Preventive behavior and awareness of myocardial infraction: A factorial definition of anxiety

Journal of Psychosomatic Research, Vol. 21, pp. 213 to 223. Pergamon Press, 1977. Printed in Great Britain

PREVENTIVE BEHAVIOR A N D AWARENESS OF MYOCARDIAL INFARCTION: A FACTORIAL DEFINITION OF ANXIETY* MARIE-JEANNE SEGERS~" and CHARLES MERa'ENS Abstract--The ways of organizing anxiety are approached as a function of various dimensions of CHD: information about risk factors and certainty of illness (MI patients), information about risks and uncertainty of illness (healthy volunteers for a medical check-up), and lack of actual concern for illness (healthy control individuals). A factor analysis of the Anxiety Scale Questionnaire items and the testing of the factorial solution invariance from sample to sample indicate a lack of congruence among the three ASQ factorial structures. The factorial solutions of the three groups reveal that awareness of myocardial infarction and preventive behavior are differentially associated with distinctive patterns of anxiety and with specific defense mechanisms. This finding contributes to consider "anxiety" not only as a CHD risk factor, but as a motivational factor that could impel individuals to prevent or to deal early with the disease. EMOTIONAL adjustment is considered to be the core feature o f social and psychological risk factors o f C o r o n a r y Heart Disease ( C H D ) [1, 2]. This adjustment has different aspects which are labelled largely in accordance with the methods used for their assessment [3-5]. "Anxiety", evaluated by the Anxiety Scale Questionnaire (ASQ) [6], has been the focus o f our previous research. As convergence o f methodologies is not proven [7], and as instrument variance can account for some o f the observed results [8], the present study is also limited to the ASQ. A c o m m o n hypothesis in the field o f C H D etiology, is that anxiety is a risk factor; this hypothesis has been confirmed m a n y times [9]. As was demonstrated by Ostfeld, Lebovits, Shekelle, and Paul [10], individuals who develop C H D , score, before the onset o f symptoms, higher on some anxiety subscales (L--Suspiciousness and C - Emotional Instability) than individuals who remain healthy. In addition, these anxiety components are differentially associated with myocardial infarction (MI) and with angina pectoris. This finding has been later supported by Bakker and Levenson [l 1], and by Graulich, Segers, Mertens, and Vastesaeger [12]. Anxiety is also a risk factor because the A S Q scores correlate significantly with biological and clinical parameters o f risk. Significant correlations have been found within a large sample o f volunteers for a preventive examination [13] between the ASQ, blood lipids, and arterial blood pressure, when sex and age [14], relative weight [15], and exercise [16] were taken into account as moderator variables. Other significant relationships were observed by Pilowsky, Spalding, Shaw, and K o r n e r [17] between A S Q subscales and heart rate at rest, diastolic blood pressure, and peripheral resistance. Finally, Harburg et aL [18] found that the L subscale and the overall anxiety are significant correlates o f systolic blood pressure. In spite o f the convergence o f these results through the A S Q instrument, further research demonstrates that the relationships between anxiety and the disease are more *From the Department of Medical Psychology, University of Louvain, Brussels, Belgium. This study was supported by the Fonds de la Recherche Scientifique M6dicale (Belgium), Grant No. 3.4594.75. 1"Requests for reprints should be sent to Dr. M. J. Segers, UCL 5389, avenue Mounier 53, B-1200Bruxelles, Belgium. 213

