from other affective states (n\u0026thinsp;=\u0026thinsp;15).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDesign and questionnaires\u003c/h3\u003e\n\u003cp\u003eThis study employed an experimental, cross-sectional design with a non-probability (convenience) sampling approach. Data collection was conducted in a single session for each participant and included a structured clinical interview followed by a battery of self-report and clinician-administered instruments. Sociodemographic and clinical data were obtained during the initial interview.\u003c/p\u003e\u003cp\u003ePsychopathological symptoms were assessed using the Brief Symptom Inventory (BSI), a 53-item self-report measure covering nine symptom dimensions, including somatization, depression, and anxiety [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The Brazilian Portuguese version demonstrated adequate internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.71\u0026ndash;0.85) and construct validity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Defensive functioning was evaluated with the Defensive Style Questionnaire \u0026ndash; 40 items (DSQ-40), which classifies defense mechanisms into mature, neurotic, and immature categories [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The Brazilian validation showed satisfactory reliability (α\u0026thinsp;=\u0026thinsp;0.72\u0026ndash;0.84) and factorial stability (21). Depressive and anxiety symptoms were measured with the Hospital Anxiety and Depression Scale (HADS), designed for the detection of mood and anxiety disorders in non-psychiatric populations [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Its Brazilian Portuguese version demonstrated good internal consistency (α\u0026thinsp;=\u0026thinsp;0.77\u0026ndash;0.87) and adequate sensitivity for screening purposes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Generalized anxiety severity was assessed with the clinician-administered Hamilton Anxiety Rating Scale (HAM-A), which has shown high inter-rater reliability (intraclass correlation coefficient\u0026thinsp;\u0026gt;\u0026thinsp;0.85) in Brazilian samples [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Situational and trait anxiety were measured with the State\u0026ndash;Trait Anxiety Inventory (STAI) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], whose Brazilian adaptation demonstrated strong internal consistency (α\u0026thinsp;=\u0026thinsp;0.87\u0026ndash;0.92) and convergent validity with other anxiety measures [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Psychiatric diagnoses and comorbidities were established with the Mini International Neuropsychiatric Interview (MINI), a structured diagnostic interview administered by trained clinicians [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The Brazilian Portuguese version showed excellent diagnostic agreement with the Structured Clinical Interview for DSM (kappa\u0026thinsp;\u0026gt;\u0026thinsp;0.80) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. All questionnaires were administered in their validated Brazilian Portuguese versions, and scoring procedures followed the guidelines established by the original developers.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were conducted using R version 4.3.2 (R Core Team, Vienna, Austria). Two-tailed tests were applied, and the level of statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Analyses were carried out in two sequential phases: descriptive and inferential.\u003c/p\u003e\u003cp\u003eIn the descriptive phase, four steps were undertaken. First, participants with and without anguish were compared on nominal and numerical variables using Pearson\u0026rsquo;s χ\u0026sup2; test (or Fisher\u0026rsquo;s exact test when expected frequencies were \u0026lt;\u0026thinsp;5) and the Wilcoxon\u0026ndash;Mann\u0026ndash; Whitney test for non-normally distributed numerical variables. Second, sociodemographic characteristics were described for the overall sample and by group. Third, correspondence analysis was applied to visually explore associations between anguish and psychiatric diagnoses, including anxiety disorders, depressive disorders, and other psychiatric conditions. Fourth, comparative significance testing was performed for key study variables across groups defined by the presence of anguish, anxiety, and depression.\u003c/p\u003e\u003cp\u003eThe inferential phase comprised two steps. First, dimensionality reduction of selected questionnaire items was performed using Item Response Theory (IRT) to derive latent variables with optimal discriminatory capacity between participants with and without anguish. Second, binomial logistic regression models were used to identify independent predictors of anguish. Variable selection was based on a stepwise procedure minimising the Akaike information criterion (AIC). Model calibration was assessed using the Hosmer\u0026ndash;Lemeshow goodness-of-fit test, and discriminative ability was quantified by the area under the receiver operating characteristic curve (AUC).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eGroup comparisons\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the comparison between participants with and without anguish, the only significant continuous variable was BSI Somatisation, with higher mean scores among the anguish group (M = 1.45, SD = 0.68) than the no-anguish group (M = 0.82, SD = 0.55; t (83) = 5.12, p \u0026lt; 0.001). Among nominal variables, the most significant were gender, education level, HAM-A Fears, HAM-A Depressed Mood, HAM-A Gastrointestinal Symptoms, and HAM-A Neurovegetative Symptoms. Sociodemographic analysis indicated that gender was the only demographic variable significantly associated with anguish, with women more frequently affected than men (\u0026chi;\u0026sup2; (1) = 4.17, p = 0.041).