Low prevalence of disability among patients with inflammatory bowel diseases a decade after diagnosis.

BACKGROUND & AIMS: Disability is defined by chronic limitations that preclude the ability to engage in usual daily activities. Studies of disability in patients with inflammatory bowel disease (IBD) have focused on work and employment, with few descriptions of more general disability among multiple domains. We examined disability and the factors associated with it a decade after diagnosis in a population-based cohort of IBD patients. METHODS: We interviewed 125 patients with Crohn's disease (CD) and 119 with ulcerative colitis (UC) from the population-based Manitoba IBD Cohort study a median of 12.3 years after diagnosis. Disability was assessed by using 2 validated measures. Disease activity was assessed semiannually, and long-term activity was defined as symptoms of active IBD at more than 65% of semiannual assessments. RESULTS: Mean levels of disability were significantly higher among patients with CD than those with UC (P < .01). On the basis of the Work and Social Adjustment Scale, rates of disability were 19% among patients with CD vs 11% among those with UC (P < .05). Results from the World Health Organization Disability Assessment Schedule v.2 and the Work and Social Adjustment Scale correlated (r = 0.58 for patients with CD and 0.60 for those with UC; P < .01). Disability was associated with reduced quality of life. Long-term active disease and a lifetime history of major depression were associated with disability, whereas history of IBD-related surgeries or hospitalizations was not. CONCLUSIONS: A minority of patients with IBD have significant disability after a decade of disease, although a higher proportion of patients with CD are disabled than those with UC. Long-term active disease and psychological factors are important predictors of disability. Depression should be treated as aggressively as the IBD itself.

Changes in fatigue over 2 years are associated with activity of inflammatory bowel disease and psychological factors.

BACKGROUND & AIMS: Cross-sectional studies have identified high levels of fatigue in patients with active or quiescent inflammatory bowel disease (IBD), but there has been little attention to the long-term effects of fatigue in these patients. We performed a longitudinal study of fatigue in patients with IBD to determine its course and contributing factors. METHODS: Data were obtained from participants in the Manitoba IBD Cohort Study (N = 312; 51% with Crohn's disease), a longitudinal population-based study. Symptomatic disease activity was measured every 6 months for 2 years to characterize long-term disease patterns as active, fluctuating, or inactive, based on the validated Manitoba IBD Index. We collected data concurrently on fatigue (Multidimensional Fatigue Inventory), psychological function, and laboratory biomarkers at the point of study entry and 1 and 2 years later. RESULTS: Of the study participants, 26% had consistently inactive, 29% had fluctuating, and 45% had consistently active disease over the 2-year time period. Mean levels of fatigue were strongly associated with disease activity; participants with consistently inactive disease had the lowest level of fatigue at each time point. Multivariate analyses indicated fatigue levels increased over time regardless of disease pattern (P < .001). Adjusting for disease activity, disease type and age, sex (female; P < .001), and psychological variables of distress (P < .001), reduced psychological well-being (P = .002) and poor sleep quality (P < .001) were associated independently with increases in fatigue over time. CONCLUSIONS: Fatigue can increase over time in patients with IBD, even when their disease is in remission. Psychological factors are useful targets for intervention to reduce fatigue.

Is iron deficiency in the absence of anemia associated with fatigue in inflammatory bowel disease?

OBJECTIVES: We explored whether iron deficiency in the absence of anemia is associated with fatigue in inflammatory bowel disease (IBD). METHODS: We assessed iron deficiency and anemia in 280 participants from the population-based Manitoba IBD Cohort Study. RESULTS: Iron deficiency was identified in 20% with Crohn's disease and 27% with ulcerative colitis. Anemia was identified overall in 50 (18%), with 230 who were nonanemic. In the nonanemic subgroup, there were no significant differences between iron-deficient and -sufficient groups in mean fatigue levels or proportions with problematic fatigue. There was no unique contribution of iron deficiency to problematic fatigue after adjustment for active disease and anemia. CONCLUSIONS: There was no evidence of an association between iron deficiency and fatigue in the absence of anemia, suggesting that iron deficiency is not a clinically relevant contributor to fatigue in IBD.