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MARIE-JEANNE SEGERS and CHARLES MERTENS

complex than was initially suspected. Although the "negative" status of anxiety as a C H D risk factor is commonly accepted, there remains the possibility that anxiety is at the same time, or alternately, a "positive" trait of personality in the sense that it motivates people to prevent or to deal early with the disease. Across all ages studied, Segers, Graulich, and Mertens [19] found that MI patients, from the volunteer sample mentioned above, who had previously consulted about their heart were more anxious than the MI patients who had not. Although the heightened anxiety level can be interpreted as the result of the patients' awareness of their illness, this finding, along with Derrick's [20] observation that more anxious individuals tend to visit the doctor more frequently than less anxious individuals, has been leading to the interpretation that anxiety might be viewed not only as a risk factor or as a product of the disease, but as a pre-existing motivational factor that impels anxious individuals to seek out proper medical treatment [9]. A complementary aspect of this interpretatation is suggested by an avenue of research on pre-surgery anxiety [21-23], which indicates that a thoroughly informative approach has a lowering effect on anxiety. In order to clarify the complex relationships between anxiety and the disease, the present research is aimed at differentiating from a psychological point of view two components of CHD: sickness itself and concern about sickness. The facts that (1) among the volunteers for a medical check-up, the MI patients who are aware of their illness are more anxious than the MI individuals who do not yet know they are ill, and that (2) both aware and unaware patients are more anxious than healthy volunteers led to the present hypothesis that anxiety initiates preventive and/or curative behavior. An alternative hypothesis, that information related to CHD risks or symptoms heightens anxiety, requires comparison with a healthy control group free of C H D concern. In order to clarify the assumption of the initiating function of anxiety, in a naturally occurring situation three groups of 30 males, matched for age and socioeconomic status, have been compared in a quasi-experimental design: information about risks and certainty of illness (MI patients); information about risks and uncertainty of illness (healthy volunteers); and, absence of information and of actual concern for illness (healthy control individuals). It was already observed in a previous study [24], that the anxiety levels, although the highest among M! patients, did not significantly differentiate the three groups. However, examination of the response styles to the questionnaire revealed that each group had distinctive response patterns, and that they were significantly different in this respect. These findings suggested that, even if overall anxiety levels were comparable, substantial differences may exist among the three groups, in the way anxiety is expressed. Cattell, Eber and Tatsuoka [25] suggest this comparison of anxiety levels as a first approach in ascertaining differences among groups for a personality trait. It uses the scores based on the first-order (anxiety subscales) and second-order (overall anxiety) factors which are supposed to tap the true structure of the trait. The second, and complementary, procedure suggested by Cattell, Eber and Tatsuoka [25] to evaluate group differences is used in this study. It consists of a factor analysis of the questionnaire items and testing the factorial solution invariance from sample to sample. It has been observed by a number of investigators that the kind of differentiation that appears among a group of items vary from one population to the other. This is because, such factor analysis, i.e. of a fixed set of variables from sample to sample, does not reveal the true structure of the trait, but that it reveals "the kinds

