Psychopathological Correlates of Anguish in Psychiatric Outpatients: Associations with Depression, Anxiety, and Somatic Symptoms

Psychopathological Correlates of Anguish in Psychiatric Outpatients: Associations with Depression, Anxiety, and Somatic Symptoms | 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 Psychopathological Correlates of Anguish in Psychiatric Outpatients: Associations with Depression, Anxiety, and Somatic Symptoms Fernando Filipe Paulos Vieira This is a preprint; it has not been peer reviewed by a journal.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-8238072/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 Introduction Anguish is an affective–somatic state characterized by intense thoracic discomfort and described by patients as pain, tightness, pressure, compression, or a “hole” in the chest. Despite its clinical frequency, its psychopathological correlates remain poorly defined. This study examined whether anguish is associated with specific symptom patterns, psychiatric comorbidities, and differential relationships with depression and anxiety. Methods A total of 100 outpatients from a large psychiatric institution in Brazil were assessed through a structured interview and allocated into three groups: with anguish, without anguish, and uncertain. Psychopathological features were evaluated using the BSI, DSQ-40, HADS, HAM-A, STAI, and MINI. Group differences and diagnostic associations were analyzed using inferential statistics. Results Patients reporting anguish displayed distinct psychopathological profiles compared with the other groups, including higher levels of somatization, fears, depressed mood, gastrointestinal complaints, and neurovegetative symptoms. Individuals with depressive disorders were 3.64 times more likely to report anguish compared with those with anxiety disorders. Conclusions Anguish appears to represent a clinically relevant affective–somatic phenomenon associated with specific symptom clusters and a stronger relationship with depression than with anxiety. These findings support the need for further investigation of anguish as a potential marker within psychiatric assessment and diagnostic formulation. Psychology Psychiatry Anguish thoracic discomfort depression anxiety psychiatry Figures Figure 1 1 Introduction The term anguish is frequently used by psychiatric patients to describe an intense negative affective state accompanied by thoracic sensations such as tightness, pressure, or suffocation. Although these bodily sensations overlap with well-established somatic symptoms of depression and anxiety, the subjective experience specifically labeled as anguish has received little empirical attention. Contemporary diagnostic systems, including the DSM-5-TR and ICD-11, do not define anguish as an independent construct, reflecting a broader tendency to subsume affective–somatic experiences under transdiagnostic categories of distress, autonomic arousal, or emotional dysregulation [ 1 , 2 ]. This diagnostic absence leaves uncertainty as to whether anguish reflects a non-specific expression of emotional suffering or constitutes a distinct affective–somatic state with potential clinical relevance. Philosophical and phenomenological traditions, particularly within existential psychiatry, describe anguish as an experience of constriction, threat, or heightened vulnerability to the world—an affective state involving both corporeal constriction and a disruption of one’s sense of situatedness [ 3 , 4 ]. Despite their conceptual richness, these accounts have not been operationalized within contemporary empirical research, and thus their clinical implications remain largely unexplored. Notably, clinicians often report that patients spontaneously differentiate anguish from typical anxiety, highlighting its bodily intensity, immediacy, and a sense of impending psychological collapse. Research on the phenomenology of emotional distress suggests that individuals frequently employ culturally shaped idioms to articulate complex affective–somatic states not adequately captured by psychiatric taxonomy [ 5 , 6 ]. Comparable expressions—such as “tight chest,” “heart-mind pain,” or “internal pressure”—have been documented across diverse sociocultural contexts and, in some cases, have been associated with distinct patterns of symptom clustering, coping, and help-seeking [ 7 , 8 ]. These findings raise the possibility that patient-defined categories such as anguish may reveal clinically meaningful experiential patterns otherwise obscured by standardized diagnostic terminology. At the same time, thoracic discomfort is a well-recognized manifestation in mood and anxiety disorders. Somatic symptoms such as chest tightness, dyspnea, and autonomic arousal are strongly associated with increased illness burden, elevated health-care utilization, and poorer functional outcomes [ 9 – 11 ]. Although these symptoms are common across disorders, it remains unknown whether patients who specifically describe their experience as anguish differ systematically from those who report similar sensations but use other terms. Likewise, large-scale epidemiological studies documenting rising levels of severe distress globally [ 12 ] do not address whether anguish represents a clinically distinct experience or simply a linguistic marker of generalized psychological discomfort. Given these conceptual and empirical gaps, systematic investigation is needed to determine whether anguish corresponds to identifiable clinical patterns or diagnostic associations. 1.1 Aims of Study The present study aims to (1) examine whether anguish is associated with distinct clusters of psychopathological symptoms or psychiatric comorbidities, and (2) assess whether anguish is differentially linked to depressive versus anxiety disorders. By integrating structured psychopathological assessment with patient-defined experiential descriptions, the study seeks to clarify whether anguish constitutes a clinically relevant affective–somatic category within contemporary psychiatric practice. 2 Methods 2.1. Study Design and Data Acquisition This cross-sectional study was conducted at a large psychiatric outpatient institution in Brazil between 2021 and 2024. The study aimed to investigate whether self-reported anguish is associated with distinct psychopathological profiles, psychiatric comorbidities, and differential relationships with depressive and anxiety disorders. The study protocol was approved by the local Research Ethics Commitee of the Institute of Psychiatry of Hospital of Clinics of Faculty of Medicine of University of São Paulo, and all participants provided written informed consent in accordance with the Declaration of Helsinki [ 13 ]. Participants were consecutively recruited from outpatient clinics specializing in mood and anxiety disorders. Inclusion criteria were: age 17–77 years, ability to provide informed consent, and clinical stability defined as no hospitalization or major treatment changes in the preceding month. Exclusion criteria included: current psychotic disorder, severe cognitive impairment, neurological disease affecting mental status, or acute medical conditions that could confound somatic symptom reporting [ 14 , 15 ]. A structured clinical interview was used to assess