Relative importance measures for reprioritization response shift.

PURPOSE: Response shift (RS), a change in the meaning of an individual's self-evaluation of a target construct, such as health-related quality of life (HRQOL), can affect the interpretation of change in measures of the construct collected over time. This study proposes new statistical methods to test for reprioritization RS, in which the relative importance of HRQOL domains changes over time. METHODS: The methods use descriptive discriminant analysis or logistic regression models and bootstrap inference to test for change in relative importance weights (method 1) or ranks (method 2) for discriminating between patient groups at two occasions. The methods are demonstrated using data from the Manitoba Inflammatory Bowel Disease (IBD) Cohort Study (n = 388). Reprioritization of domains from the IBD Questionnaire (IBDQ) and SF-36 was investigated for groups with active and inactive disease symptoms. RESULTS: The IBDQ bowel symptoms and SF-36 bodily pain domains had the highest ranks for group discrimination. Using Method 1, there was evidence of reprioritization RS in the IBDQ social functioning domain and the SF-36 bodily pain and social functioning domains. Method 2 did not detect change for any of the domains. CONCLUSIONS: Compared to IBD patients without active disease symptoms, those with active symptoms were likely to change the meaning of their self-evaluations of pain and social interactions. Further research is needed to compare these new RS detection methods under a variety of data analytic conditions before recommendations about the optimal method can be made.

The Manitoba Inflammatory Bowel Disease Cohort Study: a prospective longitudinal evaluation of the use of complementary and alternative medicine services and products.

OBJECTIVE: To determine the prevalence of complementary and alternative medicine (CAM) use over time in a population-based cohort of patients with inflammatory bowel disease (IBD). METHODS: The Manitoba IBD Cohort Study is a longitudinal, population-based study of multiple determinants of health outcomes in an IBD cohort. Participants completed semi-annual surveys, and annual in-person interviews. Enquiries about the use of 12 types of CAM service providers and 13 CAM products, based on items from a national survey, were included at months 0, 12, 30 and 54. RESULTS: Overall, 74% of respondents used a CAM service or product in the 4.5-year period, with approximately 40% using some type of CAM at each time point, and 14% using CAM consistently at every time point. There was a trend for women to use CAM more than men; there was no difference in CAM use between patients with Crohn's disease and those with ulcerative colitis. The most often used CAM services (on average) were massage therapy (30%) and chiropractic (14%), physiotherapy (4%), acupuncture (3.5%) and naturopathy/homeopathy (3.5%). A wide range of CAM products were used, with Lactobacillus acidophilus (8%), fish and other oils (5.5%), glucosamine (4%) and chamomile (3.5%) as the most common. On average, only 18% of consumers used CAM for their IBD, so the majority chose it for other problems. There were no differences in psychological variables between CAM users and non-users. CONCLUSIONS: Those with IBD commonly try CAM, although very few use these approaches regularly over the years. CAM is not usually used by patients with IBD for disease management, but clinicians should be aware that many will test the services and products.

Longitudinal change in bone mineral density in a population-based cohort of patients with inflammatory bowel disease.