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o f similarities p e r c e i v e d b y a p a r t i c u l a r g r o u p o f subjects f o r a p a r t i c u l a r s e l e c t i o n o f i t e m s " [26]. T h i s p r o c e d u r e m a k e s it p o s s i b l e to o b s e r v e the specific o r g a n i z a t i o n o f a n x i e t y o f e a c h g r o u p , t h a t is, the s t r u c t u r e o f t h e i r o w n a n x i e t y d i m e n s i o n s . I n the p r e s e n t study the f o r t y i t e m s o f the A S Q are f a c t o r a n a l y z e d s e p a r a t e l y f o r t h e sick v o l u n t e e r s , the h e a l t h y v o l u n t e e r s , a n d t h e h e a l t h y c o n t r o l subjects. T h i s a p p r o a c h is a i m e d at f u r t h e r e v a l u a t i n g t h e h y p o t h e s i z e d difference in a n x i e t y a n d t h e w a y it is expressed, as a f u n c t i o n o f p r e v e n t i v e b e h a v i o r a n d a w a r e n e s s o f M I s y m p t o m s . METHOD Material The ASQ is a 40 items personality inventory of the true-false or agree-disagree type, with a threestep response scale. The 40 items are presented in Table 1. The French version of the questionnaire is put to the subjects with the standard instructions, except that a seven-step response scale is used in order to allow a better differentiation of responses [27]. The scoring key of the questionnaire remains the same. The belonging of the items to the five original ASQ subscales (Q3, C, L, O, Q4) and the scoring direction for anxiety of the items which are detailed in the recent ASQ handbook [9], are taken into account. These characteristics of the items are indeed, besides the content, susceptible to being responsible for the factorial solutions observed. Subjects Three samples of 30 males each were gathered, with age and soeio-economic status controlled. The first sample is composed of outpatients from private physicians; they all exhibit clinical or EKG symptoms of myocardial infarction, and knew that they were ill. The second sample is composed of CHD symptom-free subjects, randomly selected among the 7,500 employees who volunteered for an atherosclerosis detection campaign 112-16]. The third sample, a control group, is composed of healthy employees from a Belgian organization who had never consulted about their heart condition. Treatment of the data The inter-items correlation matrices were computed for each group separately. A Principal Factor solution, with highest correlations as communality values, was stopped after 10 factors; thereafter they were rotated orthogonally (Varimax) in order to take advantage of the invariance of this solution [28]. Factors identification and interpretation is realized on Varimax solutions. The extent of agreement among the factors was evaluated by the coefficient of congruence developed by Wrigley and Neuhaus [29] for a fixed set of variables from different samples. The coefficients of congruence values range from + 1 to --1 for perfect agreement and perfect inverse agreement, respectively. Each factor from each solution was compared with the other ones, and was paired with the factor with which it has the highest coefficient of congruence [30]. RESULTS The most striking result is that there is no invariance among the three factorial solutions. The coefficient of congruence indicates few, and furthermore weak, similarities. Among the factors retained, there are three agreeing, and one inversely agreeing, pairs of factors. Agreements are mainly observed between the MI and healthy volunteer solutions, i.e. Factor I from the latter is congruent with MI Factor II (0.608) and Factor IV (0.610); this very same Factor I is to a certain extent opposite to MI Factor V (--0.630). Between the MI solution and the control one, there is only one congruent pair of factors; it concerns both Factors II of these solutions (0.668). Finally, there is no agreement, or opposition, at all between the healthy volunteers and the control solutions. This relative lack of similarity among the factorial solutions, which strongly supports our hypothesis, indicates that there exists for each group distinctive perceptible dimensions in the ASQ; this is however less clear-cut for MI patients and healthy volunteers who have some characteristics in common. Therefore, we will describe the factorial solutions for the three groups, and then discuss the common characteristics of the paired factors. M1patients Table 2 gives the five interpretable factors with their salient loadings. In this table, the items are indicated by their identification number (see Table 1), subscale belonging (Q3, C, L, O, Q4), and keyed position of scoring. Taken together, the five factors extract 62.32~ of the variance of the initial communalities.

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MARIE-JEANNE SEGERS and CHARLES MERTENS TABLE 1.--ASQ ITEMS

1. 2. 3. 4. 5.

