Clinical correlates of thoracic anguish in patients with depression and anxiety

Clinical correlates of thoracic anguish in patients with depression and anxiety | 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 Clinical correlates of thoracic anguish in patients with depression and anxiety Fernando Filipe Paulos Vieira This is a preprint; it has not been peer reviewed by a journal.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-8215760/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 : In this study, anguish is defined as a negative affective state characterized by intense thoracic discomfort, described by patients as sensations of pain, tightness, pressure, a “hole,” or compression in the chest. Objectives : This study examined whether anguish contributes to the psychopathological profile of psychiatric patients by identifying associated symptoms and comorbidities, and by assessing its relationship with diagnoses of depression and anxiety. Methods : A total of 100 outpatients from a large psychiatric institution in Brazil were evaluated and classified into three groups based on a structured interview assessing the presence of anguish: with anguish, without anguish, and uncertain. Psychopathology was assessed using the BSI, DSQ-40, HADS, HAM-A, STAI, and MINI. Results : Individuals reporting anguish showed significant differences in symptom patterns and comorbidities compared to the other groups. The anguish group presented higher levels of somatization, fears, depressed mood, gastrointestinal complaints, and neurovegetative symptoms. Inferential analyses further indicated that patients with depression were 3.64 times more likely to report anguish compared to those with anxiety. Conclusions : The findings suggest that the subjective experience of anguish may have clinical relevance within psychiatric assessment. The association with specific symptom clusters and its stronger relationship with depression highlight the potential value of further investigating anguish as a meaningful affective–somatic phenomenon in psychiatric practice. Anguish thoracic discomfort depression anxiety psychiatry 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 or autonomic arousal (American Psychiatric Association, 2022 ; World Health Organization, 2019 ). As a result, it remains unclear whether anguish reflects a non-specific expression of emotional suffering or a distinct affective–somatic state with potential clinical significance. Although philosophical and phenomenological traditions have described anguish as a form of constriction, threat, or existential vulnerability, these accounts have not been operationalized within contemporary psychiatric research (Ratcliffe, 2013 ; Fuchs, 2020 ). Clinicians nonetheless report that patients frequently distinguish anguish from typical anxiety, emphasizing both its somatic intensity and its subjective immediacy. Studies on the phenomenology of emotional distress indicate that individuals often employ culturally shaped terms to describe complex affective–somatic states not captured by formal diagnostic terminology (Kirmayer & Ryder, 2016 ; Fernando, 2014 ). Similar idioms—such as “tight chest,” “heart-mind pain,” or “internal pressure”—have been documented across multiple cultural settings and sometimes correlate with specific clinical profiles (Dere et al., 2019 ; Ryder et al., 2015 ). This suggests that patient-defined categories may reveal clinically relevant experiential patterns overlooked by conventional diagnostic frameworks. At the same time, chest-related discomfort is a recurrent somatic manifestation in mood and anxiety disorders and is associated with heightened autonomic arousal, catastrophic interpretations, and increased functional impairment (Kemp et al., 2014 ; Meuret et al., 2011 ; Tully et al., 2017 ). However, research has not determined whether the subset of patients who describe these sensations as anguish exhibit distinct symptom patterns, comorbidities, or diagnostic distributions compared with those who do not use this term. Population surveys indicating rising levels of severe distress provide broad epidemiological context (Keyes et al., 2020 ), but such studies do not address whether self-reported anguish represents a specific clinical phenomenon or a linguistic variant of severe emotional discomfort. To clarify this conceptual and clinical ambiguity, empirical investigation is needed to determine whether individuals reporting anguish differ meaningfully from those who do not in terms of psychopathological profile and diagnostic associations. The present study therefore aims to (1) assess whether anguish is associated with distinct clusters of symptoms or psychiatric comorbidities, and (2) examine whether anguish is differentially linked to depressive versus anxiety disorders. By focusing on patient-defined experience within a structured clinical assessment, the study seeks to evaluate whether anguish may constitute a clinically relevant affective–somatic state within contemporary psychiatric practice. Methods Participants A total of 100 outpatients attending the general, anxiety, and adult affective disorders outpatient clinics at the Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, were included in this study. Participants were aged 17 to 77 years (M = 44.5, SD = 13.2), and 69% were female, 29% male, and 2% identified as transgender. Regarding marital status, 47% were single, 32% married, 13% divorced, and 7% widowed. Educational attainment varied: 47% had completed higher education, 21% had not completed higher education, 19% had completed high school, 2% had not completed high school, 2% had completed elementary school, and 9% had not completed elementary school. Participants were classified into groups based on the presence of anguish using a predefined operational criterion. The “with anguish” group consisted of patients who, during a structured interview, described thoracic discomfort (tightness, pressure, pain, or suffocation) accompanied by intense negative affect, consistent with the study’s conceptual definition of anguish. Responses were coded by two independent raters using a structured coding grid, with inter-rater reliability calculated (Cohen’s kappa = 0.82). Patients who explicitly denied experiencing such sensations were classified as “without anguish.” Those who reported experiencing distress but were unable to articulate it in a manner consistent with the operational definition were noted as “uncertain” for descriptive purposes; given the small size and ambiguous nature of this subgroup, it was not included in inferential analyses. Measures A sociodemographic questionnaire was administered to collect relevant information (age, sex, marital status, education, and experience of anguish). The following psychometric instruments were applied: Brief Symptom Inventory (BSI; Derogatis, 1993; Portuguese version validated in Brazil: Canavarro, 1999, 2007) – a 53-item self-report instrument measuring general psychopathology across nine symptom dimensions. Although originally validated for Portugal, its use in Brazil was considered with caution; results were interpreted in light of potential cultural differences. Scores are rated on a 0–4 Likert scale. Defense Style Questionnaire (DSQ-40; Bond et al., 1989; Portuguese version: Blaya et al., 2003) – a 40-item self-report instrument assessing defense mechanisms across three domains: mature, neurotic, and immature. Participants rate items from 1 to 9. Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983; Portuguese version: Botega et al., 1998) – 14 items measuring anxiety and depression symptoms, each scored 0–3. Overlap with other anxiety measures was acknowledged, and multicollinearity was examined in subsequent analyses. Hamilton Anxiety Rating Scale (HAM-A; Hamilton, 1959; Portuguese version: Moreno & Moreno, 1998) – clinician-administered, 14 items rated 0–4, assessing anxiety severity. Applied to complement HADS and STAI with clinician judgment. State-Trait Anxiety Inventory (STAI; Spielberger et al., 1970; Portuguese version: Biaggio, 1979) – 40-item self-report instrument measuring state and trait anxiety. Used to capture temporal variations in anxiety.Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998; Portuguese version: Amorim, 2000) – structured diagnostic interview assessing DSM-5 and ICD-10 psychiatric disorders. Administration time: ~15 minutes. Justification: While some overlap exists among the instruments assessing anxiety and depression, each scale captures complementary dimensions (self-report vs. clinician-rated, state vs. trait), providing a richer characterization of psychopathology. None of these instruments specifically assess “anguish,” which was captured through the structured interview described above. Procedures Patients awaiting outpatient care were invited to participate and provided written informed consent. The study protocol was approved by the institutional ethics committee. Participants completed the sociodemographic questionnaire and psychometric instruments in a standardized order. A structured interview specifically targeting the experience of anguish was conducted by trained clinicians. Patients were asked to describe any experiences of intense emotional distress accompanied by thoracic sensations. Interviews were audio-recorded, transcribed, and coded independently by two raters using a predefined coding grid. Inter-rater reliability was calculated to ensure replicability. Only participants meeting the operational criteria for anguish were included in the “with anguish” group for inferential analyses. Data were then analyzed to assess symptom patterns and comorbidities associated with the presence of anguish, while accounting for potential collinearity among psychometric measures. The “uncertain” subgroup was used descriptively but excluded from statistical models to avoid ambiguity in group classification. Data analysis Data were analyzed using both descriptive and inferential approaches. Analyses were conducted using R (version 4.1.0). All assumptions for each statistical test were verified, and non-parametric alternatives were used when appropriate. Descriptive Analysis The descriptive analysis aimed to characterize participants and examine group differences in sociodemographic and clinical variables. This analysis proceeded in three steps: Group Comparisons: Continuous variables (e.g., age, questionnaire scores) were compared between the “with anguish” and “without anguish” groups using independent-samples t-tests or Mann–Whitney U tests for non-normal distributions. Categorical variables (e.g., sex, marital status, educational level) were compared using chi-square tests or Fisher’s exact tests where expected cell counts were small. Symptom Patterns: Questionnaire data (BSI, DSQ-40, HADS, HAM-A, STAI) were summarized to identify symptom profiles. Given overlap across anxiety and depression measures, correlation analyses were conducted to assess redundancy and inform the selection of variables for inferential analyses. Sensitivity Analysis: Given the small number of participants in the “uncertain” subgroup, a sensitivity analysis was conducted by temporarily including these participants in the “with anguish” group to assess whether results were robust to alternative classifications. Inferential analyses were ultimately based on the clearly defined “with anguish” and “without anguish” groups. Inferential Analysis Given the small sample size relative to the number of measured variables, conventional logistic regression with all questionnaire items would have led to overfitting (35 events in the “with anguish” group; 50 in “without anguish”). To address this, the following strategy was employed: Dimensional Reduction: Rather than applying Item Response Theory (IRT) inappropriately, principal component analysis (PCA) was used to reduce questionnaire data into a smaller set of orthogonal latent factors representing core symptom dimensions (e.g., anxiety, depression, somatization, defense style). Factor scores were used as predictors, minimizing multicollinearity and preserving interpretability. Predictive Modeling: Logistic regression models were then applied using these latent factors as independent variables, with group membership (“with anguish” vs. “without anguish”) as the dependent variable. The number of predictors was limited to maintain at least 10 events per variable, following standard recommendations for logistic regression (Peduzzi et al., 1996). Model fit and discrimination were evaluated using the Akaike Information Criterion (AIC), Hosmer–Lemeshow goodness-of-fit test, and the area under the receiver operating characteristic curve (AUC). Exploratory Associations: To visualize relationships among anguish, anxiety, and depression, correspondence analysis and heatmaps of symptom co-occurrence were used. This exploratory approach allowed the identification of symptom clusters most strongly associated with the presence of anguish without overfitting statistical models. Results 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. 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. 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. Summary of Findings Anguish was found to be associated with higher levels of somatization, fear, depressed mood, gastrointestinal symptoms, and neurovegetative symptoms. Women were more likely to report experiencing anguish than men. Logistic regression analyses indicated that depression, higher HAM-A scores, and greater somatization were positively associated with the presence of anguish. In contrast, defense styles measured by the DSQ-40 did not significantly differentiate participants with and without anguish. Sensitivity analyses, which involved reclassifying participants with uncertain status as experiencing anguish, confirmed the robustness of these findings. Overall, these results suggest that the experience of anguish is largely reflected by symptoms commonly observed in anxiety and depressive disorders. No clear evidence was found to support the notion of anguish as a distinct construct beyond these established psychopathological profiles. Discussion This study investigated the psychopathological symptoms associated with the experience of anguish and examined which clinical diagnoses were most frequently linked to this experience. Consistent with our first hypothesis, the symptoms most strongly associated with anguish included BSI somatization, HAM-A fears, HAM-A depressed mood, HAM-A gastrointestinal symptoms, and HAM-A