Persons with inflammatory bowel disease (IBD) are reported to have a high prevalence of osteoporosis and reduced bone mineral density (BMD) and to be at higher risk of fracture. The course of BMD loss over time is poorly characterized in persons with IBD. Eighty-six persons, stratified by age, were enrolled from a population-based longitudinal IBD cohort study to undergo BMD testing at baseline, with final BMD testing a mean of 4.3 years later. The proportion of subjects with significant change in BMD at the lumbar spine, total hip, and femoral neck was assessed, as were clinical, biochemical, and anthropomorphic changes. Vertebral radiographs were also obtained at baseline and at the end of follow-up in those aged 50 years and above to detect vertebral fractures. The change in BMD seen in this cohort of IBD patients was similar to the expected rate of BMD loss in the general population. Age >50 years, decreasing body mass index (BMI), and corticosteroid use were most notably correlated with BMD loss. Subjects aged <50 years did not have statistically significant declines in BMD. IBD symptom activity scores correlated poorly with BMD loss. Vertebral fractures were uncommon, with only two subjects out of 41 >50 years old developing a definite radiographic fracture over the course of follow-up. No major nonvertebral fractures were observed. Patients with IBD do not appear to have significantly accelerated BMD loss. Older age, decreasing BMI, and corticosteroid use may identify IBD patients at greater risk for BMD loss.

Measures of relative importance for health-related quality of life.

PURPOSE: In health-related quality of life (HRQOL) studies, data are often collected on multiple domains for two or more groups of study participants. Quantitative measures of relative importance, which are used to rank order the domains based on their ability to discriminate between groups, are an alternative to multiple tests of significance on the group differences. This study describes relative importance measures based on logistic regression (LR) and multivariate analysis of variance (MANOVA) models. METHODS: Relative importance measures are illustrated using data from the Manitoba Inflammatory Bowel Disease (IBD) Cohort Study. Study participants with self-reported active (n = 244) and inactive (n = 105) disease were compared on 12 HRQOL domains from the Inflammatory Bowel Disease Questionnaire (IBDQ) and Medical Outcomes Study 36-item Short-Form (SF-36) Questionnaire. RESULTS: All but two relative importance measures ranked the IBDQ bowel symptoms and emotional health domains as most important. CONCLUSIONS: MANOVA-based importance measures are recommended for multivariate normal data and when group covariances are equal, while LR measures are recommended for non-normal data and when the correlations among the domains are small. Relative importance measures can be used in exploratory studies to identify a small set of domains for further research.

The information needs and preferences of persons with longstanding inflammatory bowel disease.

BACKGROUND: Understanding the information needs and preferred vehicles of information delivery to patients with inflammatory bowel disease (IBD) will enhance their care. OBJECTIVE: To survey persons with longstanding IBD as to their information needs and preferred vehicles of information delivery. METHODS: The population-based Manitoba IBD Cohort (n=271, mean disease duration 11 years) was surveyed to assess its information needs across 23 issues, both retrospectively at the time of diagnosis and currently. RESULTS: Most participants (64%) were initially diagnosed by a gastroenterologist, or otherwise by a family physician (19%) or surgeon (12%). Recalling time of diagnosis, at least 80% rated as very important information about common symptoms of IBD, possible complications, long-term prognosis, medication side effects, self management of symptoms and when to involve the doctor, yet only 10% to 36% believed they received the right amount of information about these issues. Dietary guidance was also regarded as important by 80% to 89%, yet only 8% to 16% received the correct amount of information. Regarding current needs, a large proportion believed it would be very helpful to have more information about long-term prognosis (66%) and diet considerations (60% to 68%). The following information sources were regarded as very acceptable: medical specialist (81%); brochure (79%); family doctor (64%); and website (64%), with 51% ranking the medical specialist as the first choice. In a comparison of the responses of this cohort to those of a recently diagnosed sample, there was remarkable consistency in the information needs and most desired sources of information. DISCUSSION: In the present population-based cohort with longstanding disease, dietary information was regarded as the least adequately addressed. There was clear openness to receiving information through other routes than just the medical specialist, suggesting that optimizing brochures and websites would be an important adjunct source of information. CONCLUSION: Approximately 10 years after diagnosis, only a small percentage of persons with IBD believed they received the correct amount of information about the issues they regarded as most important to have discussed at diagnosis.

Prevalence of metabolic syndrome in the Canadian adult population.