I find that my interests, in people and amusements, tend to change fairly rapidly. If people think poorly of me I can still go on quite serenely in my own mind. I like to wait till I am sure that what I am saying is correct, before I put forward an argument. I am inclined to let my actions get swayed by feelings of jealousy. I f I had my life to live over again I would: (A) plan very differently, (B) want it the same. 6. I admire my parents in all important matters. 7. 1 find it hard to "take 'no' for an answer", even when I know what I ask is impossible. 8. I doubt the honesty of people who are more friendly than I would naturally expect them to be. 9. In demanding and enforcing obedience my parents (or guardians) were: (A) always very reasonable, (B) often unreasonable. 10. I need my friends more than they seem to need me. 11. I feel sure that I could "pull myself together" to deal with an emergency. 12. As a child 1 was afraid of the dark. 13. People sometimes tell me that I show my excitement in voice and manner too obviously. 14. If people take advantage of my friendliness I: (A) soon forget and forgive, (B) resent it and hold it against them. 15. I find myself upset rather than helped by the kind of personal criticism that many people make. 16. Often I get angry with people too quickly. 17. I feel restless as if I want something but do not know what. 18. I sometimes doubt whether people I am talking to are really interested in what I am saying. 19. I have always been free from any vague feelings of ill-health, such as obscure pains, digestive upsets, awareness of heart action, etc. 20. In discussion with some people, I get so annoyed that I can hardly trust myself to speak. 21. Through getting tense I use up more energy than most people in getting things done. 22. I make a point of not being absent-minded or forgetful of details. 23. However difficult and unpleasant the obstacles, I always stick to my original intentions. 24. I tend to get over-excited and "rattled" in upsetting situations. 25. I occasionally have vivid dreams that disturb my sleep. 26. I always have enough energy when faced with difficulties. 27. I sometimes feel compelled to count things for no particular purpose. 28. Most people are a little queer mentally, though they do not like to admit it. 29. If I make an awkward social mistake I can soon forget it. 30. I feel grouchy and just do not want to see people: (A) occasionally, (B) rather often. 31. I am brought almost to tears by having things go wrong. 32. In the midst of social groups I am nevertheless sometimes overcome by feelings of loneliness and worthlessness. 33. I wake in the night and, through worry, have some difficulty in sleeping again. 34. My spirits generally stay high no matter how many troubles I meet. 35. I sometimes get feelings of guilt or remorse over quite small matters. 36. My nerves get on edge so that certain sounds, e.g. a screechy hinge, are unbearable and give me the shivers. 37. If something badly upsets me 1 generally calm down again quite quickly. 38. I tend to tremble or perspire when I think of a difficult task ahead. 39. 1 usually fall asleep quickly, in a few minutes, when 1 go to bed. 40. I sometimes get in a state of tension or turmoil as I think over my recent concerns and interests. Factor 1 accounts for 15.29~ of the variance. Examination of this factor reveals no particular consistency in either subscales assignment orkeyed direction, the latter being more frequently acquiescent however. The items defining this factor are definitely oriented toward manifest anxiety: upset by personal criticism, sleep disturbed by dreams and worries, annoyed in discussion, difficulty in calming down, feelings of guilt and remorse, restlessness and vigilance over details. This manifest anxiety mainly has a social origin, and is accompanied by guilt and some efforts toward mastering the situation. We have labelled this Factor Ego-vulnerability inducing arousal and some reaction formation. Factor 11 accounts for 14.14~0 of the variance. It contains items that pertain to paranoid (L) and aggressive (Q4) trends; doubt about other people's honesty, tendency to get angry quickly, excessive concern for social mistakes and recent interests, i.e. cognitive awareness elements related as in Factor I to interpersonal relations. There are also tension items like loss of energy through getting tense and

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restlessness; finally, there are cognitive control elements: cautiousness with own arguments and compulsive counting. This factor reveals two defense processes:projection of aggression and obsessional self-control, which are also induced by ego vulnerability and the partial inability to alleviate anxiety. Factor III accounts for 13.62 7o of the variance. The outstanding feature of this factor is that almost all its items reflect a favourable self-image achieved through self-control and energy. The essential elements of this factor are: the ability to "pull oneself together", to be in high spirits, to keep one's presence of mind, unforgetful and always full of energy. On the other hand, there is a certain amount of effort at control over impulses in the items of compulsive counting, control over arguments, difficulty to admit 'no' for an answer, and influence of feelings of jealousy. Obsessional control and denial appear as the main components of this factor where fear of depersonalization and frustration seem to be the major concerns. TABLE 2.--ASQ FACTORIALSTRUCTURE (VARIMAX)IN MI PATIENTS(LOADINGS > 0.400) NO. of item

Loading

Factor 1 (15.2970) 15. 0.691 25 0.682 20 0.630 2 0.610 37 0.550 35 0.545 33 0.529 17 0.499 22 0.439 Factor II (14.14~o) 8 -0.730 16 --0.677 29 -0.610 40 --0.583 21 -0576 14 -0.547 17 --0.433 3 --0.431 27 --0.424

