ee cone rcs Disability and Poor Quality of Life Associated With Comorbid Anxiety Disorders and Physical Conditions Jitender Sareen, BSc, MD, FRCPC: Frank Jacobi, PhD; Brian J. Cox, PhD; Shay-Lee Belik, BSc(Hons), Jan Clara, MA; Murray B. Stein, MD, MPH Background: Evidence has been emerging that an y disorders are associated with several physical hes conditions. We used the first community survey, w! assessed physical conditions based on physician asses ment and included standardized diagnostic assessment ‘of mental disorders by trained health professionals, o ex- amine the relationship between anxiety disorders and physical conditions, he bh Metheds: The German Health Survey (N=4181; re- sponse rate, 87.6%; ages 18-65 years) used the Compos- \ernational Diagnostic Interview to assess Diagnos- ticand Statistical Manual of Mental Disorders, Fourth Edition mood, substance use, and anxiety disorders (panic dis- order, social phobia, specific phobia, generalized anxi- y disorder, agoraphobia, obsessive-compulsive disor ler) and a standardized medical interview supplemented. by laboratory data to assess a broad range of physical con- ditions. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) was used to measure health- related quality of life. Number of days of role impairment ‘was used to measure past 30-day disability Results: Aller adjusting for soctodemographie factors and other common mental disorders, the presence of an anxiety disorder was significantly associated with thy- roid disease, respiratory disease, gastrointestinal dis- ‘ease, arthritis, migraine headaches, and allergic condi- tions (adjusted odds ratios between 1.39 and 2.12; P<05). Compared with physical disorders alone, the presence ‘of comorbid anxiety disorder with 1 or more physical dis ‘orders was associated with poorer physical component scores on the SF-36 (adjusted mean scores for physical condition alone and physical condition with anxiety dis- ‘order, 48.50 and 45.86, respectively; P<.001) and past 30-day disability due to physical problems (adjusted odds ratio, 1.69; 05% confidence interval, 1.20-2.37) Conelusion: Anxiety disorders are independently asso- ciated with several physical conditions in the comm nity, and this comorbidity is significantly associated with poor quality of fe and disability Arch Intern Med. 2006;166:2109-2116 HE NEGATIVE IMPACT OF CO- morbidity of depression with physical illness has been well documented," and evidence has been Although evidence is mounting that anxiety disorders are often comorbid with physical disorders, 4 specific limitations fof the current literature on this topic ex- ist, First, the association between anxiety Author Affiliations: Department of Psychiatry and ‘Community Health seiences, University of Manitoba, Winnipeg (Drs Sareen and Cox, ‘Ms Belk, and Mr Cla); Institute of Clinical Peychology and Psychotherapy Uni: Epidemiology and Service Research, echnical University of Dresden, Dresden, Germany (Ds Jacobi); and Departments of Psychiatry and Family & Preventive Medicine, Univesity of California, San Diego (Dr tein). (aepRnyTeD) ARCHINTERN MEDVOL Tes OCT Se ‘emerging to show that anxiety disorders are associated with several physical health problems.” For instance, phobic anxi- ety symptomsat baseline have been linked tosudden cardise death." Clinical stud- ies of individuals with specific phystcal illnesses (thyroid disease," cardiac dis- - hypertension, diabe- autoimmune diseases,"* peptic ul- cer disease,**and asthma’) have noted higher than expected levels of anxiety dis- orders among patients seeking treatment for physical conditions.” Similarly, epi- demiologte studies!" have found a positive association between the pres- ence ofanxiety disorder diagnoses and self- reported physical disorders, disordersand physical disorders found in clinical samples may be limited by sar pling biases." Second, although epide- tiologie samples reduce the likelihood of sampling bias, most of these studies have used self-report diagnosis of physical health conditions." Since individuals with anxiety disorders are more likely report physical symptoms, its possible that there may be a self-report bias of physical health conditions among indi- viduals with anxiety disorders." Third, most epidemiologic studies have used lay interviewers to diagnose mental dis- orders rather than trained health profe sionals. Fourth, findings have been dis- erepant on the relationship between (©2000 American Medical Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/intemed/SS60/ on 06/09/2017comorbidity of anxiety disorders and physical cond tions with disability and quality of ie, Some