BACKGROUND: Metabolic syndrome refers to a constellation of conditions that increases a person's risk of diabetes and cardiovascular disease. We describe the prevalence of metabolic syndrome and its components in relation to sociodemographic factors in the Canadian adult population. METHODS: We used data from cycle 1 of the Canadian Health Measures Survey, a cross-sectional survey of a representative sample of the population. We included data for respondents aged 18 years and older for whom fasting blood samples were available; pregnant women were excluded. We calculated weighted estimates of the prevalence of metabolic syndrome and its components in relation to age, sex, education level and income. RESULTS: The estimated prevalence of metabolic syndrome was 19.1%. Age was the strongest predictor of the syndrome: 17.0% of participants 18-39 years old had metabolic syndrome, as compared with 39.0% of those 70-79 years. Abdominal obesity was the most common component of the syndrome (35.0%) and was more prevalent among women than among men (40.0% v. 29.1%; p=0.013). Men were more likely than women to have an elevated fasting glucose level (18.9% v. 13.6%; p=0.025) and hypertriglyceridemia (29.0% v. 20.0%; p=0.012). The prevalence of metabolic syndrome was higher among people in households with lower education and income levels. INTERPRETATION: About one in five Canadian adults had metabolic syndrome. People at increased risk were those in households with lower education and income levels. The burden of abdominal obesity, low HDL (high-density lipoprotein) cholesterol and hypertriglyceridemia among young people was especially of concern, because the risk of cardiovascular disease increases with age.

Substance abuse versus dependence and the structure of common mental disorders.

BACKGROUND: In 1999, using data from the National Comorbidity Survey (NCS), Krueger presented a model that gave a novel taxonomic approach to mental disorders and their core psychopathologies. He proposed that the relationships among 10 common mental disorders could be understood in a factor structure composed of higher-order "Internalizing" and "Externalizing" factors, with the Internalizing factor subdivided into an "Anxious-Misery" subfactor and a "Fear" subfactor. However, Krueger did not include all of the mental disorders assessed in the NCS. The objective of the current study was to examine how alcohol abuse and drug abuse compare to alcohol dependence and drug dependence in Krueger's model. METHOD: The sample for this research was the 8098 noninstitutionalized US civilians aged 15 to 54 years who participated in the NCS between 1990 and 1992. The data from the NCS were analyzed using confirmatory factor analyses. RESULTS: Alcohol abuse and drug abuse loaded on both the Anxious-Misery subfactor and the Externalizing factor and were distinct from alcohol dependence and drug dependence. CONCLUSIONS: Individuals with drug abuse and alcohol abuse constitute a different population than individuals with drug dependence and alcohol dependence and have a different pattern of comorbidities. This suggests that underlying etiologies may vary between these 2 groups, leading to different approaches for both research and treatment.

Pathological gambling and the structure of common mental disorders.

This study investigated a proposed three-factor model of common mental disorders in the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC; N = 43,093). It also evaluated the inclusion of pathological gambling (PG) in the three-factor model to determine whether PG loaded more strongly on a higher-order externalizing factor comprised of alcohol and drug dependence and antisocial personality disorder. The results indicated the three-factor model showed good fit to the NESARC data. PG loaded onto the externalizing factor for men and women, but in women, PG showed the best fit when it was allowed to load on the externalizing factor as well as a lower-order internalizing factor of anxious-misery composed primarily of mood disorders. Findings emphasize the need to investigate the differences in the nature of PG behavior between men and women.

Sex-differences in relation to the association between patterns of physical activity and sedentary behavior with frailty.