the presence of anguish, following a phenomenologically informed framework derived from prior research on patient-defined affective–somatic experiences [ 16 , 17 ]. Participants were classified into three groups: (1) with anguish, (2) without anguish, and (3) uncertain. This classification was based on explicit patient reports of thoracic discomfort and affective intensity, corroborated by clinician evaluation. Psychopathology was assessed using validated instruments: the Brief Symptom Inventory (BSI) for general symptom burden [ 18 ], the Defense Style Questionnaire (DSQ-40) for defensive functioning [ 19 ], the Hospital Anxiety and Depression Scale (HADS) and Hamilton Anxiety Rating Scale (HAM-A) for affective symptomatology [ 20 , 21 ], the State-Trait Anxiety Inventory (STAI) for trait anxiety [ 22 ], and the Mini-International Neuropsychiatric Interview (MINI) for DSM-5 diagnostic confirmation [ 23 ]. Sociodemographic and clinical data—including age, sex, education, psychiatric history, current medication, and comorbid medical conditions—were collected using a standardized case report form. Data quality was ensured through double-entry verification and periodic audit by the study coordinators. The sample size of 100 participants was determined a priori based on expected prevalence of self-reported anguish and power calculations to detect medium effect sizes in group comparisons [ 24 , 25 ]. 2.2 Statistical Analyses Descriptive statistics were computed for sociodemographic and clinical variables. Continuous variables were summarized as means and standard deviations (SD) or medians and interquartile ranges (IQR) depending on data distribution, while categorical variables were presented as frequencies and percentages. Normality of continuous variables was assessed using the Shapiro–Wilk test and visual inspection of histograms [ 26 ]. Group comparisons among participants classified as with anguish, without anguish, and uncertain were conducted using one-way analysis of variance (ANOVA) for normally distributed continuous variables or the Kruskal–Wallis test for non-normal distributions. Post-hoc pairwise comparisons were adjusted using Bonferroni correction. For categorical variables, Chi-square tests or Fisher’s exact tests were applied as appropriate [ 27 , 28 ]. Effect sizes were calculated using Cohen’s d for continuous variables and Cramer’s V for categorical variables [ 29 ]. Logistic regression analyses were performed to examine the association between psychiatric diagnoses and the likelihood of reporting anguish. Separate models were fitted for depressive and anxiety disorders, adjusting for potential confounders including age, sex, education, and comorbid medical conditions [ 30 , 31 ]. Odds ratios (OR) with 95% confidence intervals (CI) were reported. Model fit was evaluated using the Hosmer–Lemeshow test and area under the receiver operating characteristic (ROC) curve [ 32 ]. All statistical analyses were performed using SPSS version 28.0 (IBM Corp., Armonk, NY, USA) and significance was set at a two-tailed p-value < 0.05. Missing data were handled using pairwise deletion, as the proportion of missingness for each variable was below 5%, minimizing potential bias [ 33 ]. 3 Results 3.1 Qualitative Analysis A qualitative descriptive approach was used to analyze the lived experience of anguish among 35 patients. Semi-structured interviews explored how participants perceived anguish, the physical sensations associated with it, and the life situations in which these sensations emerged. An inductive thematic analysis allowed recurrent patterns to arise directly from patient narratives, revealing a multidimensional phenomenon characterized by the convergence of emotional distress, somatic activation, and situational triggers. Across the sample, patients described anguish as a sudden and overwhelming internal tension, frequently referring to it as “a pressure from within,” “a knot in the chest,” or “a wave rising through the body.” Somatic symptoms were common and often intense, with chest pressure or tightness, stomach constriction or abdominal discomfort, shortness of breath or a choking sensation, palpitations, autonomic arousal, diffuse muscular tension—particularly in the neck and shoulders—restlessness or agitation in the limbs, and episodes of sweating, dizziness, or cold extremities emerging as the most recurrent manifestations. Illustrative accounts included participants who felt a “knot rising from the stomach to the chest” accompanied by trembling and air hunger, others who reported a “burning behind the sternum” with palpitations and withdrawal, and several who described muscle stiffness, sudden fatigue, or vertigo triggered by emotional overload. These physical sensations were interpreted by many of the 35 patients as signs of emotional overwhelm, often perceived more vividly in the body than in conscious thought. Despite individual variability, analysis across the narratives revealed consistent situational contexts associated with the onset of anguish. These included interpersonal conflict, such as arguments, criticism, or relational instability; experiences of uncertainty or perceived loss of control related to financial insecurity, academic pressure, or job instability; situations involving vulnerability or threat, such as the illness of a family member; overstimulating environments, including crowds, excessive noise, or busy public spaces; and moments marked by fear of abandonment or emotional exposure. For many participants, anguish emerged at the intersection of internal vulnerability and external stressors, with somatic symptoms serving as early and embodied signals of emotional dysregulation. 3.2 Descriptive Analysis The descriptive analysis compared participants with and without self-reported anguish in terms of sociodemographic and psychometric variables. Table 1 presents the key variables showing notable differences between groups. Table 1 Descriptive comparison of key variables between participants with and without anguish. Variable With Anguish Without Anguish p-value Gender (female %) 65% 48% 0.041* Education (Higher Education %) 30% 45% 0.048* BSI Somatization (median, IQR) 12 (8–16) 9 (6–13) 0.020* HAM-A Fears (median, IQR) 6 (4–8) 3 (2–6) < 0.05 HAM-A Depressed Mood 5 (3–7) 2 (1–4) < 0.05 HAM-A Gastrointestinal Symptoms 4 (2–6) 2 (1–4) < 0.05 HAM-A Neurovegetative Symptoms 5 (3–7) 3 (2–5) < 0.05 *Chi-square test for categorical variables; Wilcoxon-Mann-Whitney test for continuous variables. The analysis indicates that participants with anguish showed higher somatization scores, fear, depressed mood, gastrointestinal, and neurovegetative symptoms, which are core components of anxiety and depressive disorders. Women were more likely to report anguish than men, and higher education was slightly more prevalent in the non-anguish group. The DSQ-40 scores (Neurotic, Immature, and Mature defense styles) did not show significant differences between groups, suggesting that defense mechanisms were not distinctly associated with self-reported anguish. 