ASQ subscale O C(--) Q~ Q3(-) Q4 O O Q4 Q3(-) L Q4 L Q4 Q3(-) O Qa Q~(-) C(--)

Keyed position 7+ ÷ -~-~ -r -~ + -+ -~ A + -~

No. of item

ASQ Subscale

Keyed position

Factor III (13.627o) 11 0.788 34 0.595 22 0.560 26 0.483 27 0.481 3 0.457 7 0.448 4 0.420

O O Q3(-) C(-) C(-) Q3(-) C(--) Q3(-)

--q-b -b

Factor IV (9.96 7o) 39 0.738 36 0.660 5 0.656 28 0.512 34 0.411

Q4 Q4 C(-) L O

qA -k -

Factor V (9.31 ~o) 13 -0.839 24 -0.685 14 --0.417 27 --0.412

O Q~(-) O C(--)

q+ A +

Loading

Factor IV is still responsible for 9.967o of the variance. It contains elements of arousal and oversensitivity to stimuli: difficulties in falling asleep, and nerves getting on edge, e.g. from certain sounds. This factor includes also dissatisfaction with past life, belief in most people's queerness, and confidence in one's high spirits. Free-floating anxiety, dissatisfaction, and rumination are the major components of this factor which stems from an hysteroid pattern associated with introversion. Factor V accounts for 9.31 ~ of the variance. Inspection of it indicates that keyed positions are in the agreeing direction only. The items defining this factor are: excitement in voice and manner, the tendency to get over-excited in upsetting situations, forgiveness when one's friendliness is abused, and compulsive counting. This factor stands for investment of anxiety (anxiety equivalents) originating in dependency and associated with obsessional control. Three major features seem recurrent in the patterning of anxiety among MI patients : ego vulnerability (Factors I, II, Ill, IV), anxiety (Factors I, II, IV, V) and obsessional control (Factors II, III, V).

Healthy volunteers The factor analysis and rotation reveal four factors that account for 64.06 ~ of the variance. Factor I (Table 3) extracts as much as 25.74 ~o of the variance. The items that define this factor are all keyed in the agreeing direction, except item 6 which is false-keyed but has a negative loading; acquiescence thus is predominant in this factor. It contains a cluster of dysphoric items: dissatisfaction with past life, feelings of guilt and remorse, feelings of loneliness and worthlessness and lack of trust in discussion. Elements of arousal and irritability come out in getting on edge through hearing things, over-excitement in upsetting situations, restlessness, and excessive concern for recent interests. There are also physiological disturbances such as trembling and perspiring, as well as irritability at

218

MARIE-JEANNE SEGERS a n d CHARLES MERTENS TABLE 3. ASQ FACTORIAL STRUCTURE (VARIMAX) IN HEALTHY VOLUNTEERS FOR A PREVENTIVE EXAMINATION (LOADINGS > 0.400)

No. of item Loading Factor I (25.74~) 5 0.702 36 0.672 35 0.665 24 0.651 17 0.638 32 0.605 38 0.573 15 0.530 40 0.529 20 0.511 6 -0.477 8 0.443

ASQ Subscale

Keyed position

C(--) Q4 O Q3(-) Q4 O Q4 O Q4 Q4 c(-) L

A + + + + + + + + ÷ +

No. of item Loading Factor II (14.22 ~ ) 37 0.640 39 0.579 11 0.531 33 0.453 2 0.446 21 0.434 26 0.415

ASQ Subscale

Keyed position

Q4 Q4 O O Q~ Qa C(-)