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCorrespondence analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Figure 1, correspondence analysis of the MINI diagnostic categories (anxiety, depression, and other psychiatric disorders) demonstrated that participants with depression (D_Y) clustered more closely with those reporting anguish (Ang_Y) than with those presenting anxiety (A_Y), indicating a stronger association between anguish and depressive symptoms. In contrast, individuals without depression (D_N) were located proximally to those without anguish (Ang_N). This spatial pattern suggests that anguish may represent an important affective dimension overlapping with, but distinct from, anxiety in clinical populations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuestionnaire-based descriptive analyses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross the HAM-A and BSI domains, the variables most strongly linked to anguish were BSI Somatisation, HAM-A Depressed Mood, HAM-A Fears, HAM-A Gastrointestinal Symptoms, and HAM-A Neurovegetative Symptoms. Median scores for the anguish group were consistently higher; the Wilcoxon Mann\u0026ndash;Whitney test confirmed statistical significance (p = 0.020). In the comparison between anguish and psychiatric diagnoses, BSI Somatisation was the only continuous variable significantly associated with a psychiatric diagnosis. Among nominal variables, Chi-square testing indicated HAM-A Fears was linked to anxiety, whereas HAM-A Neurovegetative Symptoms was linked to depression (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eItem Response Theory (IRT) and score reduction\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs summarised in Table 1, IRT was applied to the HAM-A and DSQ-40 to construct latent variables with potentially greater discriminatory power. For the HAM-A, two IRT-based scores were generated: the Hamilton IRT Score (all 13 items) and the Reduced Hamilton IRT Score (items with the strongest association to anguish: HAM-A Fears, Depressed Mood, Gastrointestinal Symptoms, and Neurovegetative Symptoms). Parallel sum-based scores (HAM-A Sum Score, Reduced Sum Score) were also calculated. Graphical comparisons indicated that IRT-derived scores demonstrated superior discriminatory capacity relative to sum scores. The DSQ-40 was analysed in its three latent dimensions (Neurotic, Immature, Mature), using both sum scores and IRT, with no meaningful association with anguish.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Significant HAM-A and BSI variables associated with anguish and their relationship to psychiatric diagnoses.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"585\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssociation\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ewith\u0026nbsp;Anguish\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssociation\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ewith\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePsychiatric\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value (Anguish)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value (Diagnosis)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eBSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eHigher median\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eOnly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eSomatization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003ein anguish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003econtinuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003evariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003esignificantly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003elinked\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eHAM-A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eHigher median\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eNo significant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003enot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eDepressed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003ein anguish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eassociation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eMood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHAM-A Fears\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigher median\u003c/p\u003e\n \u003cp\u003ein anguish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLinked to\u003c/p\u003e\n \u003cp\u003eanxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003egroup;\u0026nbsp;linked\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eto anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eHAM-A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eHigher median\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eNo significant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003enot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eGastrointestinal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003ein anguish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eassociation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003egroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHAM-A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigher median\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLinked to\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eNeurovegetative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003ein anguish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003edepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003egroup;\u0026nbsp;linked\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003eto depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eLogistic regression model\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs illustrated in Figure 2, a logistic regression excluding uncertain cases (n = 85) identified gender, Reduced Hamilton IRT Score, BSI Somatisation, BSI Hostility, BSI Obsession\u0026ndash;Compulsion, age, and MINI Depression as predictors of anguish. Higher levels of somatisation were positively associated with anguish, with each 1-point increase in the BSI Somatisation score corresponding to a 9.4% increase in odds. Age exerted a protective effect, with each additional year reducing the odds by 4.6%. The Reduced Hamilton IRT Score emerged as the strongest predictor: each 1-point increase was linked to an 185% increase in odds, underscoring the substantial impact of symptom severity. In contrast, higher hostility scores were associated with a 15.5% reduction, and higher obsession\u0026ndash;compulsion scores with a 12.6% reduction in the odds of anguish. Women had\u003c/p\u003e\n\u003cp\u003e2.76 times the odds of experiencing anguish compared with men, and those diagnosed with depression via the MINI had 3.64 times the odds, highlighting the amplifying effect of depressive comorbidity. Collectively, these results indicate a complex interplay of emotional, cognitive, demographic, and psychiatric factors in\u0026nbsp;\u003cbr\u003edetermining the likelihood of anguish.