3.3 Inferential Analysis To explore associations between anguish and psychological variables, a logistic regression model was fitted. The dependent variable was the presence of anguish (yes/no). Independent variables included BSI domains, HAM-A scores, DSQ-40 TRI scores, MINI diagnoses, demographic factors, and HADS scores. Table 2 Logistic regression predicting anguish. Variable Odds Ratio (OR) 95% CI p-value Gender (female) 2.76 1.20–6.35 0.017* HAM-A Reduced Score 2.85 1.45–5.61 0.002* BSI Somatization 1.094 1.01–1.19 0.030* BSI Hostility 0.845 0.73–0.97 0.019* BSI Obsession Compulsion 0.874 0.77–0.99 0.036* Age (years) 0.954 0.92–0.99 0.012* MINI Depression 3.64 1.65–8.04 0.001* *p < 0.05. Interpretation: The odds ratio indicates that participants with depression are 3.64 times more likely to report anguish compared to those without depression, holding other variables constant. Similarly, higher HAM-A scores and somatization are positively associated with anguish. Age and certain BSI domains (hostility, obsession-compulsion) show negative associations. 3.4 Sensitivity Analysis A sensitivity analysis was conducted by reclassifying participants in the “doubt” group as “with anguish.” Results remained consistent, indicating that group reallocation did not significantly affect the observed associations between anguish and the psychological variables. Table 3 Sensitivity analysis: comparison of key variables after reclassifying the “doubt” group as “with anguish” Variable Original Analysis: With Anguish Sensitivity Analysis: With Anguish p-value (Sensitivity) Interpretation Gender (female %) 65% 66% 0.039* Association remains Education (Higher Education %) 30% 29% 0.052 Slight change, not significant BSI Somatization (median, IQR) 12 (8–16) 12 (8–16) 0.022* Consistent HAM-A Fears (median, IQR) 6 (4–8) 6 (4–8) 0.043* Consistent HAM-A Depressed Mood 5 (3–7) 5 (3–7) 0.048* Consistent HAM-A Gastrointestinal Symptoms 4 (2–6) 4 (2–6) 0.045* Consistent HAM-A Neurovegetative Symptoms 5 (3–7) 5 (3–7) 0.041* Consistent MINI Depression (%) 40% 41% 0.021* Association remains MINI Anxiety (%) 35% 35% 0.056 No significant change *Chi-square test for categorical variables; Wilcoxon-Mann-Whitney test for continuous variables. Interpretation: Reassigning the “doubt” group as “with anguish” did not meaningfully alter the associations observed in the original analysis. All key variables maintained similar distributions and significance levels, confirming the robustness of the results. 4 Discussion This study examined the psychopathological symptoms and clinical variables associated with the experience of anguish, with a particular focus on the relative contribution of depressive and anxiety disorders. Consistent with our hypotheses, the symptoms most strongly associated with self-reported anguish included somatization, as measured by the Brief Symptom Inventory (BSI), as well as fears, depressed mood, gastrointestinal symptoms, and neurovegetative manifestations measured by the Hamilton Anxiety Rating Scale (HAM-A). These results align with previous research suggesting that anguish often manifests primarily through somatic complaints and physiological dysregulation, rather than as purely cognitive or affective phenomena [ 34 , 35 ]. The prominence of somatic and neurovegetative symptoms among participants reporting anguish is consistent with the broader literature linking affective distress to bodily sensations. For example, studies have shown that patients with depressive disorders frequently report gastrointestinal discomfort, musculoskeletal tension, and cardiovascular symptoms, reflecting dysregulation of autonomic and hypothalamic-pituitary-adrenal (HPA) axis functioning [ 36 , 37 ]. Furthermore, the overlap between somatic symptoms of depression and patient-described anguish highlights the potential importance of patient-defined experiential categories in capturing clinically meaningful states not fully operationalized in standard diagnostic systems [ 38 , 39 ]. Regarding diagnostic associations, a markedly higher proportion of patients with depressive disorders (87.2%) reported experiencing anguish compared with those with anxiety disorders (69.2%), suggesting that anguish is more prevalent among individuals with depression. Logistic regression analyses confirmed that depression and higher HAM-A scores were significant predictors of anguish, whereas anxiety diagnoses and defense styles measured by the Defense Style Questionnaire (DSQ-40) were not independently associated. This pattern aligns with prior evidence that depressive episodes are frequently accompanied by heightened somatic and visceral symptoms, including neurovegetative disturbances, fatigue, and psychomotor changes, whereas anxiety disorders may present with more discrete or episodic autonomic arousal [ 40 ]. Symptom-level analyses further indicated that participants reporting anguish commonly experienced chest discomfort, musculoskeletal tension, tachycardia, and gastrointestinal complaints. Notably, the fears reported in this context were generalized rather than object-specific, reflecting a diffuse physiological arousal that resonates with conceptualizations of panic-like somatic experiences and interoceptive hypervigilance [ 41 , 42 ]. The application of Item Response Theory (IRT) to HAM-A data allowed dimensionality reduction, demonstrating that a subset of items—particularly depressed mood, fears, gastrointestinal, and neurovegetative symptoms—provided greater discriminatory power than total HAM-A scores, highlighting their utility for identifying participants experiencing anguish [ 43 ]. Gender differences were observed, with female participants reporting higher prevalence of anguish. This finding is consistent with epidemiological literature indicating that women are more likely than men to experience depression and to report somatic symptoms, potentially reflecting both biological susceptibility and sociocultural factors influencing symptom expression [ 44 , 45 ]. Nevertheless, the data suggest that anguish is not unique to females, as a substantial proportion of males also reported this experience, emphasizing that the phenomenon likely reflects broader psychopathological processes rather than gender-specific mechanisms. Several methodological limitations should be considered. Socioeconomic status and ethnicity were not assessed, which may moderate the experience or reporting of anguish and could be relevant for cross-cultural generalizability. The Portuguese version of the BSI, while widely used, has limited validation for the Brazilian population, potentially affecting measurement precision. Finally, the cross-sectional design precludes causal inference, and the operationalization of “anguish” relied on self-report, which may overlap substantially with somatic manifestations of depression and anxiety, limiting conclusions about its status as a distinct psychopathological construct. Table 4 Psychopathological Symptoms and Diagnostic Associations with Anguish in Psychiatric Outpatients. Domain / Symptom Assessment Tool Key Findings Diagnostic Association Somatic Symptoms BSI (Brief Symptom Inventory) Chest discomfort, musculoskeletal tension, gastrointestinal complaints, fatigue Strongly associated with self-reported anguish; more prevalent in depression Neurovegetative & Gastrointestinal Symptoms HAM-A (Hamilton Anxiety Rating Scale) Tachycardia, gastrointestinal complaints, neurovegetative symptoms Positively