neurovegetative symptoms. These findings are in line with previous research suggesting that anguish often manifests through somatic complaints and physiological dysregulation (Beck, 2011). Regarding the second hypothesis, a higher proportion of patients with depression (87.2%) reported experiencing anguish compared with patients with anxiety (69.2%), indicating that the presence of anguish is more frequent among patients with depressive disorders. This association is consistent with prior literature documenting that depressive episodes frequently co-occur with heightened somatic and visceral symptoms (Kendler et al., 2003; Nolen-Hoeksema, 2001). Logistic regression analyses confirmed that depression, higher HAM-A scores, and BSI somatization were positively associated with anguish, whereas defense styles measured by the DSQ-40 did not significantly differentiate participants with and without anguish. Symptom-level analyses revealed that patients reporting anguish most commonly experienced chest discomfort, musculoskeletal tension, tachycardia, and gastrointestinal complaints, echoing earlier findings on the somatic dimension of depressive symptomatology (Clark & Watson, 1991). HAM-A variables with the strongest associations to anguish were depressed mood, fears, gastrointestinal symptoms, and neurovegetative symptoms. Notably, fears reported in this context were not object-specific but rather related to generalized physiological distress, aligning with the conceptualization of panic-like somatic experiences (Craske & Barlow, 2007). Item Response Theory (IRT) applied to the HAM-A data enabled dimensionality reduction, demonstrating that a subset of items—particularly depressed mood, fears, gastrointestinal, and neurovegetative symptoms—provided greater discriminatory power than simple summation scores, highlighting the relevance of these symptoms for identifying participants reporting anguish. Binomial logistic regression further reinforced these associations, showing that individuals with depression were more likely to experience anguish than those without depression, while anxiety-related variables did not emerge as significant predictors in the model, except for certain HAM-A domains. Gender differences were observed, with females reporting a higher prevalence of anguish. This finding is consistent with epidemiological data indicating higher rates of depression and somatic symptom reporting among women (Kuehner, 2017; Piccinelli & Wilkinson, 2000). However, the results do not indicate that anguish is a phenomenon unique to women, and the observed gender effect may reflect the broader epidemiology of depressive and somatic symptoms. Several methodological limitations should be considered. First, socioeconomic status and ethnicity were not assessed, which may moderate the experience or reporting of anguish. Second, the Portuguese version of the BSI has limited validation for the Brazilian population, potentially affecting measurement precision. Third, the cross-sectional design precludes causal inference, and the operationalization of “anguish” relies on self-report, which may overlap substantially with somatic manifestations of depression and anxiety, limiting the ability to define anguish as a distinct construct. In summary, the present study provides evidence that self-reported anguish is associated with somatic and neurovegetative symptoms commonly observed in depressive and anxiety disorders, particularly in depression. While these findings 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 clarify the nature and specificity of this construct. Table 4 . Key Symptoms and Clinical Variables Associated with Anguish. Domain Variable / Symptom Description Association with Anguish Statistical Evidence Somatic / Psychophysiological BSI Somatization Somatic complaints such as chest pain, musculoskeletal tension, tachycardia Positive Median higher in anguish group; Wilcoxon-Mann-Whitney, p < .05 HAM-A (Hamilton Anxiety Scale) Fears Generalized fear of distress, not object-specific Positive p < .05 HAM-A Depressed Mood Depressive affect Positive p < .05 HAM-A Gastrointestinal Symptoms Nausea, heartburn, abdominal fullness Positive p < .05 HAM-A Neurovegetative Symptoms Fatigue, malaise, heaviness, chest discomfort Positive p < .05 Psychiatric Diagnosis MINI Depression Major depressive disorder diagnosis Positive 87.2% of depressed patients reported anguish; Logistic regression OR = 3.64 Psychiatric Diagnosis MINI Anxiety Anxiety disorder diagnosis Moderate 69.2% reported anguish; not significant in logistic regression except HAM-A domains Demographics Gender (Female) Participant sex Higher prevalence OR = 2.76 for females vs. males Defense Styles DSQ-40 Defense mechanisms No significant association – Note : Positive association indicates higher prevalence or severity of symptom/diagnosis among participants reporting anguish. OR = odds ratio. Conclusions This study examined the psychopathological symptoms and clinical variables associated with the experience of anguish and evaluated the relative contribution of depression and anxiety diagnoses. The results indicate that anguish is most strongly associated with somatic and neurovegetative symptoms, including somatization, fears, depressed mood, gastrointestinal complaints, and neurovegetative manifestations, as measured by the BSI and HAM-A scales. Logistic regression analyses further demonstrated that depression and higher HAM-A scores are significant predictors of anguish, whereas anxiety diagnoses and defense styles (DSQ-40) were not independently associated. Gender differences were observed, with females reporting higher prevalence of anguish, consistent with the broader epidemiology of depressive and somatic symptoms. Sensitivity analyses confirmed the robustness of the findings, suggesting that these associations are not substantially affected by reclassification of participants with uncertain status. Overall, the findings suggest that anguish largely reflects symptomatology typical of depressive and anxiety disorders, particularly depression, rather than constituting a distinct psychopathological construct. Future research should employ longitudinal designs, validated measures of anguish, and diverse populations to further clarify the nature, specificity, and clinical relevance of this experience. Understanding the symptom profile most strongly associated with anguish may improve screening, assessment, and intervention strategies in clinical practice. References American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing. Amorim, P. (2000). 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Cardiovascular disease and anxiety: Epidemiological and clinical evidence. Progress in Cardiovascular Diseases, 59(5), 429–438. https://doi.org/10.1016/j.pcad.2017.02.006. World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/en. Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8215760","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":551374387,"identity":"22130d67-52f9-486c-8cc8-8eb43ab5ba8d","order_by":0,"name":"Fernando Filipe Paulos Vieira","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABHklEQVRIiWNgGAWjYBAC9gYwxQzhPQCzmQ8ASQkZXFp4DiBrSQCz2UCUBA8JWhh4DMAkTi3svc8e/NxhLccg3fxMIqGiLk++nefzqxs1FjwM7IePbsCmhee4uWHvmXRjBpljZhIJZw4XGxzm3WadcwzoMJ60tBtYtNhLpLFJ8LYdTmyQSDCTSGw7kLiBmXebcQ4bUIsEjxk2LTzyz9gk/4K1pH8DaqlLnN/M88w45x8eLRJsbNIQW3JAtjAnNhzmYX6c24ZHC08am7RsW7oxm8yZYguIX9jMmHP7JHjYcPiFh/0Ym+TbNms5fun2jTc+gEKs//Djzznf6uT42Q8fw6YFDtgkIHQCnM2GTzkYIGlh/kBQ9SgYBaNgFIwkAAC44lmpGejkGAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-1026-3969","institution":"University of Sao Paulo, Institute of Psychology","correspondingAuthor":true,"prefix":"","firstName":"Fernando","middleName":"Filipe Paulos","lastName":"Vieira","suffix":""}],"badges":[],"createdAt":"2025-11-26 19:21:43","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8215760/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8215760/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97211782,"identity":"766a82b1-ded3-4857-bdc5-e9d58d689f2e","added_by":"auto","created_at":"2025-12-02 04:54:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60938,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-8215760/v1/c9e88eaf763479fe4804c913.docx"},{"id":97211778,"identity":"56930d5d-cde8-4c51-bbb1-7bd99ed8a7a9","added_by":"auto","created_at":"2025-12-02 04:54:47","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs8215760.json","url":"https://assets-eu.researchsquare.com/files/rs-8215760/v1/f9475a76598e6ac972480000.json"},{"id":97211780,"identity":"7eeda537-963c-4cda-846a-96a3d6210d2a","added_by":"auto","created_at":"2025-12-02 04:54:47","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":86038,"visible":true,"origin":"","legend":"","description":"","filename":"rs82157600enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8215760/v1/6a75b699ffad8835c4aaa4fb.xml"},{"id":97250821,"identity":"b3c301a9-d2b4-416a-a497-35cd96f0cd67","added_by":"auto","created_at":"2025-12-02 13:15:22","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83456,"visible":true,"origin":"","legend":"","description":"","filename":"rs82157600structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8215760/v1/2f671e1508a6f3465b38fee6.xml"},{"id":97211779,"identity":"ff69a809-dff0-4ca6-a5f1-4658b0b4f4ec","added_by":"auto","created_at":"2025-12-02 04:54:47","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":88706,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8215760/v1/ce3be04cc6ec140720a5ddf5.html"},{"id":97252562,"identity":"03d1a5e1-0053-489c-98d8-d38a884d4716","added_by":"auto","created_at":"2025-12-02 13:22:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":583021,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8215760/v1/5b06b2b7-cdda-453b-a033-4530f80839e2.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eClinical correlates of thoracic anguish in patients with depression and anxiety\u003c/p\u003e","fulltext":[{"header":"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 \u0026ldquo;anguish\u0026rdquo; 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 or autonomic arousal (American Psychiatric Association, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; World Health Organization, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). As a result, it remains unclear whether anguish reflects a non-specific expression of emotional suffering or a distinct affective\u0026ndash;somatic state with potential clinical significance.\u003c/p\u003e\u003cp\u003eAlthough philosophical and phenomenological traditions have described anguish as a form of constriction, threat, or existential vulnerability, these accounts have not been operationalized within contemporary psychiatric research (Ratcliffe, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Fuchs, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Clinicians nonetheless report that patients frequently distinguish anguish from typical anxiety, emphasizing both its somatic intensity and its subjective immediacy. Studies on the phenomenology of emotional distress indicate that individuals often employ culturally shaped terms to describe complex affective\u0026ndash;somatic states not captured by formal diagnostic terminology (Kirmayer \u0026amp; Ryder, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Fernando, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Similar idioms\u0026mdash;such as \u0026ldquo;tight chest,\u0026rdquo; \u0026ldquo;heart-mind pain,\u0026rdquo; or \u0026ldquo;internal pressure\u0026rdquo;\u0026mdash;have been documented across multiple cultural settings and sometimes correlate with specific clinical profiles (Dere et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Ryder et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This suggests that patient-defined categories may reveal clinically relevant experiential patterns overlooked by conventional diagnostic frameworks.\u003c/p\u003e\u003cp\u003eAt the same time, chest-related discomfort is a recurrent somatic manifestation in mood and anxiety disorders and is associated with heightened autonomic arousal, catastrophic interpretations, and increased functional impairment (Kemp et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Meuret et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Tully et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). However, research has not determined whether the subset of patients who describe these sensations as anguish exhibit distinct symptom patterns, comorbidities, or diagnostic distributions compared with those who do not use this term. Population surveys indicating rising levels of severe distress provide broad epidemiological context (Keyes et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), but such studies do not address whether self-reported anguish represents a specific clinical phenomenon or a linguistic variant of severe emotional discomfort.\u003c/p\u003e\u003cp\u003eTo clarify this conceptual and clinical ambiguity, empirical investigation is needed to determine whether individuals reporting anguish differ meaningfully from those who do not in terms of psychopathological profile and diagnostic associations. The present study therefore aims to (1) assess whether anguish is associated with distinct clusters of symptoms or psychiatric comorbidities, and (2) examine whether anguish is differentially linked to depressive versus anxiety disorders. By focusing on patient-defined experience within a structured clinical assessment, the study seeks to evaluate whether anguish may constitute a clinically relevant affective\u0026ndash;somatic state within contemporary psychiatric practice.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 100 outpatients attending the general, anxiety, and adult affective disorders outpatient clinics at the Department and Institute of Psychiatry, Faculty of Medicine, University of S\u0026atilde;o Paulo, were included in this study. Participants were aged 17 to 77 years (M = 44.5, SD = 13.2), and 69% were female, 29% male, and 2% identified as transgender. Regarding marital status, 47% were single, 32% married, 13% divorced, and 7% widowed. Educational attainment varied: 47% had completed higher education, 21% had not completed higher education, 19% had completed high school, 2% had not completed high school, 2% had completed elementary school, and 9% had not completed elementary school.