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study identified gender, reduced Hamilton TRI Score, BSI Somatization, BSI Hostility, BSI Obsession\u0026ndash;Compulsion, age, and MINI Depression as significant predictors of anguish after excluding uncertain cases (n\u0026thinsp;=\u0026thinsp;85). Taken together, these findings confirm the multidimensional nature of anguish, which integrates somatic, affective, and psychiatric components. This aligns with contemporary dimensional models of distress disorders that emphasise the convergence between mood and anxiety spectra [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAmong all predictors, BSI Somatization emerged as the strongest continuous factor: each one-point increase corresponded to a 9.4% higher odds of anguish. This reinforces evidence that somatic symptom severity robustly predicts psychological burden and functional impairment, particularly in individuals with comorbid mood and anxiety disorders [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The centrality of somatic distress as both a driver of help-seeking and a determinant of disability underscores the view of anguish not merely as an affective state, but as an embodied form of suffering.\u003c/p\u003e\u003cp\u003eAnalysis of the Hamilton Anxiety Rating Scale (HAM-A) revealed four domains\u0026mdash;Depressed Mood, Fears, Gastrointestinal Symptoms, and Neurovegetative Symptoms\u0026mdash;significantly elevated in the anguish group. This pattern is consistent with observations that neurovegetative dysregulation (e.g., autonomic arousal, appetite, and sleep disturbances) and visceral anxiety manifestations underpin severe emotional distress [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Such domain\u0026ndash;diagnosis associations support the hypothesis that anguish reflects overlapping affective and somatic circuits, potentially implicating both limbic\u0026ndash;cortical networks and brainstem autonomic centres.\u003c/p\u003e\u003cp\u003ePsychometric modelling through Item Response Theory (IRT) further demonstrated that the Reduced Hamilton IRT Score\u0026mdash;derived from items most strongly linked to anguish\u0026mdash;outperformed traditional sum scores in discriminatory capacity. IRT\u0026rsquo;s strengths, including enhanced measurement precision, interval-level scaling, and improved cross-study comparability, are well established [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The incorporation of IRT-based metrics into psychiatric assessment could pave the way for adaptive screening protocols, improving efficiency and diagnostic accuracy in clinical practice.\u003c/p\u003e\u003cp\u003eFrom a sociodemographic perspective, female gender was associated with more than double the odds of reporting anguish, consistent with extensive epidemiological evidence of greater prevalence of internalising disorders among women [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Likewise, depression (MINI) conferred a threefold increase in the likelihood of anguish, highlighting the amplifying role of depressive comorbidity in both the intensity and persistence of distress [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. By contrast, DSQ-40 defensive style dimensions\u0026mdash;Mature, Neurotic, and Immature\u0026mdash;showed no significant associations, suggesting that habitual defensive functioning may play a limited role in the immediate phenomenology of anguish, or that their effects are mediated by other affective or cognitive processes.\u003c/p\u003e\u003cp\u003eClinically, these results emphasise the value of combining symptom-specific psychometric tools with structured diagnostic interviews. Identifying core somatic and neurovegetative markers provides a potential pathway for earlier detection, particularly within primary care and consultation\u0026ndash;liaison psychiatry. Future research should evaluate these predictors longitudinally to clarify causal pathways, investigate neurobiological correlates (e.g., insula\u0026ndash;anterior cingulate connectivity, HPA axis reactivity), and assess whether IRT-enhanced tools can translate into tangible improvements in patient outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identifies key somatic, affective, and psychiatric predictors of anguish, with BSI Somatisation and the Reduced Hamilton IRT Score as the strongest markers. The results support viewing anguish as an embodied distress state and highlight gender and depressive comorbidity as important amplifiers. These insights may inform targeted detection and intervention, warranting further longitudinal and neurobiological research.