associated with anguish; depression strongest predictor Psychological Symptoms HAM-A Fears (generalized, not object-specific), depressed mood Positively associated with anguish; anxiety diagnoses not independently predictive Defense Styles DSQ-40 No significant differences between participants with and without anguish Not predictive of anguish Gender Demographics Female participants reported higher prevalence of anguish Consistent with higher rates of depression and somatic symptom reporting Overall Prevalence of Anguish Self-report 87.2% in depression, 69.2% in anxiety Depression > Anxiety In summary, the present findings indicate that self-reported anguish is associated with somatic and neurovegetative symptoms commonly observed in depressive and anxiety disorders, particularly depression. While these results clarify the symptom profile most strongly linked to anguish, they do not provide evidence that anguish constitutes a distinct psychopathological entity. Future research should incorporate longitudinal designs, validated measures of anguish, and more diverse populations to further elucidate the nature, specificity, and clinical relevance of this construct. Understanding the symptom patterns associated with anguish may enhance screening, assessment, and intervention strategies in psychiatric practice. Declarations Ethics Statement The research project was reviewed and approved by the Research Ethics Committee of the Institute of Psychiatry of the Hospital of Clinics, Faculty of Medicine, University of São Paulo, Brazil (permission 27 Jan 2021; CAAE: 37028419.2.0000.0068). References American Psychiatric Association (2022) Diagnostic and Statistical Manual of Mental Disorders. 5th ed., Text Revision (DSM-5-TR). 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14:57:32","extension":"html","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":90046,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8238072/v1/c2897c39f0e5d7827f258a1a.html"},{"id":97270744,"identity":"336e355a-6274-416d-bc85-1ef4916a8ece","added_by":"auto","created_at":"2025-12-02 14:57:32","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":94128,"visible":true,"origin":"","legend":"\u003cp\u003eCore Components of the Experience of Anguish.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8238072/v1/6da0e2647c5628ec19349abf.jpg"},{"id":97372851,"identity":"bc9f5094-0a19-491b-abb7-edd900492e6a","added_by":"auto","created_at":"2025-12-03 16:33:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":701346,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8238072/v1/0f3c6651-a12e-4c49-89e3-87813baf012a.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003ePsychopathological Correlates of Anguish in Psychiatric Outpatients: Associations with Depression, Anxiety, and Somatic Symptoms\u003c/p\u003e","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eThe term anguish is frequently used by psychiatric patients to describe an intense negative affective state accompanied by thoracic sensations such as tightness, pressure, or suffocation. Although these bodily sensations overlap with well-established somatic symptoms of depression and anxiety, the subjective experience specifically labeled as anguish has received little empirical attention. Contemporary diagnostic systems, including the DSM-5-TR and ICD-11, do not define anguish as an independent construct, reflecting a broader tendency to subsume affective\u0026ndash;somatic experiences under transdiagnostic categories of distress, autonomic arousal, or emotional dysregulation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This diagnostic absence leaves uncertainty as to whether anguish reflects a non-specific expression of emotional suffering or constitutes a distinct affective\u0026ndash;somatic state with potential clinical relevance.\u003c/p\u003e\u003cp\u003ePhilosophical and phenomenological traditions, particularly within existential psychiatry, describe anguish as an experience of constriction, threat, or heightened vulnerability to the world\u0026mdash;an affective state involving both corporeal constriction and a disruption of one\u0026rsquo;s sense of situatedness [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite their conceptual richness, these accounts have not been operationalized within contemporary empirical research, and thus their clinical implications remain largely unexplored. Notably, clinicians often report that patients spontaneously differentiate anguish from typical anxiety, highlighting its bodily intensity, immediacy, and a sense of impending psychological collapse.\u003c/p\u003e\u003cp\u003eResearch on the phenomenology of emotional distress suggests that individuals frequently employ culturally shaped idioms to articulate complex affective\u0026ndash;somatic states not adequately captured by psychiatric taxonomy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Comparable expressions\u0026mdash;such as \u0026ldquo;tight chest,\u0026rdquo; \u0026ldquo;heart-mind pain,\u0026rdquo; or \u0026ldquo;internal pressure\u0026rdquo;\u0026mdash;have been documented across diverse sociocultural contexts and, in some cases, have been associated with distinct patterns of symptom clustering, coping, and help-seeking [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These findings raise the possibility that patient-defined categories such as anguish may reveal clinically meaningful experiential patterns otherwise obscured by standardized diagnostic terminology.\u003c/p\u003e\u003cp\u003eAt the same time, thoracic discomfort is a well-recognized manifestation in mood and anxiety disorders. Somatic symptoms such as chest tightness, dyspnea, and autonomic arousal are strongly associated with increased illness burden, elevated health-care utilization, and poorer functional outcomes [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Although these symptoms are common across disorders, it remains unknown whether patients who specifically describe their experience as anguish differ systematically from those who report similar sensations but use other terms. Likewise, large-scale epidemiological studies documenting rising levels of severe distress globally [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] do not address whether anguish represents a clinically distinct experience or simply a linguistic marker of generalized psychological discomfort.\u003c/p\u003e\u003cp\u003eGiven these conceptual and empirical gaps, systematic investigation is needed to determine whether anguish corresponds to identifiable clinical patterns or diagnostic associations.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Aims of Study\u003c/h2\u003e\u003cp\u003eThe present study aims to (1) examine whether anguish is associated with distinct clusters of psychopathological symptoms or psychiatric comorbidities, and (2) assess whether anguish is differentially linked to depressive versus anxiety disorders. By integrating structured psychopathological assessment with patient-defined experiential descriptions, the study seeks to clarify whether anguish constitutes a clinically relevant affective\u0026ndash;somatic category within contemporary psychiatric practice.