primary care sample studies" have found that ansiety symptoms and. anxtety disorders are associated with excess disability among primary care patients with physical health prob lems, whereas others have found that the associated dis- ability was either minimal or due to comorbidity with ther mental disorders." It remains uncertain whether the comorbidity of anxiety disorders with physical health problems is associated with functional impairments To address these limitations, we used the German Health Survey (GHS) to examine the relationship be- tween anxiety disorders and physical illness. The GHS isthe fist survey to assign Diaghostic an Statistical Maal of Mental Disorders, Fourth Edition (DSM-IV) mental dis- forder diagnoses using the highly reliable Composite In- temational Diagnostic Interview and to use physician ‘nased diagnosis of physical health conditions by interview, physical examination, and laboratory assessment." ln addition, the GHS included @ comprehensive assess- ment of functional status: (1) the Medical Outcomes Study 36-ltem Short-Form Health Survey (SF-36)," which isa Jhghly reliable, widely used measure of health-related qual- ity of life, and (2) past 30-day role impairment duc to physical and emotional problems. ‘We hud 2 specifi objectives forthe current study. Firs, ‘we examined whether there were unique associations be- tween the presence of an anxiety disorder with particu- lar physical conditions. Second, we examined whether the comorbidity of anxiety and physical health prob- lems was independently associated with poor quality of life and disability even after adjusting for potential con- founding factors (eg, overall burden of physica illness) 2s} SAMPLE “The GHS was based on a stratified, multistage, cross-sectional, nationally representative sample of individuals, aged 18 079 years, {rom the noninstitutionalzed population of Germany." The survey was approved by the institutional review board ofthe Rob- crt Koch Insutute (Berlin, Germany). A detailed description of the survey design is avilable elsewhere." In summary. all participants provided weitten informed con- sent, Data were collected between 1997 and 1999. The GHS had 2 components: the core survey (N=7124; 61.5% response rate) and the mental health supplement (N=4181; 87.6% re- sponse rate)" The responders and nonresponders did not dif- {er significantly by age, sex, and self-reported health status on the core survey." MEASURES: Assessment of Physical Conditions, “The GH assessed physical conditions based ona combination 3 method (1) stleport questionnaire asking aboot the Presence of 4 physical contitons, 2) astandardied computer Essned medial nerve by «general practice physician, ad G)anthropomrc blood press meastrements as wellascol- Ieevon ot blood and urine samples. ‘The curren analysis used Phys condtons that were dagnosel on the basis ofthe phy (aepRnyTeD) ARCHINTERN MEDVOL Tes OCT Se sician assessment and laboratory results, We included physical ‘conditions only if there was previous empirical evidence of an ‘association between anxiety disorders and the physical condi tion was prevalent enough to be included on the basis of power Medical Morbidity In the previons lierture,2speiic methods have been used toadjst for the effects overall burden of physical ines on quality of ie ad service wlzation: (1) variable that counts the total namberof physical conditions" and (2) the Cha. som Comorbidity Index (CCI) The latte measure ws devel {ped empirically orelbly index physical conditions hats aly or in combination increase the short-term risk of thovlity > all he chronic conditions assesed the sur ‘ey wer ven a CCI weight Irom Ita 8). A toll score was Computed by addngall assigned eights for each chronic con- {ition The cl Was signicantyasoctaed wit ower mean Scores on the physial component score (PCS) ofthe SF-36 (r=-042, P= BI [2iledl} and wath 1 oF more days of de ati compared with no days of daly due to physical health problems dds ratio [OR]. 