OBJECTIVE: To investigate the sex-difference in relation to the association between moderate-vigorous physical activity (MVPA) and sedentary time (ST) patterns with frailty. METHOD: Accelerometry from ≥50 year olds from the National Health and Nutrition Examination Survey (2003-04/2005-06 cycles) were included. Bouted and sporadic MVPA were defined as MVPA in ≥10 min or <10 min durations, respectively. MVPA was analyzed based on meeting 0 %, 1-49 %, 50-99 %, and ≥100 % of the physical activity guidelines of 150 min/week. A duration of ≥30 minutes defined prolonged ST. The frequency (≥1 min interruption in ST), intensity and duration of breaks from ST were calculated. A 46-item frailty index (FI) quantified frailty. Multivariable linear regression models adjusted for demographics, total sedentary time, and accelerometer wear time. RESULTS: There were 1143 females and 1174 males available for analysis. Bouted MVPA was associated with lower frailty levels; the association peaked at meeting 50-99 % of the guidelines in females and ≥1.0 % in males (p = NS for sex-interaction). Meeting a higher proportion of the guidelines through sporadic MVPA was significantly associated with a lower FI in males only (p = NS for sex-interaction). Prolonged ST bouts were associated with worse frailty in females but not males (p < 0.05 sex-interaction). Average break intensity was associated with a lower FI in both sexes, whereas, total sedentary breaks were not (p = NS for sex-interaction). Average break duration was associated with frailty in males (p = NS for sex-interaction). CONCLUSION: Prolonged ST was more detrimentally associated with frailty in females than males, which could influence tailored movement prescriptions and guidelines.

The Manitoba IBD Index: evidence for a new and simple indicator of IBD activity.

OBJECTIVES: A single-item indicator of disease activity over an extended period of time, the Manitoba Inflammatory Bowel Disease Index (MIBDI), is introduced and compared against several standard measures for assessing activity in patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS: Participants enrolled in the Manitoba IBD Cohort Study, a population-based longitudinal cohort study (N=353), were assessed semiannually by survey, clinical interview, and blood sample during a 2-year period. The MIBDI is based on patient self-reports of symptom persistence for the previous 6 months, using a 6-level response format. RESULTS: The MIBDI had good sensitivity compared with the Harvey-Bradshaw Index (HB; 0.88), Powell-Tuck Index (PT; 0.84), and Inflammatory Bowel Disease Questionnaire (IBDQ; 0.89), which was maintained at two subsequent annual measurements. Test-retest reliability was also strong (Spearman's r=0.81). Discriminant function analyses identified common discriminating variables of active disease for CD and UC that included HB, PT, and IBDQ subscales of bowel and systemic symptoms, prolonged symptom severity (e.g., abdominal and joint pain, tiredness, diarrhea), and recent persistent pain related to IBD. Unique discriminators included weight problems (CD) and blood in stool (UC). CONCLUSIONS: A single-item, patient-defined disease activity measure, the MIBDI, showed a high degree of sensitivity for classifying individuals with regard to disease status over time compared with the existing disease activity measures, and strong convergent validity with expected proxy measures of disease. These relationships remained consistent over time. Thus, the MIBDI shows promise as a valid, brief tool for measuring disease activity over an extended period.

Stress coping, distress, and health perceptions in inflammatory bowel disease and community controls.

OBJECTIVES: This study compares a community inflammatory bowel disease (IBD) sample of individuals with a matched non-IBD community sample of individuals on psychological functioning and health perceptions. METHODS: Participants in the population-based Manitoba IBD Cohort Study (n=388) were directly compared with sex-, age-, and region-matched controls from a national random-sample health survey on the aspects of psychological health, coping, and perceived general health. RESULTS: Overall, the IBD sample had lower psychological well-being and mastery, as well as higher distress than did the non-IBD controls (P

Are personality dimensions associated with sleep length in a large nationally representative sample?

OBJECTIVES: The purpose of this hypothesis-generating study was to determine whether personality domains and specific personality traits are uniquely associated with sleep duration using data obtained from the National Comorbidity Survey (NCS). METHODS: Using trained interviewers, we administered to the 5877 noninstitutionalized adults living in the United States the Composite International Diagnostic Interview (World Health Organization. Composite International Diagnostic Interview. Geneva, Switzerland: WHO, 1990) to assess for any DSM-III-R psychiatric diagnoses, and they completed self-report measures of personality and sleep. This was a secondary data analysis using information from a large existing public use data set (NCS-part II). The NCS-part II was an epidemiologic survey based on a stratified multistage area probability method with a response rate of 82.4%. RESULTS: Using a multivariate logistic regression technique, we found significant and positive associations between short sleep (defined as or=9 hours per 24 hour period) and a diagnosis of dysthymia (OR = 1.52), the use of a sedating medication in the past 12 months (OR = 1.52), emotional reliance on another person (OR = 1.37), employment status (OR = 1.31), and marital status (OR = 1.20). CONCLUSIONS: Findings suggest that personality, even after controlling for psychiatric and medical conditions, is associated with sleep length and may be an additional factor to consider when assessing any individual patient.