\u003c/p\u003e\u003c/div\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study Design and Data Acquisition\u003c/h2\u003e\u003cp\u003eThis cross-sectional study was conducted at a large psychiatric outpatient institution in Brazil between 2021 and 2024. The study aimed to investigate whether self-reported anguish is associated with distinct psychopathological profiles, psychiatric comorbidities, and differential relationships with depressive and anxiety disorders. The study protocol was approved by the local Research Ethics Commitee of the Institute of Psychiatry of Hospital of Clinics of Faculty of Medicine of University of S\u0026atilde;o Paulo, and all participants provided written informed consent in accordance with the Declaration of Helsinki [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eParticipants were consecutively recruited from outpatient clinics specializing in mood and anxiety disorders. Inclusion criteria were: age 17\u0026ndash;77 years, ability to provide informed consent, and clinical stability defined as no hospitalization or major treatment changes in the preceding month. Exclusion criteria included: current psychotic disorder, severe cognitive impairment, neurological disease affecting mental status, or acute medical conditions that could confound somatic symptom reporting [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA structured clinical interview was used to assess the presence of anguish, following a phenomenologically informed framework derived from prior research on patient-defined affective\u0026ndash;somatic experiences [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Participants were classified into three groups: (1) with anguish, (2) without anguish, and (3) uncertain. This classification was based on explicit patient reports of thoracic discomfort and affective intensity, corroborated by clinician evaluation. Psychopathology was assessed using validated instruments: the Brief Symptom Inventory (BSI) for general symptom burden [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], the Defense Style Questionnaire (DSQ-40) for defensive functioning [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], the Hospital Anxiety and Depression Scale (HADS) and Hamilton Anxiety Rating Scale (HAM-A) for affective symptomatology [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], the State-Trait Anxiety Inventory (STAI) for trait anxiety [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and the Mini-International Neuropsychiatric Interview (MINI) for DSM-5 diagnostic confirmation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSociodemographic and clinical data\u0026mdash;including age, sex, education, psychiatric history, current medication, and comorbid medical conditions\u0026mdash;were collected using a standardized case report form. Data quality was ensured through double-entry verification and periodic audit by the study coordinators. The sample size of 100 participants was determined a priori based on expected prevalence of self-reported anguish and power calculations to detect medium effect sizes in group comparisons [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Statistical Analyses\u003c/h2\u003e\u003cp\u003eDescriptive statistics were computed for sociodemographic and clinical variables. Continuous variables were summarized as means and standard deviations (SD) or medians and interquartile ranges (IQR) depending on data distribution, while categorical variables were presented as frequencies and percentages. Normality of continuous variables was assessed using the Shapiro\u0026ndash;Wilk test and visual inspection of histograms [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGroup comparisons among participants classified as with anguish, without anguish, and uncertain were conducted using one-way analysis of variance (ANOVA) for normally distributed continuous variables or the Kruskal\u0026ndash;Wallis test for non-normal distributions. Post-hoc pairwise comparisons were adjusted using Bonferroni correction. For categorical variables, Chi-square tests or Fisher\u0026rsquo;s exact tests were applied as appropriate [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Effect sizes were calculated using Cohen\u0026rsquo;s d for continuous variables and Cramer\u0026rsquo;s V for categorical variables [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLogistic regression analyses were performed to examine the association between psychiatric diagnoses and the likelihood of reporting anguish. Separate models were fitted for depressive and anxiety disorders, adjusting for potential confounders including age, sex, education, and comorbid medical conditions [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Odds ratios (OR) with 95% confidence intervals (CI) were reported. Model fit was evaluated using the Hosmer\u0026ndash;Lemeshow test and area under the receiver operating characteristic (ROC) curve [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAll statistical analyses were performed using SPSS version 28.0 (IBM Corp., Armonk, NY, USA) and significance was set at a two-tailed p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Missing data were handled using pairwise deletion, as the proportion of missingness for each variable was below 5%, minimizing potential bias [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Qualitative Analysis\u003c/h2\u003e\u003cp\u003eA qualitative descriptive approach was used to analyze the lived experience of anguish among 35 patients. Semi-structured interviews explored how participants perceived anguish, the physical sensations associated with it, and the life situations in which these sensations emerged. An inductive thematic analysis allowed recurrent patterns to arise directly from patient narratives, revealing a multidimensional phenomenon characterized by the convergence of emotional distress, somatic activation, and situational triggers. Across the sample, patients described anguish as a sudden and overwhelming internal tension, frequently referring to it as \u0026ldquo;a pressure from within,\u0026rdquo; \u0026ldquo;a knot in the chest,\u0026rdquo; or \u0026ldquo;a wave rising through the body.\u0026rdquo; Somatic symptoms were common and often intense, with chest pressure or tightness, stomach constriction or abdominal discomfort, shortness of breath or a choking sensation, palpitations, autonomic arousal, diffuse muscular tension\u0026mdash;particularly in the neck and shoulders\u0026mdash;restlessness or agitation in the limbs, and episodes of sweating, dizziness, or cold extremities emerging as the most recurrent manifestations. Illustrative accounts included participants who felt a \u0026ldquo;knot rising from the stomach to the chest\u0026rdquo; accompanied by trembling and air hunger, others who reported a \u0026ldquo;burning behind the sternum\u0026rdquo; with palpitations and withdrawal, and several who described muscle stiffness, sudden fatigue, or vertigo triggered by emotional overload. These physical sensations were interpreted by many of the 35 patients as signs of emotional overwhelm, often perceived more vividly in the body than in conscious thought. Despite individual variability, analysis across the narratives revealed consistent situational contexts associated with the onset of anguish. These included interpersonal conflict, such as arguments, criticism, or relational instability; experiences of uncertainty or perceived loss of control related to financial insecurity, academic pressure, or job instability; situations involving vulnerability or threat, such as the illness of a family member; overstimulating environments, including crowds, excessive noise, or busy public spaces; and moments marked by fear of abandonment or emotional exposure. For many participants, anguish emerged at the intersection of internal vulnerability and external stressors, with somatic symptoms serving as early and embodied signals of emotional dysregulation.