1.85:95% confidence eral [ll Tlas-.25). The mimber of physical conditions was also sig nile associated withthe PCS of the sF-36(r=-0-41;P OL [D-aled|) and with | or more days day compared with nodays of dnb de to physi! health problems (OR, 121 95% C1, 112-130) Thu although either the count variable forthe CCl expinined a substantial proportion of variance in funetonal outcomes, we chose to seth more widely sed CCL toadjst for overall burden of physica ins. Assessment of Mental Disorders “The Munich Composite International Diagnostic Interview, ad- tnistered by clinall tained interviewers (peychologlts and physicians), wae sed to make IMetime,pas-year, and past tnonth DSM-IV diagnoses" Since all quality oF Me and dis stily variables were from the past month, we used only past tnonth mental disorder diagnoses, For the curent analysis, we Clegorized a DSMGIV anaety disorder dlagnosis based on the resenceof any ofthe following aiety disorders: panic disr- {cr agoraphobia, soil phobia simple phobia, generalized nxt- tty disorder, and obsessive-compuleive disorder, (Posta- tie stes disorder was ot assed in this survey.) We also Calegorized a mood disorder diagnose (major depression, dys thymia bipolar disorders) and asubsiance se diorderdagno- sis alcol and lic substance abuse or dependence) Assessment of Health-Related Quality of Lil “The German version of the well-validated""® SF-36 was used" Eight health concepts were asesed within the past 50 days: physical functioning socal functioning, role Unita tons duet physical problems bodily pain, mental health, role limtationsdtetocmational problems, aly and general ealh Principal components analysts has identified 2 dimensions ofthe Sf-36 the PCS andthe mental component score (M1CS)= Assessment of Disability Similar to previous surveys2" past 30-day disability was ex- amined by the sel-reported numberof days of being snable to ‘carry out usual daily activities. Parallel questions were asked for number of days of disability due to physical problems and ‘emotional problems or use of alcohol or other drugs. Respon- dents were asked how many daysin the prior 30 days they were totally unable to do the things they normally did. Responses (©2000 American Medical Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/intemed/SS60/ on 06/09/2017ranged from 0 to 30 days. Because ofthe skewed nature ofthe responses, with most people in he community reporting days ‘of disability, a dichotomous variable was created: 0 days vs 1 for more days of disability. Sociodemographic Factors ‘Sex, age, education, and maria status were entered as covari- ate in the analysis. Age was treated as a continuous measure in the analysis, Education was dichotomized into either com- pleted high school orany higher education based on the format ffthe German educational system. Marital status was trichoto- ‘mized into (1) never marred, 2) married or common-law spouse, (oF (3) divorced, separated, or widowed. Analytic Strategy inal analyses, the appropriate statistical weight was used sue tha he data were eprescnative othe population stan. ci ctor were caledatl using the Taylor Scfes inca tom method in the SUDAAN programs (Research Tangle Path, NO) based on sttatcation information provided speiclly forcalculating design based standard errors-To account formal tpl compurionn we presenta more coroeratie PCO, ‘dition tothe P05 significance evel ‘We used multiple lytic regression to determine associa- tions beeen anaety disorders and individual physical com tions: Covariates inthe analysis included sociodemographic factors, presence ofa mood disorder, and presence of sub- Stance use disorder Next usingage-of-onset data aval for both anxiety dhorders and physical conditions, we examined the temporal onde of onset of comorbid cases Wealso examined the association of comorbidity of anxi- cty disorders an physical health condition with funtional Status: SF-36 scores and pas 30-day disablty, This analysis ‘eas limited to physical conditons that were significant a Sociated vith anxiety disorders. In all regressions described ierein, we included the following covariates. sociodemo- sraphic actor mor order sibwtanc se dsorder, and Cc ove, Malis near regression was used texan thea Sectation of comorbidity of anaiety disorders and physical hess with the PCS and MCS of the S96 Finally, lige lo oii eprenion was taed to detrmine whether smmotidty Stan ansety disorder anda physical helt condition was ase Soctaed with an increased ibelthood of past 30-day dsabiity (de to emotional problems and physical conditions). ss} Table 1 provides the characteristics of the sample and all the independent variables and dependent variables, ‘An anxiety disorder diagnosis was significantly associ- ated with a mood disorder (OR,9.64; 05% Cl, 7.44. 