The association between patterns of physical activity and sedentary time with frailty in relation to cardiovascular disease.

OBJECTIVE: The associations of moderate-vigorous physical activity (MVPA) bouts and patterns of sedentary time (ST) with frailty according to cardiovascular disease (CVD) status are unknown. METHODS: Accelerometry in adults ≥50 years old from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey were used. Bouted and sporadic MVPA in ≥10-minute or <1-minute bouts were assessed based on meeting a percentage of physical activity guidelines of 150 minutes/wk, respectively. ST patterns included: prolonged ST lasting ≥30 minutes, and the frequency, intensity, and duration of breaks from ST. A 46-item frailty index defined frailty. Multivariable linear regression was used. RESULTS: There were 827 and 1490 CVD-free and CVD participants, respectively. Meeting a higher percentage of the physical activity guidelines through bouted MVPA was associated with lower frailty in CVD-only participants (P < 0.05 for CVD interaction). Sporadic MVPA was associated with lower frailty levels in both groups. Prolonged ST was associated with worse frailty in CVD (P > 0.05 for CVD interaction). Frequency of ST breaks was not associated with frailty. Average ST break intensity was protective in both groups. The duration of breaks in ST was associated with lower frailty in CVD participants only (P > 0.05 for CVD interaction). CONCLUSION: Insufficient MVPA and prolonged ST are detrimental despite CVD status.

The Manitoba IBD cohort study: a population-based study of the prevalence of lifetime and 12-month anxiety and mood disorders.

BACKGROUND AND AIMS: Given the impact of anxiety and mood disorders on health, it is important to consider these disorders in persons with inflammatory bowel disease (IBD). We assessed the prevalence of anxiety and mood disorders in a population-based IBD cohort. METHODS: A structured diagnostic interview was administered to participants in the cohort (N = 351), and rates were compared to age-, gender-, and region-matched controls drawn from a national survey (N = 779). RESULTS: A comparison of lifetime prevalence suggests higher rates of panic, generalized anxiety, and obsessive-compulsive disorders and major depression and lower rates of social anxiety and bipolar disorders in the IBD sample than in national samples in the United States and New Zealand. Direct comparisons with matched controls (with data available for three anxiety disorders) found lifetime prevalence (IBD vs controls) as follows: social anxiety disorder lower in IBD (6%vs 11%, OR 0.52, 95% CI 0.32-0.85), panic disorder not significantly different (8.0%vs 4.7%, OR 1.59, 95% CI 0.96-2.63), agoraphobia without panic not significantly different (1.1%vs 0.6%, OR 1.44, 95% CI 0.37-5.55), and major depression higher (27.2%vs 12.3%, OR 2.20, 95% CI 1.64-2.95). Comparing IBD respondents with and without lifetime anxiety or mood disorder, those with a disorder reported lower quality of life and earlier onset of IBD symptoms and there was a trend toward earlier IBD diagnosis. CONCLUSIONS: Clinicians should be aware of the increased prevalence of depression and possibly other anxiety disorders in persons with IBD as these disorders may influence response to treatment and quality of life.

Population-based controlled study of social support, self-perceived stress, activity and work issues, and access to health care in inflammatory bowel disease.