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Descriptive Analysis\u003c/h2\u003e\u003cp\u003eThe descriptive analysis compared participants with and without self-reported anguish in terms of sociodemographic and psychometric variables. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the key variables showing notable differences between groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive comparison of key variables between participants with and without anguish.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWith Anguish\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWithout Anguish\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (female %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.041*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation (Higher Education %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.048*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBSI Somatization (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (8\u0026ndash;16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (6\u0026ndash;13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.020*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAM-A Fears (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (4\u0026ndash;8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAM-A Depressed Mood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAM-A Gastrointestinal Symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAM-A Neurovegetative Symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (2\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*Chi-square test for categorical variables; Wilcoxon-Mann-Whitney test for continuous variables.\u003c/p\u003e\u003cp\u003eThe analysis indicates that participants with anguish showed higher somatization scores, fear, depressed mood, gastrointestinal, and neurovegetative symptoms, which are core components of anxiety and depressive disorders. Women were more likely to report anguish than men, and higher education was slightly more prevalent in the non-anguish group.\u003c/p\u003e\u003cp\u003eThe DSQ-40 scores (Neurotic, Immature, and Mature defense styles) did not show significant differences between groups, suggesting that defense mechanisms were not distinctly associated with self-reported anguish.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Inferential Analysis\u003c/h2\u003e\u003cp\u003eTo explore associations between anguish and psychological variables, a logistic regression model was fitted. The dependent variable was the presence of anguish (yes/no). Independent variables included BSI domains, HAM-A scores, DSQ-40 TRI scores, MINI diagnoses, demographic factors, and HADS scores.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLogistic regression predicting anguish.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOdds Ratio (OR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.20\u0026ndash;6.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.017*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAM-A Reduced Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.45\u0026ndash;5.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.002*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBSI Somatization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.094\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.01\u0026ndash;1.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.030*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBSI Hostility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.845\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.73\u0026ndash;0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.019*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBSI Obsession Compulsion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.874\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.77\u0026ndash;0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.036*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.954\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.92\u0026ndash;0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.012*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMINI Depression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.65\u0026ndash;8.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003eInterpretation: The odds ratio indicates that participants with depression are 3.64 times more likely to report anguish compared to those without depression, holding other variables constant. Similarly, higher HAM-A scores and somatization are positively associated with anguish. Age and certain BSI domains (hostility, obsession-compulsion) show negative associations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Sensitivity Analysis\u003c/h2\u003e\u003cp\u003eA sensitivity analysis was conducted by reclassifying participants in the \u0026ldquo;doubt\u0026rdquo; group as \u0026ldquo;with anguish.\u0026rdquo; Results remained consistent, indicating that group reallocation did not significantly affect the observed associations between anguish and the psychological variables.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSensitivity analysis: comparison of key variables after reclassifying the \u0026ldquo;doubt\u0026rdquo; group as \u0026ldquo;with anguish\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOriginal Analysis: With Anguish\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSensitivity Analysis: With Anguish\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value (Sensitivity)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eInterpretation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (female %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.039*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAssociation remains\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation (Higher Education %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSlight change, not significant\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBSI Somatization (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (8\u0026ndash;16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (8\u0026ndash;16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.022*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAM-A Fears (median, IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (4\u0026ndash;8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (4\u0026ndash;8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.043*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAM-A Depressed Mood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.048*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAM-A Gastrointestinal Symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.045*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHAM-A Neurovegetative Symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.041*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMINI Depression (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.021*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAssociation remains\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMINI Anxiety (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.056\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo significant change\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*Chi-square test for categorical variables; Wilcoxon-Mann-Whitney test for continuous variables.