12.49) and substance use disorder (OR, 3.04; 95% Cl 201-459) diagnosis, supporting the need to adjust for the latter variables in all analyses Table 2 indicates that in the most stringent models, adjusting for sociodemographics and other common men- tal disorders, we found that the presence of an anxiety dis- order was associated with respiratory diseases, gastroin- testinal diseases, arthritic conditions, allergic conditions, thyroid diseases, migraine headaches, and any past” month physical condition. Table 3 indicates that across all physical conditions, most comorbid cases had the on- set of the anxiety disorder before the physical conditions. (aepRnyTeD) ARCHINTERN MEDVOL Tes OCT SN Se Independent and Dependent Variables Included in the Analysis, Tota wo. (2) of Parepants vara (wea See se 913,603) Feral 7268 407) Aos.y 025 517 (120) 26.35 940,240) 3645 902,235) 1655 853,188) 5655 855,208) Edition igh thal ores 2314 61.0) Some cole of more *790(300) antl sta arti 2817641) Single 493,119) Diora widowed or aparates 901 249) Past month aod disorder (epresion, ystymia, 2926.3) ipl disorder) Pastmonth ubsiance se dsréer(acoholand 120,20), ‘har drug abuse or dependence) Past month ny ansaty disorder 220 (84) Pane dior wth ar vithotagraphobia 9019) ‘Aeraphbia 6313), Simple phobia 249(47) Soda phobia 58(12) Genera arty ort 55(12), Obsessie-compusiv disorder 25(04) Past month any pial contion 2810 608), ypatensan| 438,110) Cac diseases (nyocardialntacon, congestive 108,24) ‘are Respatory dstasos asthma, chronic broncits) 2345.8) Gasromtesinal conditions (gastritis, le) 1203) Dae (uth or wht nel ester) 147) ‘Ahi condos (ear and tar yp, 004 (253), nflaratory diseases fh jit) Alecia ever, lege etema, alergihives, 536 (128) ‘aurodermai food ary alae cajun) Migaine heaaches 34871) Thyed diseases 408,01) Past month = dy of sabiity Disabil ds to physical problems 625 (142) Disability det motional probiznsorsubstance 222(7) Mecia Outcomes Stuy 36am Shor-Form Heath Survey sor, weighed man (SE) Metal component scare 5050 (010) Physi component score 40100010) Carlson ComoridyIndexscora measure of oral 064 (0.02), ‘Physi dase burden), weighted men (SE) Daa are presenta as number (unweghed percentage of study parcipans tress otherwise nat Figure 1 shows the relationship among the pres- cence of ananxiety disorder, a physical condition, and the ‘combination of both with the MCS and PCS of the SF- 36. Importantly, the presence of a combination of anxi- ‘ety disorders with any physical condition was assoc ated with a lower mean PCS score than presence of any physical condition alone (ie, without an anxiety disor- (©2000 American Medical Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/intemed/SS60/ on 06/09/2017Table 2. Multiple Logistic Regression Analyses Examining the Comorbidity of Past-Month Physical Conditions With ‘Anlely Disorders| Physica onatons Aajusted On (09% Ci}t__ Adjusted On (05% Ct iperarsio (= 485) 122 (08417) 134 (0.90-19) Cardiac diseases (n= 106) 4.97 (1.0238), 179(085379, Faspiratoy disses ( zoo(iazaorn anqusesm Gastric dacs (a zee (istatan zio(i essen ‘ist o8e320) tau 072288) 1is8(1.202 199 es t2tozn9 ‘lege codtions (n= 536) 4.42 (105-198), 4139(1.00-195) Mian eataces (9 = 343) 2se(igeasan 2215-2951 ‘hyo dseases (= 408) tei (i722in 1s0(1132201 ‘ay past-month pysicalcondion (n= 2510) sisetas2san sroqiar2am ‘Abrevtons: i, conden tral OR, od ra. *Pastsnonth ans sore soi phobia, pan sore, agoraphobia, generalized ans ior, simple phobia, obsessive-compusv disor) ‘djstod ORS contling fr sociodemographic factors (ge, sex, mata status, and educatan). ‘Ajustod ORs contain or saiodamographic actos, presen of past-meth rood dard, and ary past- month substance abuse or dependence ‘enon pope th hypertension, 8% met rea or ahaa dence, ios shoot Table 3. Temporal Sequence of Onset of Ansley Disorders nysicalCondtons Among Those With Comarbidty Any Det ays adn Iya a pent ‘oma Cares whee Any yt Cnt ho ny oe rode Peceea Pay yr Phe Cadon Pata conation Conon, (93%) iar 720 (635.701), a. (de dss 607 (552813) Respiratory disses sia(s24704) 0 Gastonia dnses 588 (525610) Diabeas Tas (6a7.872) tie condone naater2768) a. ‘Alagi candtons sia (seer) 5 Migraine headaches sa7 664704) Ba ‘yod deste 13 g60713) 3 ‘revo: Cl anne era » 1 der). This finding remained statistically significant in mil ‘ tiple linear regression models that adjusted for sociode- Tg Poca mographic factors, presence of mental disorders, and ‘sa sae ‘overall physical disease burden (as indexed by the CCD). Table 4 indicates that for cach physical condition the Figue 1 Te assocaton fancy dsr ad phys coptions wih eater quality mean PCS score was significantly lower for those who ‘ested man scr (rial arp Pes nificantly lower for those who ae ad poe conga ct) an sn ras (oot ba) Fo had an anxiety disorder in addition tothe physical con- Fala pcan yan tse on ar at dition. Funher adjustment for mental disordersandover- eet, remo mcd ti, emesis ae at All physical disease burden attemuated the association for ‘dts and Gran Comyn rsd Te all pyc dings burden tenuate the sociation for Sy dan pct gt sy rel armponent ad physical component scoes compared