The 'revolving door' of mental illness: A meta-analysis and systematic review of current versus lifetime rates of psychological disorders.

OBJECTIVES: Therapists have long observed a phenomenon referred to as the 'revolving door' of mental health services, in which individuals often develop, seek treatment for, and recover from multiple mental illnesses across their life. However, this has not been systematically examined. If this phenomenon is widespread, one would expect that the number of lifetime disorders would exceed that of current disorders. The aim of this meta-analysis was to test this hypothesis. METHODS: A search was conducted of the following databases: MEDLINE, PsycINFO and Web of Science. In total, 38 studies were included in the current review; 27 of these contained sufficient quantitative data to be included in the meta-analysis, addressing the primary research aim. The remaining 11 studies were included in the systematic review only. RESULTS: Meta-analyses of the 27 studies indicated that the average number of lifetime disorders was 1.84 times that of current disorders. Previous treatment significantly moderated this relationship, while the clinical nature of the sample did not. Examination of the remaining studies revealed common temporal sequences, indicating disorders which typically develop first or consequently to other disorders. CONCLUSIONS: These findings provide support for the revolving door of mental illness, suggesting a need for transdiagnostic treatments and broader conceptualisation of relapse prevention.

A systematic review of the relationship between death anxiety, capability for suicide, and suicidality.

This systematic review aimed to examine the relationship between death anxiety and suicidality in adults, and the impact of death anxiety interventions on the capability for suicide and suicidality. MEDLINE, PsycINFO, PubMed, and Web of Science were extensively searched using purpose-related keywords from the earliest to July 29th, 2022. A total of 376 participants were included across four studies which met inclusion. Death anxiety was found to relate significantly and positively with rescue potential, and although weak, negatively with suicide intent, circumstances of attempt, and a wish to die. There was no relationship between death anxiety and lethality or risk of lethality. Further, no studies examined the effects of death anxiety interventions on the capability for suicide and suicidality. It is imperative that future research implements a more rigorous methodology to establish the relationship between death anxiety and suicidality and establish the impacts of death anxiety interventions on the capability for suicide and suicidality.

Starving off death: Mortality salience impacts women's body image and disordered eating.

From a Terror Management perspective, the pursuit of thinness that characterizes eating disorders (EDs) is arguably a culturally endorsed way to mitigate death anxiety. In the present studies, we used the mortality salience (MS) paradigm to examine whether priming death increases ED symptoms. We recruited two samples of women from undergraduate (Study 1, N = 120), and clinically relevant (Study 2, N = 154) populations. After priming, participants completed measures of potential confounds (e.g., neuroticism, affect). Next, we assessed ED attitudes and behavior using a portion size estimation task, and measures of body dissatisfaction and eating intention. Study 1 findings were inconsistent with the claimed role of death anxiety in ED related behavior. However, in Study 2, MS priming led to increased dissatisfaction with current thinness and smaller portion sizes for high-fat compared to low-fat food. Overall, the results suggest that death anxiety may, at least partially, drive ED symptoms.

Do Beliefs About Sexual Orientation Predict Sexual Identity Labeling Among Sexual Minorities?

Research has found that sexual orientation beliefs predict heterosexuals' attitudes toward sexual minorities, and important sexual identity outcomes in sexual minority populations. To this point, no studies have systematically examined how sexual orientation beliefs may be associated with sexual identity self-labeling among sexual minority individuals. The present study examined this question in a sample of 1840 same-gender attracted individuals recruited for a cross-sectional online survey. Beliefs in the naturalness and discreteness of sexual orientation categories were highest in gay/lesbian individuals, intermediate in bisexual people, and lower in queer and pansexual individuals. Beliefs in the importance of sexual orientation were highest in gay/lesbian and queer identified individuals and lower in bisexual people. Within-group analysis demonstrated that gay/lesbian individuals who reported more exclusive same-gender attraction reported higher naturalness, discreteness, and importance beliefs than those with less-exclusive same-gender attraction. However, naturalness, discreteness, and importance beliefs were not associated with sexual attraction patterns in bisexual individuals. Finally, among predominately same-gender attracted populations, the adoption of a queer identity (over a gay/lesbian identity) was predicted by lower naturalness and discreteness beliefs, and increased perceived importance in females. Among non-monosexual populations, adoption of a pansexual identity over a bisexual identity was predicted by lower naturalness beliefs in females, but not predicted by sexual orientation beliefs in males. Collectively, these findings suggest that sexual orientation beliefs differ between sexual identity groups and may partly explain the adoption of particular sexual identity labels among contemporary sexual minority populations.