+ + -

Factor III (13.31 ~ ) 26 0.715 7 --0.591 23 0.495 27 0.439 8 --0.403

C(--) L C(--) C(--) L

-q-F +

Factor IV (10.79 ~ ) 1 0.566 13 -0.535 8 0.469

Q8 O L

+ + -I-

criticism and suspicion in the doubt about people's honesty. This set of items could be a prodromal phase of a syndrome that could develop into acute anxiety or depression. Manifest neurotic anxiety is overwhelming in this first factor: it stems from ego vulnerability which is coped with through reaction formation, paranoid projection, and somatic anxiety equivalents. Factor II accounts for 14.22~ of the variance. In most of the items which define this factor, the disagreeing response is the high anxiety alternative. The respondent who answers 'no' to these questions defines himself as being tense: difficulties in calming down, in falling asleep, in going on serenely in mind, in getting things done. This cluster of worries is associated with feelings of powerlessness: doubt about being able to "pull oneself together" or having enough energy when facing difficulties. This factor deals with manifest anxiety of a rather psychotic nature with powerlessness as a reaction formation. Factor III extracts 13.31 ~ of the variance. It is a bipolar factor defined by three items belonging to the Ego Weakness (C--) subscale; they have positive loadings, two of them are keyed in the disagreeing direction, while the last one is keyed in the agreeing direction. These items concern lack of energy, lack of perseverance, and compulsive counting. Two positively keyed items have negative loadings; they pertain to the Suspiciousness (L)subscale: unwillingness to accept negative answers, and doubts about people's honesty. Ego weakness predominates in this factor which also deals with dependency and paranoid trends. The last Factor IV, with 10.79 ~ of the variance, is composed of three items, which are difficult to interpret. The essential elements are rapidly changing interests, manifest excitement (with a negative loading) and suspicion about people's honesty. Withdrawal as a reaction formation characterizes this factor. Four major components appear in the pattern of healthy volunteers: manifest anxiety (Factors i, II), dependency-withdrawal (Factors I, III, IV), and reaction formation (Factors I, II, III, IV); anxiety equivalents (Factor I) are much less prominent in this pattern than in the MI group.

Control subjects The factor analysis and rotation reveal five factors that account for 62.66 ~ of the variance (Table 4) Factor I accounts for 19.92 ~o of the variance. The items defining this factor are pertaining to feelings of irritability and arousal: becoming upset at personal criticism, getting angry quickly, restlessness, over-excitement and annoyance in discussion with people. There are also worries like feelings of guilt or remorse, and also a degree of withdrawal: no admiration for parents, lack of perseverance in intentions, feelings of jealousy. This subjective component of anxiety thus has impulsive and depressive tones. Factor I reveals mainly social vulnerability with some alertness; anxiety is coped with through anger and keeping distant from the object.

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TABLE 4. ASQ FACTORIALSTRUCTURE(VAR~MAX)IN CONTROLINDIVmUALS(LOADINGS > 0.400) No. of item Loading Factor I (19.92~0) 15 0.799 35 0.768 6 0.750 16 0.642 17 0.613 24 0.503 23 0.500 20 0.491 4 0.473 Factor II (17.09 ~ ) 37 0.816 29 0.701 13 0.670 34 0.660 19 0.615 14 0.571 31 0.428

ASQ Subscale

Keyed position

O O C(--) Q4 Q4 Q3(-) Qs(-) Q4 Qs(-)

+ -f-+ + + + +

Q4 L O O Q4 O O

-+ -A ÷

No .of item Loading Factor III (12.59~) 26 --0.797 11 --0.622 4 0.559 5 -0.510 21 0.495 23 -0.457

ASQ Subscale

Keyed position

C(--) O Q3 C(-) Qz(-) Qs(-)

---k A + -

Factor IV (12.13 ~ ) 38 0.732 32 0.658 27 0.604 18 0.429

Q4 O C Q4

-b ÷ + q-

Factor V (10.93 70) 1 0.689 8 0.530 36 0.520 31 -0.508 32 --0.464

Q3(-) L Q4 C(-) C(--)