with natant nal disease but remained statistically significant for res- aoe nor phys condo ro andthe phys! conden group aloe piratory disease, allergies, and migraine headaches. Figure 2 illustrates the relationship between anxi- ety disorders and physical conditions with 1 or more days, ‘Table 5 provides the proportion of respondents with of disability. Compared with the presence of physical 1 or more days of disability duc to physical health prob- condition alone, we found that the combination ofananxi-_ lems for each of the physical conditions with and with- ety disorder anda physical condition wasassociated with out anxiety disorders. Compared with respondents with- 1 or more days of disability due to physical illness, even out anxiety disorders, the presence ofananxiety disorder after adjusting for sociodemographic factors, mood dis- was associated with 1 or more days of disability across orders, substance use disorders, and CCI scores. all physical conditions. In multiple logistic regression (aepRn\TED) ARCHINTERN MEDVOL Ios OCT Save WOWARCHINTERNNED CON. (©2000 American Medical Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/intemed/SS60/ on 06/09/2017‘Aajstd tor Soctdemograpte Fatorst ton of Comorbidity of Past-Month Anxiety Disorders and ‘on the Physical Component Score of the 36-Ilem Short-Form Health Survey* ‘Anat isreer ana -Month Physical Conditions ‘Adjusted fr Soeogamograpt Factors, ona isoreers, and meatal Moras ‘Ant sorder and Physical conden Physeal Canalon Pysteal conation "Paystal Conon Phys onatons nly (a= 2208) (w=519) Prvaluo __Onty (n= 203), Prvaue aspirator diseases 00 072) an5 (142) =o 48.00(075) a3 (14), OS Gastiestinal disses 46.19(115) 22008) 0 4983(107), 4875217) 2 Battie conttions 44430 037) 2001) a 4504041), 433,00), 08 ‘lagi contions 4035 (048) st (1.09) ast-Month Phys Assocation of Come conditions With Disability Due fo Physical Problems inthe German Health Survey ty of Past-Month Ancety Disorders Physica onatons ‘Aajusted OF (80% C1" __Aausta Om (9% ct Faspatory diseases 34161) 137309) 222 098-501) 173 (076-398), Gastrotstnaldnsees 23,108) 101239) 192(0.725.08) 1.50 080-420) Battie conttions 150(160) 21292) 1.04(125-8004 1.85(1052615 ‘lagi contons 20 (160) 191258) 175 0.00343) 148 072.280), Migaine headaches ert) 21319) 18070255) 1.08 082.200), hyo dseases| 45 (128) 20/283) par (17-40 1.84 092350) ny past-nonth physical ondtion 354 (148) 82259) 90(ae2 734 s0(120257 ‘Abrevatons: Gl, conidene tral OR, ode a. “furted ORs contig for said gape airs ape, sex, marital stats, and education), + justod fs contain for saiodomographic factors, presen of past-meth mond dard, presence of ast month substance abuse or dependence and (hasan amar Index score. peat bon disorders among people who present with these physi cal health problems. Dissimnilar from previous work,” the association be- tween cardiac disease and anxiety disorders was no longer statistically significant alter adjusting for comorbid de- pression and substance use disorders, We believe that this Finding can be attributed to the low prevalence of car- diac disease (2.4%) in the current analysis, which ex- cluded people older than 65 years. We did not find an association of anxiety disorders with hypertension and, diabetes. The literature has produced inconsistent find- ings with regard to these associations."2"2" The differ- cence in findings between studies is ikely attributable 10 differences in the methods of assessment of anxiety dis- ‘orders and physical health problems and the types of samples examined. The mechanisms of association between anxiety dis- orders and physical conditions remain unknown, al- though several possibilities should be considered. First, direct causal relationship between physical health and anxiety disorders may exist. For example, the presence (ofa physical illness, especially a life-threatening illness, may lead to the onset of increased anxiety and worry that reaches anxiety disorder proportions. Second, the pres- cence of an anxiety disorder may increase the likelihood, of physical illness through biological mechanisms (eg, changes in the hypothalamie-pituitary axis system or al- terations in autonomic nervous system activity). Psy- chological mechanisms, such as anxiety sensitivity (fear of body symptoms),”"" may be important in both main- tenance of the anxiety disorder and the physical health problem. Third, an indirect mechanism might explain the relationship, in which a third variable may lead to co- morbidity. For example, the presence of anxiety disor- der may lead to substance use disorder (eg, alcohol or other drug or nicotine use) that in turn leads