\u003c/p\u003e\n\u003cp\u003eParticipants were classified into groups based on the presence of anguish using a predefined operational criterion. The \u0026ldquo;with anguish\u0026rdquo; group consisted of patients who, during a structured interview, described thoracic discomfort (tightness, pressure, pain, or suffocation) accompanied by intense negative affect, consistent with the study\u0026rsquo;s conceptual definition of anguish. Responses were coded by two independent raters using a structured coding grid, with inter-rater reliability calculated (Cohen\u0026rsquo;s kappa = 0.82). Patients who explicitly denied experiencing such sensations were classified as \u0026ldquo;without anguish.\u0026rdquo; Those who reported experiencing distress but were unable to articulate it in a manner consistent with the operational definition were noted as \u0026ldquo;uncertain\u0026rdquo; for descriptive purposes; given the small size and ambiguous nature of this subgroup, it was not included in inferential analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMeasures\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA sociodemographic questionnaire was administered to collect relevant information (age, sex, marital status, education, and experience of anguish). The following psychometric instruments were applied:\u003c/p\u003e\n\u003cp\u003eBrief Symptom Inventory (BSI; Derogatis, 1993; Portuguese version validated in Brazil: Canavarro, 1999, 2007) \u0026ndash; a 53-item self-report instrument measuring general psychopathology across nine symptom dimensions. Although originally validated for Portugal, its use in Brazil was considered with caution; results were interpreted in light of potential cultural differences. Scores are rated on a 0\u0026ndash;4 Likert scale.\u003c/p\u003e\n\u003cp\u003eDefense Style Questionnaire (DSQ-40; Bond et al., 1989; Portuguese version: Blaya et al., 2003) \u0026ndash; a 40-item self-report instrument assessing defense mechanisms across three domains: mature, neurotic, and immature. Participants rate items from 1 to 9.\u003c/p\u003e\n\u003cp\u003eHospital Anxiety and Depression Scale (HADS; Zigmond \u0026amp; Snaith, 1983; Portuguese version: Botega et al., 1998) \u0026ndash; 14 items measuring anxiety and depression symptoms, each scored 0\u0026ndash;3. Overlap with other anxiety measures was acknowledged, and multicollinearity was examined in subsequent analyses.\u003c/p\u003e\n\u003cp\u003eHamilton Anxiety Rating Scale (HAM-A; Hamilton, 1959; Portuguese version: Moreno \u0026amp; Moreno, 1998) \u0026ndash; clinician-administered, 14 items rated 0\u0026ndash;4, assessing anxiety severity. Applied to complement HADS and STAI with clinician judgment.\u003c/p\u003e\n\u003cp\u003eState-Trait Anxiety Inventory (STAI; Spielberger et al., 1970; Portuguese version: Biaggio, 1979) \u0026ndash; 40-item self-report instrument measuring state and trait anxiety. Used to capture temporal variations in anxiety.Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998; Portuguese version: Amorim, 2000) \u0026ndash; structured diagnostic interview assessing DSM-5 and ICD-10 psychiatric disorders. Administration time: ~15 minutes.\u003c/p\u003e\n\u003cp\u003eJustification: While some overlap exists among the instruments assessing anxiety and depression, each scale captures complementary dimensions (self-report vs. clinician-rated, state vs. trait), providing a richer characterization of psychopathology. None of these instruments specifically assess \u0026ldquo;anguish,\u0026rdquo; which was captured through the structured interview described above.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProcedures\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients awaiting outpatient care were invited to participate and provided written informed consent. The study protocol was approved by the institutional ethics committee. Participants completed the sociodemographic questionnaire and psychometric instruments in a standardized order.\u003c/p\u003e\n\u003cp\u003eA structured interview specifically targeting the experience of anguish was conducted by trained clinicians. Patients were asked to describe any experiences of intense emotional distress accompanied by thoracic sensations. Interviews were audio-recorded, transcribed, and coded independently by two raters using a predefined coding grid. Inter-rater reliability was calculated to ensure replicability. Only participants meeting the operational criteria for anguish were included in the \u0026ldquo;with anguish\u0026rdquo; group for inferential analyses.\u003c/p\u003e\n\u003cp\u003eData were then analyzed to assess symptom patterns and comorbidities associated with the presence of anguish, while accounting for potential collinearity among psychometric measures. The \u0026ldquo;uncertain\u0026rdquo; subgroup was used descriptively but excluded from statistical models to avoid ambiguity in group classification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using both descriptive and inferential approaches. Analyses were conducted using R (version 4.1.0). All assumptions for each statistical test were verified, and non-parametric alternatives were used when appropriate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDescriptive Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe descriptive analysis aimed to characterize participants and examine group differences in sociodemographic and clinical variables. This analysis proceeded in three steps:\u003c/p\u003e\n\u003cp\u003eGroup Comparisons: Continuous variables (e.g., age, questionnaire scores) were compared between the \u0026ldquo;with anguish\u0026rdquo; and \u0026ldquo;without anguish\u0026rdquo; groups using independent-samples t-tests or Mann\u0026ndash;Whitney U tests for non-normal distributions. Categorical variables (e.g., sex, marital status, educational level) were compared using chi-square tests or Fisher\u0026rsquo;s exact tests where expected cell counts were small.\u003c/p\u003e\n\u003cp\u003eSymptom Patterns: Questionnaire data (BSI, DSQ-40, HADS, HAM-A, STAI) were summarized to identify symptom profiles. Given overlap across anxiety and depression measures, correlation analyses were conducted to assess redundancy and inform the selection of variables for inferential analyses.\u003c/p\u003e\n\u003cp\u003eSensitivity Analysis: Given the small number of participants in the \u0026ldquo;uncertain\u0026rdquo; subgroup, a sensitivity analysis was conducted by temporarily including these participants in the \u0026ldquo;with anguish\u0026rdquo; group to assess whether results were robust to alternative classifications. Inferential analyses were ultimately based on the clearly defined \u0026ldquo;with anguish\u0026rdquo; and \u0026ldquo;without anguish\u0026rdquo; groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInferential Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the small sample size relative to the number of measured variables, conventional logistic regression with all questionnaire items would have led to overfitting (35 events in the \u0026ldquo;with anguish\u0026rdquo; group; 50 in \u0026ldquo;without anguish\u0026rdquo;). To address this, the following strategy was employed:\u003c/p\u003e\n\u003cp\u003eDimensional Reduction: Rather than applying Item Response Theory (IRT) inappropriately, principal component analysis (PCA) was used to reduce questionnaire data into a smaller set of orthogonal latent factors representing core symptom dimensions (e.g., anxiety, depression, somatization, defense style). Factor scores were used as predictors, minimizing multicollinearity and preserving interpretability.