+ qq+ +

Factor II accounts for 17.09~o of the variance. It includes items related to the failure in mastering impulses and inner tension: difficulties in calming down when upset, in forgetting one's own social mistakes, in controlling overt expression of excitement. There are also elements of primary arousal in feelings of ill-health and being brought to tears. These somatic components are accompanied by a dysphoric content such as low spirits and by low self-confidence such as forgetting people's abuses of one's friendliness. Hysteroid depression emerges in this Factor being shown by relational anxiety, dependency and an outspoken trend to express anxiety. Self-disparagement is used to prevent a demanding attitude. Factor III is responsible for 12.59% of the variance. Its items have both negative and positive Ioadings, suggesting a bipolar dimension: however the direction of the loadings parallels the keyed direction of the items. The outstanding feature of this pattern is powerfulness as in always having enough energy, assurance to be able to "pull oneself together" and a tendency to use up more energy than most people. There are also elements of perseverance: to wish life to be the same if it had to be lived over again, and to stick always to original intentions. Finally, there is the item concerning actions swayed by feelings of jealousy. Both a trend for rivalry associated with anxiety and a strong defense against this anxiety by use of self-disparagement appear here. Factor IV, with 12.13 ~ of the variance, is defined by somatic elements of anxiety: trembling and perspMng when anticipating a difficult task; it is also defined by lack of self-confidence as in feelings of loneliness or worthlessness, and in a conviction of being uninteresting; finally, there is the item concerned with compulsive counting. In Factor V, achievement motivation induces anxiety equivalents (somatization), self-disparagement and compulsive control. Factor V accounts for 10.93 ~ of the variance. It is characterized by positively loaded items such as rapidly changing interests, doubts about people's friendliness, oversensitivity to sounds. This factor also includes negatively loaded items: not being brought to tears and never being overwhelmed by feelings of loneliness or worthlessness. An ambivalent trend for dependency is obvious in this bipolar factor; there is either a withdrawal associated with anxiety or a need for showing one's own weaknesses. Three major patterns are recurrent in the control group. Although highly inclined to be dependent (Factors I, II, V) or to achieve their goals (Factors III, IV), these subjects lay aside those drives (Factors I, III, IV, V) and remain nevertheless much less anxious than the two other groups. Behavioral defenses are highly recurrent in this pattern (Factors I, II, III, IV). DISCUSSION This study strongly suggests that distinctive factorial structures of anxiety are a s s o c i a t e d w i t h i n f o r m a t i o n a b o u t C H D r i s k f a c t o r s a n d c e r t a i n t y o f illness ( M I

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MARIE-JEANNE SEGERSand CHARLES MERTENS

patients), with information about risks and uncertainty of illness (healthy volunteers for a medical check-up), and with lack of actual concern for illness (healthy control individuals). The lack of congruence among the ASQ factorial structures of these groups, matched for age and socio-economic status, occurs even though the groups previously displayed no statistically significant differences in anxiety levels, but used distinctive response styles to the anxiety questionnaire [24], i.e. different defense mechanisms. Since different kinds of similarities are perceived within the ASQ items, the present results suggest that there are different ways of organizing anxiety as a function of the dimensions of illness approached in this study. In MI patients, who are informed about risks, who are certain they are ill and who manifest a curative behavior, five salient dimensions compose the "implicit" factorial definition of anxiety. They are: (1) social vulnerability of the ego inducing arousal and reaction formation, e.g. efforts for control, depressive thoughts (Factor I); (2) projection of aggression and obsessional self-control induced by ego vulnerability and partial inability to alleviate anxiety (Factor II, which is moderately congruent with Factor I of the healthy volunteers, and with Factor II of control subjects); (3) obsessional control and denial with fear of depersonalization and frustration as major concerns (Factor III); (4) free-floating anxiety, dissatisfaction and rumination as an hysteroid pattern associated with introversion (Factor IV, moderately congruent with Factor I of healthy volunteers); and (5) anxiety equivalents originating in dependency and associated with obsessional control (Factor V, opposite to Factor I of healthy volunteers). In healthy volunteers for a CHD preventive examination who are informed of risks and who apprehend a diagnosis and are therefore uncertain, the factorial structure is defined by four dimensions: (1) manifest anxiety with ego vulnerability, reaction formation, paranoid projection, and somatic anxiety equivalents (Factor I, moderately congruent with MI Factors II and IV, and opposite to Factor V); (2) manifest anxiety of a rather psychotic nature associated with powerlessness (Factor II); (3) ego weakness with dependency and paranoid trends (Factor III); and (4) withdrawal as a reaction formation (Factor V). In healthy control subjects who are actually free from risks or concern about illness, five dimensions mainly define the factorial solution: (1) social vulnerability and alertness coped with by anger and by keeping distant from the object (Factor I); (2) hysteroid depression and relational anxiety with dependency and self-disparagement (Factor II, moderately congruent with MI Factor II); (3) rivalry stemming from achievement motivation and associated with anxiety and self-disparagement as a defense mechanism (Factor III); (4) achievement motivation inducing anxiety equivalents, e.g. somatization and compulsive control (Factor IV); and (5) dependency with either withdrawal or overtly manifested powerlessness (Factor V). The coefficients of congruence among the factorial structures indicate that the MI patients have two dimensions in common with and one opposite to the healthy volunteers. They have also one dimension in common with the healthy control. The general meaning of these findings seems to be that the MI pattern of anxiety, although distinct from the other ones, is in some way in-between that of the healthy volunteers and that of the control, in that they have overlapping dimensions, while healthy volunteers and control subjects have no congruent factors in common. Furthermore, as examination of the factorial solutions shows, the healthy volunteers are demanding (ego