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author gratefully acknowledge Professor Julia Maria Pavan Soler and colleagues for their expert guidance and support in the statistical analysis. The author also thank all participants and collaborating institutions for their contribution to this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declare that there are no potential conflicts of interest with respect to the research, authorship, or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare that no financial support was received for the research, authorship, or publication of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eL\u0026oacute;pez-Ibor JJ (1950) Anguish and anxiety in psychiatry. Actas Luso Esp Neurol Psiquiatr Cienc Afines\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoberts M, Taylor G (2021) Phenomenology of anguish: clinical perspectives. J Affect Disord 295:432\u0026ndash;439\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKierkegaard S (1844) The concept of anxiety. Reitzel, Copenhagen\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeidegger M (1927) Sein und Zeit. Niemeyer, T\u0026uuml;bingen\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFreud S (1926) Inhibitions, symptoms and anxiety. Hogarth, London\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLacan J, Seminar (1962) X: Anxiety. Seuil, Paris\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association (2022) Diagnostic and statistical manual of mental disorders, 5th edn. APA, Washington, DC\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2022) International classification of diseases (11th revision). 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NCS Pearson, Minneapolis\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBorsa JC, Dam\u0026aacute;sio BF, Bandeira DR (2012) Cross-cultural adaptation and validation of psychological instruments: Some considerations. Paideia 22(53):423\u0026ndash;432\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndrews G, Singh M, Bond M (1993) The Defense Style Questionnaire. J Nerv Ment Dis 181(4):246\u0026ndash;256\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlaya C, Dornelles M, Blaya R, Kipper L, Heldt E, Isolan L et al (2006) Brazilian Portuguese version of the Defense Style Questionnaire-40 (DSQ-40) for defense mechanisms identification. Rev Bras Psiquiatr 28(3):222\u0026ndash;225\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZigmond AS, Snaith RP (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 67(6):361\u0026ndash;370\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBotega NJ, Bio MR, Zomignani MA, Garcia C Jr, Pereira WAB (1995) Mood disorders among medical inpatients: a validation study of the Hospital Anxiety and Depression Scale (HAD) in general hospital patients. Braz J Psychiatry 17(4):247\u0026ndash;250\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHamilton M (1959) The assessment of anxiety states by rating. Br J Med Psychol 32(1):50\u0026ndash;55\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoreno RA, Moreno DH (1998) Escalas de avalia\u0026ccedil;\u0026atilde;o de ansiedade. Rev Psiquiatr Cl\u0026iacute;n (S\u0026atilde;o Paulo) 25(6):285\u0026ndash;290\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA (1983) Manual for the State-Trait Anxiety Inventory. Consulting Psychologists, Palo Alto, CA\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBiaggio AMB, Natal\u0026iacute;cio L (1979) Manual for the State-Trait Anxiety Inventory (STAI). Vetor Editora, S\u0026atilde;o Paulo\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E et al (1998) The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59(Suppl 20):22\u0026ndash;33\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmorim P (2000) Mini International Neuropsychiatric Interview (MINI): validation of a short structured diagnostic psychiatric interview. Rev Bras Psiquiatr 22(3):106\u0026ndash;115\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatson D, Naragon-Gainey K (2020) Dimensional models of general psychopathology. 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J Abnorm Psychol 100(3):316\u0026ndash;336\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anguish, Depression, Anxiety, Comorbidity, Psychiatric assessment","lastPublishedDoi":"10.21203/rs.3.rs-7639634/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7639634/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAnguish is a subjectively intense affective state frequently observed in psychiatric practice, yet its diagnostic status remains uncertain.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThis study investigated whether anguish is more closely associated with depressive or anxiety pathology by examining symptom patterns and psychiatric comorbidities in a clinical cohort.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eOne hundred outpatients (aged 17\u0026ndash;77 years; M\u0026thinsp;=\u0026thinsp;44.5) from general, anxiety, and affective disorder clinics at the University of S\u0026atilde;o Paulo were classified into three groups: no anguish (n\u0026thinsp;=\u0026thinsp;50), reported anguish (n\u0026thinsp;=\u0026thinsp;35), and reported anguish with limited articulation (n\u0026thinsp;=\u0026thinsp;15). Standardized instruments included the Brief Symptom Inventory, Defensive Style Questionnaire, Hospital Anxiety and Depression Scale, Hamilton Anxiety Rating Scale, State\u0026ndash;Trait Anxiety Inventory, and the MINI International Neuropsychiatric Interview.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ePatients reporting anguish showed significantly higher somatisation, fears, depressed mood, gastrointestinal complaints, and neurovegetative symptoms. Anguish was markedly associated with depressive disorders, which were 3.6 times more likely to co-occur with anguish than anxiety disorders.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eAnguish emerges as a distinct affective phenomenon more strongly aligned with depression than with anxiety. Its systematic assessment may improve diagnostic precision and inform more tailored interventions in psychiatric care.\u003c/p\u003e","manuscriptTitle":"Unpacking Anguish in Psychiatric Populations: Symptom Dimensions, Affective Correlates, and Evidence for Stronger Alignment with Depression","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 07:54:10","doi":"10.21203/rs.3.rs-7639634/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"45896976-21ec-4191-baf2-48bab5cdc993","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":54875773,"name":"Psychiatry"}],"tags":[],"updatedAt":"2025-09-23T07:54:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 07:54:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7639634","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7639634","identity":"rs-7639634","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}