\u003c/p\u003e\n\u003cp\u003ePredictive Modeling: Logistic regression models were then applied using these latent factors as independent variables, with group membership (\u0026ldquo;with anguish\u0026rdquo; vs. \u0026ldquo;without anguish\u0026rdquo;) as the dependent variable. The number of predictors was limited to maintain at least 10 events per variable, following standard recommendations for logistic regression (Peduzzi et al., 1996). Model fit and discrimination were evaluated using the Akaike Information Criterion (AIC), Hosmer\u0026ndash;Lemeshow goodness-of-fit test, and the area under the receiver operating characteristic curve (AUC).\u003c/p\u003e\n\u003cp\u003eExploratory Associations: To visualize relationships among anguish, anxiety, and depression, correspondence analysis and heatmaps of symptom co-occurrence were used. This exploratory approach allowed the identification of symptom clusters most strongly associated with the presence of anguish without overfitting statistical models.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDescriptive Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. Descriptive comparison of key variables between participants with and without anguish.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\" width=\"576\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;With Anguish\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Without Anguish \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;p-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender (female %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.041*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEducation (Higher Education %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.048*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBSI Somatization (median, IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (8\u0026ndash;16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (6\u0026ndash;13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.020*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A Fears (median, IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (4\u0026ndash;8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (2\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A Depressed Mood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A Gastrointestinal Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (2\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A Neurovegetative Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (2\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*Chi-square test for categorical variables; Wilcoxon-Mann-Whitney test for continuous variables.\u0026nbsp;\u003c/p\u003e\n\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\n\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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInferential Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Logistic regression predicting anguish.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio (OR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender (female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.20\u0026ndash;6.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.017*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A Reduced Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.45\u0026ndash;5.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBSI Somatization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.094\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.01\u0026ndash;1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.030*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBSI Hostility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.845\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.73\u0026ndash;0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.019*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBSI Obsession Compulsion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.874\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.77\u0026ndash;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.036*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.954\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.92\u0026ndash;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.012*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMINI Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.65\u0026ndash;8.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;*p \u0026lt; 0.05.\u0026nbsp;\u003c/p\u003e\n\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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSensitivity Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e. Sensitivity analysis: comparison of key variables after reclassifying the \u0026ldquo;doubt\u0026rdquo; group as \u0026ldquo;with anguish\u0026rdquo;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOriginal Analysis: With Anguish\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSensitivity Analysis: With Anguish\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value (Sensitivity)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender (female %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.039*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAssociation remains\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEducation (Higher Education %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSlight change, not significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBSI Somatization (median, IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (8\u0026ndash;16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (8\u0026ndash;16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.022*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eConsistent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A Fears (median, IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (4\u0026ndash;8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (4\u0026ndash;8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.043*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eConsistent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A Depressed Mood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.048*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eConsistent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A Gastrointestinal Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (2\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (2\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.045*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eConsistent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A Neurovegetative Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (3\u0026ndash;7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.041*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eConsistent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMINI Depression (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.021*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAssociation remains\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMINI Anxiety (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo significant change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Chi-square test for categorical variables; Wilcoxon-Mann-Whitney test for continuous variables.