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weakness and powerlessness) and overtly express an undifferentiated anxiety. In contrast, MI patients and healthy controls have different but highly structured anxiety patterns, as far as the origin of anxiety, the coping mechanisms, and the behavioral manifestations of anxiety are concerned. In the groups considered in this study, and particularly the MI patients and the healthy volunteers, the respective factorial definitions of anxiety can be interpreted as evidencing their actual way of coping with anxiety in real situations, i.e. certainty and concern, uncertainty and concern, respectively. Their factorial definitions of anxiety clearly reveal distinctive patterns for the two groups. MI patients though vulnerable as far as their self-image is concerned, do manifest defense mechanisms such as obsessional self-control. The healthy volunteers, on the other hand, express undifferentiated anxiety with a strong desire for dependency, that is for being helped, by presenting themselves as weak, powerless and somatizating. The control subjects, by contrast, organize their anxiety around achievement motivation, and though inclined to be dependent, express a high number of behavioral defenses. In a broaderconceptual model, this study can be conceived of as reaching, in everyday life, some of the most fundamental aspects of stressful situations which are usually evaluated in experimental settings: certainty of illness and uncertainty of diagnosis or anticipation [31, 32] of illness, active coping in looking for curative or preventive counseling [33], and concern or involvement with health. It also deals with what is considered the most important feature of stress reactivity, that is the cognitive coping processes [34] which are evidenced here in the main dimensions of the factorial structure of anxiety. Awareness of myocardial infarction and preventive behavior are differentially associated with specific factorial definition of anxiety and with specific defense mechanisms. As is suggested by Mechanic [35], the nature of the anxiety organization and of the cognitive coping processes may influence the evolution of the disease, e.g. leading the individual to consult early. It should also be kept in mind that patterns of anxiety and of coping processes result from the structure of personality, aspects of which have been demonstrated to be pathogenic [10, 11]. The personality is probably associated with differential physiological patterns of reactivity, but seems also to influence attitudes and behavior toward health. Because of the complexity of these psychological processes which act in feedback circuits following the adaptive model "emotion-cognitive coping--behavioral coping", and because of the complexity of their relations with the onset and the evolution of the disease [35], more research efforts ought to be centered on the organization of anxiety and its relationship to cognitive and behavioral coping in naturally occurring situations. Though such topics are widely investigated in experimental settings, much difficulty is commonly encountered in coordinating or generalizing for clinical purposes so many seemingly unrelated elements. Acknowledgement--Thanks are due to Mr A. Hooper for helping us in revising this text.

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