\u003c/p\u003e\u003cp\u003eInterpretation: Reassigning the \u0026ldquo;doubt\u0026rdquo; group as \u0026ldquo;with anguish\u0026rdquo; did not meaningfully alter the associations observed in the original analysis. All key variables maintained similar distributions and significance levels, confirming the robustness of the results.\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study examined the psychopathological symptoms and clinical variables associated with the experience of anguish, with a particular focus on the relative contribution of depressive and anxiety disorders. Consistent with our hypotheses, the symptoms most strongly associated with self-reported anguish included somatization, as measured by the Brief Symptom Inventory (BSI), as well as fears, depressed mood, gastrointestinal symptoms, and neurovegetative manifestations measured by the Hamilton Anxiety Rating Scale (HAM-A). These results align with previous research suggesting that anguish often manifests primarily through somatic complaints and physiological dysregulation, rather than as purely cognitive or affective phenomena [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe prominence of somatic and neurovegetative symptoms among participants reporting anguish is consistent with the broader literature linking affective distress to bodily sensations. For example, studies have shown that patients with depressive disorders frequently report gastrointestinal discomfort, musculoskeletal tension, and cardiovascular symptoms, reflecting dysregulation of autonomic and hypothalamic-pituitary-adrenal (HPA) axis functioning [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Furthermore, the overlap between somatic symptoms of depression and patient-described anguish highlights the potential importance of patient-defined experiential categories in capturing clinically meaningful states not fully operationalized in standard diagnostic systems [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding diagnostic associations, a markedly higher proportion of patients with depressive disorders (87.2%) reported experiencing anguish compared with those with anxiety disorders (69.2%), suggesting that anguish is more prevalent among individuals with depression. Logistic regression analyses confirmed that depression and higher HAM-A scores were significant predictors of anguish, whereas anxiety diagnoses and defense styles measured by the Defense Style Questionnaire (DSQ-40) were not independently associated. This pattern aligns with prior evidence that depressive episodes are frequently accompanied by heightened somatic and visceral symptoms, including neurovegetative disturbances, fatigue, and psychomotor changes, whereas anxiety disorders may present with more discrete or episodic autonomic arousal [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSymptom-level analyses further indicated that participants reporting anguish commonly experienced chest discomfort, musculoskeletal tension, tachycardia, and gastrointestinal complaints. Notably, the fears reported in this context were generalized rather than object-specific, reflecting a diffuse physiological arousal that resonates with conceptualizations of panic-like somatic experiences and interoceptive hypervigilance [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The application of Item Response Theory (IRT) to HAM-A data allowed dimensionality reduction, demonstrating that a subset of items\u0026mdash;particularly depressed mood, fears, gastrointestinal, and neurovegetative symptoms\u0026mdash;provided greater discriminatory power than total HAM-A scores, highlighting their utility for identifying participants experiencing anguish [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGender differences were observed, with female participants reporting higher prevalence of anguish. This finding is consistent with epidemiological literature indicating that women are more likely than men to experience depression and to report somatic symptoms, potentially reflecting both biological susceptibility and sociocultural factors influencing symptom expression [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Nevertheless, the data suggest that anguish is not unique to females, as a substantial proportion of males also reported this experience, emphasizing that the phenomenon likely reflects broader psychopathological processes rather than gender-specific mechanisms.\u003c/p\u003e\u003cp\u003eSeveral methodological limitations should be considered. Socioeconomic status and ethnicity were not assessed, which may moderate the experience or reporting of anguish and could be relevant for cross-cultural generalizability. The Portuguese version of the BSI, while widely used, has limited validation for the Brazilian population, potentially affecting measurement precision. Finally, the cross-sectional design precludes causal inference, and the operationalization of \u0026ldquo;anguish\u0026rdquo; relied on self-report, which may overlap substantially with somatic manifestations of depression and anxiety, limiting conclusions about its status as a distinct psychopathological construct.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePsychopathological Symptoms and Diagnostic Associations with Anguish in Psychiatric Outpatients.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain / Symptom\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssessment Tool\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKey Findings\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiagnostic Association\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSomatic Symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBSI (Brief Symptom Inventory)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChest discomfort, musculoskeletal tension, gastrointestinal complaints, fatigue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStrongly associated with self-reported anguish; more prevalent in depression\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurovegetative \u0026amp; Gastrointestinal Symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHAM-A (Hamilton Anxiety Rating Scale)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTachycardia, gastrointestinal complaints, neurovegetative symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePositively associated with anguish; depression strongest predictor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological Symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHAM-A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFears (generalized, not object-specific), depressed mood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePositively associated with anguish; anxiety diagnoses not independently predictive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDefense Styles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDSQ-40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo significant differences between participants with and without anguish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNot predictive of anguish\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDemographics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale participants reported higher prevalence of anguish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConsistent with higher rates of depression and somatic symptom reporting\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall Prevalence of Anguish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-report\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.2% in depression, 69.2% in anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDepression\u0026thinsp;\u0026gt;\u0026thinsp;Anxiety\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn summary, the present findings indicate that self-reported anguish is associated with somatic and neurovegetative symptoms commonly observed in depressive and anxiety disorders, particularly depression. While these results clarify the symptom profile most strongly linked to anguish, they do not provide evidence that anguish constitutes a distinct psychopathological entity. Future research should incorporate longitudinal designs, validated measures of anguish, and more diverse populations to further elucidate the nature, specificity, and clinical relevance of this construct. Understanding the symptom patterns associated with anguish may enhance screening, assessment, and intervention strategies in psychiatric practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cb\u003eEthics Statement\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The research project was reviewed and approved by the Research Ethics Committee of the Institute of Psychiatry of the Hospital of Clinics, Faculty of Medicine, University of S\u0026atilde;o Paulo, Brazil (permission 27 Jan 2021; CAAE: 37028419.2.0000.0068).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association (2022) Diagnostic and Statistical Manual of Mental Disorders. 5th ed., Text Revision (DSM-5-TR). Washington, DC: APA\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2019) International Classification of Diseases for Mortality and Morbidity Statistics (11th Revision). Geneva: WHO\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRatcliffe M (2013) Experiences of Depression: A Study in Phenomenology. Oxford University Press, Oxford\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFuchs T (2020) Defense of the Human Being: Foundational Questions of an Embodied Anthropology. Oxford University Press, Oxford\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKirmayer LJ, Ryder AG (2016) Culture and psychopathology. Curr Opin Psychol 8:143\u0026ndash;148\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFernando S (2014) Mental Health Worldwide: Culture, Globalization and Development. Palgrave Macmillan, London\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDere J, Sun J, Zhao Y, Kuyken W et al (2019) Cultural shaping of somatic distress: cross-cultural comparisons. 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Lawrence Erlbaum, Hillsdale, NJ\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHosmer DW, Lemeshow S, Sturdivant RX (2013) Applied Logistic Regression, 3rd edn. Wiley, Hoboken, NJ\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKleinbaum DG, Klein M (2010) Logistic Regression: A Self-Learning Text, 3rd edn. Springer, New York\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHanley JA, McNeil BJ (1982) The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143:29\u0026ndash;36\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJakobsen JC, Gluud C, Wetterslev J et al (2017) When and how should multiple imputation be used for handling missing data in randomised clinical trials \u0026ndash; a practical guide with flowcharts. BMC Med Res Methodol 17:162\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBeck AT (2011) Depression: Clinical, experimental, and theoretical aspects. 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Br J Psychiatry 177:486\u0026ndash;492\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, thoracic discomfort, depression, anxiety, psychiatry","lastPublishedDoi":"10.21203/rs.3.rs-8238072/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8238072/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnguish is an affective–somatic state characterized by intense thoracic discomfort and described by patients as pain, tightness, pressure, compression, or a “hole” in the chest. Despite its clinical frequency, its psychopathological correlates remain poorly defined. This study examined whether anguish is associated with specific symptom patterns, psychiatric comorbidities, and differential relationships with depression and anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 100 outpatients from a large psychiatric institution in Brazil were assessed through a structured interview and allocated into three groups: with anguish, without anguish, and uncertain. Psychopathological features were evaluated using the BSI, DSQ-40, HADS, HAM-A, STAI, and MINI. Group differences and diagnostic associations were analyzed using inferential statistics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients reporting anguish displayed distinct psychopathological profiles compared with the other groups, including higher levels of somatization, fears, depressed mood, gastrointestinal complaints, and neurovegetative symptoms. Individuals with depressive disorders were 3.64 times more likely to report anguish compared with those with anxiety disorders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnguish appears to represent a clinically relevant affective–somatic phenomenon associated with specific symptom clusters and a stronger relationship with depression than with anxiety. These findings support the need for further investigation of anguish as a potential marker within psychiatric assessment and diagnostic formulation.\u003c/p\u003e","manuscriptTitle":"Psychopathological Correlates of Anguish in Psychiatric Outpatients: Associations with Depression, Anxiety, and Somatic Symptoms","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 14:57:27","doi":"10.21203/rs.3.rs-8238072/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":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":58820378,"name":"Psychology"},{"id":58820379,"name":"Psychiatry"}],"tags":[],"updatedAt":"2025-12-02T14:57:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 14:57:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8238072","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8238072","identity":"rs-8238072","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}