BACKGROUND: The Manitoba IBD Cohort Study is a longitudinal, population-based study of multiple determinants of health outcomes in persons with inflammatory bowel disease (IBD) diagnosed within 7 years at enrollment. In this cross-sectional substudy we compared IBD participants' levels of social support, self-perceived stress, disability, and access to healthcare with those of a matched community sample. METHODS: IBD participants (n = 388) were interviewed using the Canadian Community Health Surveys (CCHS) 1.1 and 1.2 to assess psychosocial variables. The national CCHS data were accessed to extract a community comparison group, matched on age, sex, and geographic residence. RESULTS: Compared to the community sample, IBD participants received more tangible, affective, or emotional support in the past year and were more likely to have experienced a positive social interaction. Those with IBD were as likely to be employed as those in the community sample, although they reported greater rates of reduced activity and days missed. Work was not identified as a significant source of stress, but physical health was more likely to be identified as a main stressor by those with active IBD compared to the non-IBD sample. Individuals with IBD were twice as likely to report unmet healthcare needs than the community sample; however, there was agreement across both groups regarding common barriers, including long waits and availability. CONCLUSIONS: While the disease may contribute to greater interference with work quality and daily activities, IBD patients have similar levels of stress and appear to have enhanced social supports relative to those in the community without IBD.

Associations between arthritis and a broad range of psychiatric disorders: findings from a nationally representative sample.

UNLABELLED: Data from the National Epidemiological Study of Alcoholism and Related Conditions (NESARC) were used to investigate associations between arthritis and a wide range of psychiatric disorders in a large sample (n = 43,093) representative of the adult population of the United States. NESARC participants completed the Alcohol Use Disorder and Associated Disabilities Interview Schedule--DSM-IV Version and provided reports regarding medical conditions, including arthritis, experienced over the past year. Logistic regression analyses that adjusted for potential confounding variables (ie, gender, marital status, age, income, and other health conditions) indicated that arthritis had significant positive associations with each of the 7 personality disorders included in the NESARC (ie, avoidant, dependent, obsessive-compulsive, paranoid, schizoid, histrionic, and antisocial). Arthritis also had significant positive associations with mood and anxiety disorders. In contrast to several recent studies indicating arthritis may have relatively larger associations with anxiety disorders than with major depression, the magnitudes of the associations involving anxiety disorders were not particularly large compared with those regarding depressive disorders. Alcohol- and substance-related disorders had negative associations with arthritis. However, additional analyses indicated that age was a confounding variable in these relationships and revealed that arthritis was not associated with either alcohol- or substance-related disorders. PERSPECTIVE: This article presents the first study to investigate associations between arthritis and personality disorders and is the first study to investigate relationships between a condition characterized by pain and personality disorders using a community sample. It may prompt research and clinical attention to the role of personality disorders in arthritis.

The structure of feared social situations among individuals with a lifetime diagnosis of social anxiety disorder in two independent nationally representative mental health surveys.

The present study employed both exploratory and confirmatory factor analytic approaches with nationally representative samples of individuals with a lifetime diagnosis of social anxiety disorder (n=1123; n=3091, respectively) using split-halves of the National Comorbidity Replication Survey (n=9282) and cross-validated with the Canadian Community Health Survey on Mental Health and Wellbeing (n=36,984). Strong support was found for a three-factor solution. This model was obtained from exploratory factor analysis and was further evaluated using two confirmatory factor analytic investigations in the two national samples. The three social situational domains reflected (1) Social Interaction Fears, (2) Observation Fears, and (3) Public Speaking Fears. Individuals with generalized social anxiety disorder (i.e., those who endorsed 7 or more of 13 feared social situations assessed in the survey) were significantly more likely to report Social Interaction Fears and Observation Fears compared to individuals with non-generalized social anxiety disorder (i.e., those who endorsed only 6 or fewer of 13 feared social situations). Individuals with generalized social anxiety were particularly characterized by combinations of Public Speaking Fears plus Social Interaction Fears and Observation Fears. The clinical and classification implications of our study for DSM-V are discussed.