to a physi cal health problem. The presence ofa physical illness may lead to the use of a medication that has an adverse elfect on anxiety symptoms (eg, bronchodilators in respira- (aepRnyTeD) ARCHINTERN MEDVOL Ios OCT Se tory disease). Fourth, common genetic, environmental (x, poverty, childhood adversity), *and personality fac- tors" may explain the co-occurrence of anxiety disor- ders with physical health problems, The mechanism(s) that leads to reduced quality of life and inereased disability among those with comorbid anxi- ‘ety disorders and physical conditions requires careful con- sideration. Katon et al” present a model that poses pos- sible mechanisms to explain the adverse impact of comorbidity of anxie asthma, They sugg depressive disorder may reduce the capacity to manage asthma and other life challenges, which may lead to de- and depressive disorders with hat the presence of an anxiety oF cereased adherence to treatment of asthma. Decreased ad- erence to treatment of asthma may lead to increased asthma symptom burden and increased functional im- pairment, Further examination of the mechanisms that lead to increased morbidity among those with co- occurrence of anxiety and physical illness is required, The current study has a number of limitations. First the survey was limited to adults (aged 18-05 years); there- fore, the current findings may not be generalizable to el- derly and very young individuals. Second, the retrospec- Live recall of age of onset of conditions, commonly used in cross-sectional epidemiologic surveys, may be al- fected by recall errors. Future longitudinal studies on this topic are warranted. Third, although the CCI was signifi cantly associated with functional impairment and has been ‘commonly used to adjust for the elfects of medical mor- bidity, itis nota complete control for medical morbidity. Fourth, although physicians diagnosed the physical i nesses, certain physical illnesses are based more on sel reported data (eg, arthritis) than others eg, diabetes). Thus, some of the associations found in the current study may be biased by overreporting of physical symptoms in anx- tous patients, Finally, although the respondents to the sue- vey did not differ significantly from nonrespondents on several variables, response to the survey may nonetheless be a potential source of selection bias (©2000 American Medical Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/intemed/SS60/ on 06/09/2017Inconclusion, the current study demonstrated that anxi- ety disorders are uniquely associated with several physi- cal health conditions in the community, and this comor~ bidity is itself associated with poorer functional outcomes, In combination with recent data demonstrating that anxi- ety disorders are risk factors for suicidal behavior,” the ‘current study suggests that anxiety disorders should be com sidered an important public health problem in the com- munity. During the last decade, efforts have been substan- Lally inereased to improve recognition and treatment of | depression in general practice Similar elforts should be Goodin RD Davison A Stepored dete andpastraumat sess ds nde among ats inte commit. Prev Med 200540570574 Goodin RO, Sten MB. Generale arity sore ard papules sex ‘avon fut inthe Unio Sts, Psjtasom Med, 2025882486, Grodin RD. Stepney tee and pani atk ecm, Aan Alergy Ati rol 200 38555 59 onlin Dob, Tel Mol dors andastnanthecariuny ‘Ach Gen Psychiatry 2008501125110. ‘Serbo CD, Wel KB, Ju LL Functoring and walling pions with panic dort, AJ Pyciny.196 59:218-218. Geobin AO. Oson Shea Sa Ast and mal dcr peeary are. Ge Hop Psych. 200825470488 ‘Gououin D,Atraandaiydsos. Ad Psychosom Med 2003245171 Strongly considered for anxiety disorders, "1. Honda K oad RD, Cave and mental orden nos community ‘sping oh atonal Comeriiy Save. Payot Pychosam, 7236202 “Accepted for Publication: July 12, 2006. 15, Mein L,Gondin RO, Cox. Depression and any azote ith ‘Correspondence: Jitender Sarcen, BSe, MD, FRCPC, PZ- thee pan condtons ests trom anaonalyeresenaie sal Pain 208 430-771 Bannatyne Ave, Winnipeg, Manitoba, Canada 4g, Kayachi Sparrow , Vokonas PS, Wess ST. Symptoms of anity and isk of RSE 3N4 (sareen@ec-umanitoba.ca. Author Contributions: Study concept and design: Sa- reen, Jacobi, and Cox. Acquisition of data: Jacobi. Analy- sis and interpretation of data: Sareen, Jacobi, Belik, Clara, and Stein. Drafting of the manuseripi: Sarcen and Clara, Critical revision of the manuseript for important intellec- ‘tal content Jacobi, Cox, Belik, and Stein. Statistical analy sis: Belik and Clara, Study supervision: Sareen, Financial Disclosure: None reported. ‘ear ert