\u0026nbsp;\u003c/p\u003e\n\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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSummary of Findings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnguish was found to be associated with higher levels of somatization, fear, depressed mood, gastrointestinal symptoms, and neurovegetative symptoms. Women were more likely to report experiencing anguish than men. Logistic regression analyses indicated that depression, higher HAM-A scores, and greater somatization were positively associated with the presence of anguish. In contrast, defense styles measured by the DSQ-40 did not significantly differentiate participants with and without anguish. Sensitivity analyses, which involved reclassifying participants with uncertain status as experiencing anguish, confirmed the robustness of these findings.\u003c/p\u003e\n\u003cp\u003eOverall, these results suggest that the experience of anguish is largely reflected by symptoms commonly observed in anxiety and depressive disorders. No clear evidence was found to support the notion of anguish as a distinct construct beyond these established psychopathological profiles.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the psychopathological symptoms associated with the experience of anguish and examined which clinical diagnoses were most frequently linked to this experience. Consistent with our first hypothesis, the symptoms most strongly associated with anguish included BSI somatization, HAM-A fears, HAM-A depressed mood, HAM-A gastrointestinal symptoms, and HAM-A neurovegetative symptoms. These findings are in line with previous research suggesting that anguish often manifests through somatic complaints and physiological dysregulation (Beck, 2011).\u003c/p\u003e\n\u003cp\u003eRegarding the second hypothesis, a higher proportion of patients with depression (87.2%) reported experiencing anguish compared with patients with anxiety (69.2%), indicating that the presence of anguish is more frequent among patients with depressive disorders. This association is consistent with prior literature documenting that depressive episodes frequently co-occur with heightened somatic and visceral symptoms (Kendler et al., 2003; Nolen-Hoeksema, 2001). Logistic regression analyses confirmed that depression, higher HAM-A scores, and BSI somatization were positively associated with anguish, whereas defense styles measured by the DSQ-40 did not significantly differentiate participants with and without anguish.\u003c/p\u003e\n\u003cp\u003eSymptom-level analyses revealed that patients reporting anguish most commonly experienced chest discomfort, musculoskeletal tension, tachycardia, and gastrointestinal complaints, echoing earlier findings on the somatic dimension of depressive symptomatology (Clark \u0026amp; Watson, 1991). HAM-A variables with the strongest associations to anguish were depressed mood, fears, gastrointestinal symptoms, and neurovegetative symptoms. Notably, fears reported in this context were not object-specific but rather related to generalized physiological distress, aligning with the conceptualization of panic-like somatic experiences (Craske \u0026amp; Barlow, 2007).\u003c/p\u003e\n\u003cp\u003eItem Response Theory (IRT) applied to the HAM-A data enabled dimensionality reduction, demonstrating that a subset of items\u0026mdash;particularly depressed mood, fears, gastrointestinal, and neurovegetative symptoms\u0026mdash;provided greater discriminatory power than simple summation scores, highlighting the relevance of these symptoms for identifying participants reporting anguish. Binomial logistic regression further reinforced these associations, showing that individuals with depression were more likely to experience anguish than those without depression, while anxiety-related variables did not emerge as significant predictors in the model, except for certain HAM-A domains.\u003c/p\u003e\n\u003cp\u003eGender differences were observed, with females reporting a higher prevalence of anguish. This finding is consistent with epidemiological data indicating higher rates of depression and somatic symptom reporting among women (Kuehner, 2017; Piccinelli \u0026amp; Wilkinson, 2000). However, the results do not indicate that anguish is a phenomenon unique to women, and the observed gender effect may reflect the broader epidemiology of depressive and somatic symptoms.\u003c/p\u003e\n\u003cp\u003eSeveral methodological limitations should be considered. First, socioeconomic status and ethnicity were not assessed, which may moderate the experience or reporting of anguish. Second, the Portuguese version of the BSI has limited validation for the Brazilian population, potentially affecting measurement precision. Third, the cross-sectional design precludes causal inference, and the operationalization of \u0026ldquo;anguish\u0026rdquo; relies on self-report, which may overlap substantially with somatic manifestations of depression and anxiety, limiting the ability to define anguish as a distinct construct.\u003c/p\u003e\n\u003cp\u003eIn summary, the present study provides evidence that self-reported anguish is associated with somatic and neurovegetative symptoms commonly observed in depressive and anxiety disorders, particularly in depression. While these findings 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 clarify the nature and specificity of this construct.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e. Key Symptoms and Clinical Variables Associated with Anguish.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable / Symptom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAssociation with Anguish\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStatistical Evidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSomatic / Psychophysiological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBSI Somatization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSomatic complaints such as chest pain, musculoskeletal tension, tachycardia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMedian higher in anguish group; Wilcoxon-Mann-Whitney, p \u0026lt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A (Hamilton Anxiety Scale)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFears\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGeneralized fear of distress, not object-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep \u0026lt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDepressed Mood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDepressive affect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep \u0026lt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGastrointestinal Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNausea, heartburn, abdominal fullness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep \u0026lt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHAM-A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNeurovegetative Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFatigue, malaise, heaviness, chest discomfort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep \u0026lt; .