cies: te Nomate Aig Stuy. Ceulton 198 90225 na. nah Clit GA, schr A etal Prospective sty phobias and rio crenary heart dsease nen. Creuon 1004391802107 ‘Net (ML Chae CU, Reads Kk Manson Je, Kava | Phobc ani and Feketcrnay esr see nd suencrac cath aneng amen Con ous: 480.87 Senn HM, lace Karl 6, tl Hypa and ype in zy srr eve row daa aaa revien J Aft sod 202 e207 20, Set, Camu, Cvary Bok , Onn 8 Paing pos, Funding/Support: The GHS was supported by grant ‘rte yogis ca pats Hew ang PUTS OLEHO7OVS (German Fedral Mininiry of Research, Ed 21. Snugi Son’ ah Ress cp shin ae ses cation and Selence). Preparation of this article was sup- de and postaunate ses dcr ahr moran cen. xyeocan ported by a Manitoba Health Research Couneil Award (Dr Med 200286788-757 20. Ser her SoG Pstunat ss spnain chan Sareen), by US National Institutes of Health grant MH64122, (DrStein),and a Canada Research Chair award (Dr Cox) Additional Information: Mental disorders were as- sessed in the mental health supplement of the GHS (Max- Planck Institute of Psychiatry, Munich, Germany: prin- vith e-tiretnng aes, Chil Adee ayer Cn W Ar 200312 115.200. Hes Nipdk, GotechakLA Janus sy nd hap rng cue ft ferent melissa ty. PaychotePycosom, tsan4 212 Flack Insutute of Peychlaoy, Munich Germany; Prin- a. paw pth Osc? srs ap at pal investigator: HL) Wtichen) and physical cond {ay pena nad bens ns inthe core survey othe GHS Robert Koch Insitute, Ber- UAL eesin see wh dot bonds lin, Germany; principal investigators: B-M. Kurth, W. 25. Giga de ue Lian Peo Theleld). A public use le from the data set can be rset nae wt bers pune eer fe dered from'the second author Gacobl@peychologie S16 00. ene de 26 fe a Kanan Ge ess jas Lam rae ‘Acknowledgment: We thank Gregory E-Ratchife, BSc, (Bsa dese md ay ema ais 23 find Jina Pag, Bsc, for thelr thoughtful review of The, oe a phic ante manuscript —_ EES} Frasue Sit esperar FE epeson and eter psealgia sf ening myocar fron, Arch Gen Py, 208 6027-695 2, Stan Mf, Cox, BT, Bai SL, Saran! Carer epreseie neemag cal dardesnpatets wih json lps etme longi of ave and inacive sages of te Seas, Lopes 2035858 aly 28, Rogers UP, Wht, WachewG t Preaoe of mada as in a ‘ats with yore. nay ed 1004248396 28 Gilg $8, Hot AL, Man LL an Pet, Chine JM. Pehla di ‘rae nfs yoah wh tha, J Petr Psychol 20022736071, 20 Nasir NE, alenca AM eta. Pyeae odes thai ouiptens. yh Res. 2002110780. ‘este ingot scales: apopuaion usecpespecive Pjchalfed 3, Rmington LD Das OH Lowe, Penson MG, Rltonshipbtean ane, 2006 987-506, egrssin. and moti i abi aha pains, Thr 20156256 271 3. FasueSmih LespeanceF, Graal MassonAJunsuM, BousssaMG. SB. Vila, Nat lemancan , de Bi J Mourr-Sineors MO, Schsanzn Longtrm ural dfrences arog owas, igh-arcous and pes: Praia of DSW Vani and alive sordersina pada opustion ot tiv cours enliin th Morel Hit tack Readme Tal. Peo ‘sthnat chide rd ascent Disord 200038223281 om ed 20264571 57, <2 Harr MC. Cora KP, Merangas R Aascson ebveen anny srt 4. Thomas J Joes, Sari |, rare P-Adesepive and compariv study ‘ad pial es. Fur Ach Pjchiaty CMewse 20828831320, lth prates of dps and amy dorérsnlnincome du ih 34, Saren Cae 8. Clr Amundson GUE. Te latonep been Svity ‘ype 2dabete andar chronicles Dates Cae 2008262311291, disorders ad phys! crs he US, Maton Camery Sure, De 5, Sherburne Cason OA Meret LS, Canp P, We KB Preaencs fo ress Amity. 200521108202 ‘estat order i primary ete patie. Ach Fam Med 996: 96. Huong. Kapa J Kobe M.A naan personaly tase 527-34 ‘Staonal eee prospective sty amon. 00 ae. Alergy. 200 6 Wesbeg RE, Bruce SE, Macan J, esi RC Culpeper, Ker Ne sear, seat ess mong pinay care pains wih au hsorssandpst- 96. Onaga A, Huet SE, Carn 6 Raritz ube Sipec Mk Childboa aha, ‘tum sts sore. PaychitSare 20005398 454, (nepRaNTED) XRCHINTERN MEDVOL Tos, OCT 306 ‘rales ad psyehate src Jer Met Di 20218027528, (©2000 American Medical Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/intemed/SS60/ on 06/09/2017‘nga AN ontuin RO, Meus L Carin 6, Parental mal eh hi cd pyc doris and ata tacks initrd Pua an youth ‘rb Petr 20043083, ‘ge AN, MeDusE, Cnn 6, Goodwin Fit GX Comer of asthma tnd ait and dsrecson Panta Bicen chide. Peychosomates 20 250000, {8, Brson Limitations of appleaton of fourol ble anasto hosp dan mete 1461046753. Vis Pst of is. Sor Pantene 20027 15-161 Jah, Winzen HU Hating etl Esai preencs of mental and Sma dsorders nth commun: ais ard mates he erm onl oath re ané Eaminaton Suny Ie. Methods Peon Res. 200: 18 fvarde WS, Won Muah Val. Erato Meio Ht nr ew Survey DgrstReporing Hate, Me: onl Cnt fr Heth Siti, 104 6, Ameria Pychiatie Association. Dagroste ad Siti! Manca f Mena 14, Olson Mt St 4. 