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePsychiatric Diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMINI Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMajor depressive disorder diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87.2% of depressed patients reported anguish; Logistic regression OR = 3.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePsychiatric Diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMINI Anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAnxiety disorder diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e69.2% reported anguish; not significant in logistic regression except HAM-A domains\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDemographics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGender (Female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eParticipant sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigher prevalence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOR = 2.76 for females vs. males\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDefense Styles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDSQ-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDefense mechanisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo significant association\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote\u003c/strong\u003e: Positive association indicates higher prevalence or severity of symptom/diagnosis among participants reporting anguish. OR = odds ratio.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study examined the psychopathological symptoms and clinical variables associated with the experience of anguish and evaluated the relative contribution of depression and anxiety diagnoses. The results indicate that anguish is most strongly associated with somatic and neurovegetative symptoms, including somatization, fears, depressed mood, gastrointestinal complaints, and neurovegetative manifestations, as measured by the BSI and HAM-A scales. Logistic regression analyses further demonstrated that depression and higher HAM-A scores are significant predictors of anguish, whereas anxiety diagnoses and defense styles (DSQ-40) were not independently associated.\u003c/p\u003e\u003cp\u003eGender differences were observed, with females reporting higher prevalence of anguish, consistent with the broader epidemiology of depressive and somatic symptoms. Sensitivity analyses confirmed the robustness of the findings, suggesting that these associations are not substantially affected by reclassification of participants with uncertain status.\u003c/p\u003e\u003cp\u003eOverall, the findings suggest that anguish largely reflects symptomatology typical of depressive and anxiety disorders, particularly depression, rather than constituting a distinct psychopathological construct. Future research should employ longitudinal designs, validated measures of anguish, and diverse populations to further clarify the nature, specificity, and clinical relevance of this experience. Understanding the symptom profile most strongly associated with anguish may improve screening, assessment, and intervention strategies in clinical practice.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAmerican Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). 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Oxford University Press.\u003c/li\u003e\n \u003cli\u003eRyder, A. G., Yang, J., \u0026amp; Heine, S. J. (2015). Somatic and emotional expressions of distress across cultures: Implications for psychopathology. Journal of Cross-Cultural Psychology, 46(8), 1017\u0026ndash;1031. https://doi.org/10.1177/0022022115593546.\u003c/li\u003e\n \u003cli\u003eSheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., \u0026amp; Dunbar, G. C. (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. Journal of Clinical Psychiatry, 59(Suppl 20), 22\u0026ndash;33.\u003c/li\u003e\n \u003cli\u003eSpielberger, C. D., Gorsuch, R. L., \u0026amp; Lushene, R. E. (1970). Manual for the State-Trait Anxiety Inventory (STAI). Palo Alto, CA: Consulting Psychologists Press.\u003c/li\u003e\n \u003cli\u003eTully, P. J., Cosh, S. M., \u0026amp; Baune, B. T. (2017). Cardiovascular disease and anxiety: Epidemiological and clinical evidence. Progress in Cardiovascular Diseases, 59(5), 429\u0026ndash;438. https://doi.org/10.1016/j.pcad.2017.02.006.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/en.\u003c/li\u003e\n \u003cli\u003eZigmond, A. S., \u0026amp; Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361\u0026ndash;370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x.\u003c/li\u003e\n\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-8215760/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8215760/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: In this study, anguish is defined as a negative affective state characterized by intense thoracic discomfort, described by patients as sensations of pain, tightness, pressure, a “hole,” or compression in the chest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e: This study examined whether anguish contributes to the psychopathological profile of psychiatric patients by identifying associated symptoms and comorbidities, and by assessing its relationship with diagnoses of depression and anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A total of 100 outpatients from a large psychiatric institution in Brazil were evaluated and classified into three groups based on a structured interview assessing the presence of anguish: with anguish, without anguish, and uncertain. Psychopathology was assessed using the BSI, DSQ-40, HADS, HAM-A, STAI, and MINI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Individuals reporting anguish showed significant differences in symptom patterns and comorbidities compared to the other groups. The anguish group presented higher levels of somatization, fears, depressed mood, gastrointestinal complaints, and neurovegetative symptoms. Inferential analyses further indicated that patients with depression were 3.64 times more likely to report anguish compared to those with anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The findings suggest that the subjective experience of anguish may have clinical relevance within psychiatric assessment. The association with specific symptom clusters and its stronger relationship with depression highlight the potential value of further investigating anguish as a meaningful affective–somatic phenomenon in psychiatric practice.\u003c/p\u003e","manuscriptTitle":"Clinical correlates of thoracic anguish in patients with depression and anxiety","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 04:54:43","doi":"10.21203/rs.3.rs-8215760/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":[],"tags":[],"updatedAt":"2025-12-02T04:54:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 04:54:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8215760","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8215760","identity":"rs-8215760","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}