4 61 Dordrsthed Wash, DC: Artian Poet Asari, 108 Feder etal Pavalne of any, dpesion, sd at stznca use dsordes in an whan general edn practic. Ach Far Med aaon476-983, ‘Mayes SC, Osan M,incus WA Shar MX, Zin OA. Stepan any, eer media conn and dsabay bed dys. Ar J Pay. 197 ‘ser7eb768. Holl Kaeo W, Seppe BC. Ballenger J, Manu, FerAl. Pane sora ard quay ot le aa reve unetanal impale Ald Payehny 1007154766772 ‘faon Fireman, Wesman MM tal Met orders dss aang fawn aprnary ca group pracice An JP. B71 173-1740, Nisesan 6, Pepper CM, Scien TL, Coje. The nature 2d prevalence ot ny sores pinay exe. Ge Hsp Psychiatry 006202128 ‘oh Wnchen HU, Htng tl Praence comer and coes ‘mental ordain th oer population: es am he Geman Heath Imrie and Examination Suey (GH). Psyehl Med 200434597 511 Melorey C8, WareJE Rak AE Te DS 26-tm SorFrm Hos Su ‘wy (S36 payee and cla este of aly nrg physical ed mana cont, Med Care 1R5.1:27-253, Sehr Tl Kae. Mental sada and hyperansinatass- Sate wih avarones ard eaten of hyperenin he general pap anf Geman. Psychosom Med 200658246 252 See, re J Kol Dabs, quay ft, ane marl odes soda wih smaking and icine dependence. Aa J Pach. 208; ‘ote7ote76. Chatson ME, Pomp, As KL, Mack OR. Anu mead csiing ogres como in engin sus: developmen até valdston ‘Sovran is 10870-5728 ‘54 Oharton Mf Soon TP Petes J ol Valo of camino ‘moti Cn pei 196 7145-1251 55, Pompe P Charson ME, Douglas Gc Cnc assessmens as praetor of s one er suv ater hasiazaon:implexions or pegose sraeston. Jin Eien. 14s 275-28 sy A, Orv, ats OW, Sarat icreases mail uiizatin and costs independent pee and medial omar, Ach Gen Py aos e2a03 1, ‘eJonge, Orel van den rik RH et Sygtom dines of eps Sin folowing myecara trcbon and ha reabonship with soma haath Stas and cane pagoss. A J Psych 2006163 18-14 esl Uti TB The Wart Mtl Hey (WH uray nate Ver sin ofthe Wer et Asecinion (HHO) Corps nerairal Diagos- ie lnerien(I). ne Memos sca Res 2001398121 sa o @ cs @. Witches HU Lane 6, Wundeti , Pst, Tstaet ality othe ‘ampli DS version oh Munk Compe erntonl Dap tie lneriw (W-ID). Sac Pacha Psychiatrie. 1008; 68.578 Bullngerl nso, Aplne st Taneting eth te quaeoaes snd tating te ual OLA Projet appesh, J ln Ee. 106 srai3an3, Hopman WA, Toutes , Anastasia T, ta Canadian noma dt far ‘the S35 ath Sune. C4, 2000 163288-271. ese RE, Orme Dae, Sang PE. Comat mental orders accourt {othe oe impatent of onon ezurng cron ysl disorders: Suro th latiral Conary Sure 4 Ocyp Enon Med 20035 1257-1286. Seen, Sin MB, Cox, Heard ST. Understanding comet sity ‘srr ae anos behav: ings tom a age communty ures ere ten Oe 200410257866, ‘evar AL, Hye, Ware, The MOS Short Frm anal sat Sune Init and ayn pase pop. Md Cae. 1988 26728-722, Nevo) CA Ware JE, Lu FR, Shou CD The MOS 36am Shor: Form Heath Suny (SF 20) ste of atautyesing assamptons and easter pant groups. Med Care. 184 3040-6. ‘Ware Jed; KesinslM, Gnd The star stucreth SF-36 Heat Srey 1 eas ret am te 1O0LA Projet Inti ot Lie aSsssnsnt_ Jin neil 1065:1150-165, Gooden AD, Sin Pot er dseasandnertismin te iad Sass ‘lt populaon. shah Pychoom, 208721015. (68 Goon RD, ie DS Resp esas and parc atars among acu in the Unie Stes, Ces 2021224550, 68 Kevaeka PA Hoven CW, Wu , Wik J Mandl, Tt Assocation be 7, n 2 a 4 % %. 0. 7 (nepRaNTED) XRCHINTERN MED VOL Tos, OCT 306 ‘wen argon ary sordsin youth. Ast WZ J Pj 200 35: i501 elias LA Coc, Ene MM. Mondand aire asec ith ‘rapa: an amin na rately epesetzive sal. Pa. 2008; foster at Roose SP. Depression, ane, and te crdoasclr system: he poy tus perp. Jin Pech 2062p 8) 1022, Gown Fee Catan J Fea habs paola ith abt. Dab tas Metab es Rey, 200016287208, Goadvin RD, Hoven CW, Marsan, Hrpt Mt Asocsion toon chdhood physi abuse nd gstonestnal orders and maine in aha, An J Pub ath, 20080:1065-107 Grodvin RDS IB. Aseoiton vee cidhea aura ad ysl s- ‘des among ats int United Sates. Pjohol ed 2004 4509 520, Katoo Wi Retardson, Lozano, MeCaseyE Tha eloship fasta ‘aay orders. Pojchosam led 200438 31035, Keeler RC Chu WT, Demi O, Ware E, Pavano, ery an omar: tidy of 2-month SHY rcs ote Hina Comority Survey plain. Ach Gn Pacha. 20055261767. eter RO, args, Waters Pravaece of an itr for esma su ‘ede tugs ite Nana Comer Survey. Ach Gn sent 1986 Ses17-26 Kesler RE, Sang, Wchen HU, Shin MB, Waters E.Liteime conor 5 batvoen oil pobiz ard oad sede inthe US. Nata amar Srey Pst Me 100920555 557 Saran J CoxB, RTO al. nity sors and is fr sul ition snd suis tata populaton eden yf dt. rch en Psyenay. 2005621240257 Panne MP. Goes BU, Rshian Je. Seening ord Suna ofthe eden fortheSPrewrve ences tu 2002.12665-76. joni atte: Fare An (©2000 American Medical Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/intemed/SS60/ on 06/09/2017