Are Fear Campaigns Effective for Increasing Adherence to COVID-Related Mitigation Measures?

BACKGROUND: Using fear to increase the uptake of preventative health behaviours is a longstanding practice, which could be useful in mitigating the spread of COVID-19. However, the impact of fear campaigns beyond behavioural outcomes has rarely been considered. It is possible that these threatening health messages could heighten health-related anxiety by inducing a tendency to interpret ambiguous stimuli in a threatening manner. This research aimed to evaluate the effects of fear-based articles about COVID-19, on intentions to adhere to mitigation measures and interpretation bias-a core maintenance factor in health anxiety. METHOD: Two pilot studies were conducted with the aim of validating our novel COVID-related measures and assessing engagement with the threat manipulation. Following this, 375 community members were recruited through social media for the main study. Participants were then randomly allocated to read an article about COVID which was manipulated on both threat and efficacy. After reading the article, participants then completed measures of interpretation bias and intentions to engage in COVID-19 mitigation measures. RESULTS: Although the threatening articles consistently produced greater COVID-related threat, they only generated a stronger interpretation bias in the first pilot study. Importantly, threat-based communications failed to enhance intentions to perform mitigation measures in any of the studies. Likewise, reading an article which bolstered self-efficacy did not increase intentions, compared to reading a low efficacy article. CONCLUSION: This research suggests that fear appeals are unlikely to increase intentions to perform COVID-related mitigation measures.

The vegan dilemma: Do peaceful protests worsen attitudes to veganism?

A body of research has shown that violent protests reduce support for social movements. However, few studies have examined whether the same is true for protests which are peaceful, yet disruptive (e.g., blocking traffic). Across two pre-registered experimental studies, we explored whether pro-vegan protests that are depicted as causing social disruption lead to more negative attitudes towards veganism, compared to non-disruptive protests or a control condition. Study 1 utilised a combined sample of Australian and United Kingdom residents (N = 449; Mage = 24.7 years). Study 2 employed a larger sample of undergraduate Australian students (N = 934; Mage = 19.8 years). In Study 1, disruptive protests were associated with more negative attitudes towards vegans, but only among women. In Study 2, no such effect was found. Instead, a significant main effect was found for the protest's cause (vegan vs. fast fashion), but not protest type (disruptive vs. non-disruptive). That is, reading about a vegan protest, irrespective of how disruptive it was, led to worse attitudes towards vegans, and greater defense of meat consumption (i.e., endorsement of meat eating as natural, necessary, and normal), than reading about a control protest. This effect was mediated by the perceived immorality of the protestors, and, in turn, reduced identification with them. Taking together both studies, the purported location of the protest (i.e., domestic vs. overseas) did not significantly impact attitudes toward the protestors. The current findings suggest that depictions of vegan protests elicit worse attitudes toward this movement, regardless of how peaceful that protest may be. Future research is needed to examine whether other forms of advocacy can ameliorate negative reactions to vegan activism.

Reduced death anxiety as a mediator of the relationship between acute subjective effects of psychedelics and improved subjective well-being.

Research over the past several decades suggests that meaningful psychedelic experiences can engender long-term effects on subjective wellbeing. However, less research has investigated the psychological mechanisms through which these effects may emerge. In the present study, participants (N = 201) completed an online survey that retrospectively measured the acute effects of a meaningful psychedelic experience, as well as changes in subjective well-being and death anxiety. Reductions in death anxiety significantly mediated the effects of mystical experience on satisfaction with life, positive affect, and negative affect. Reductions in death anxiety did not mediate any of the effects of psychological insight. Although correlational, the findings are consistent with the hypothesis that some of the benefits of psychedelic-induced mystical experiences on subjective well-being may emerge due to reductions in death anxiety. Nevertheless, further research is needed to establish a causal effect of reduced death anxiety on well-being in the context of psychedelic experiences.

Overcoming death anxiety: a phase I trial of an online CBT program in a clinical sample.

BACKGROUND: Growing research indicates that death anxiety is implicated in many mental health conditions. This increasing evidence highlights a need for scalable, accessible and cost-effective psychological interventions to reduce death anxiety. AIMS: The present study outlines the results of a phase I trial for one such treatment: Overcome Death Anxiety (ODA). ODA is the first CBT-based online intervention for fears of death, and is an individualised program requiring no therapist guidance. METHOD: A sample of 20 individuals with various mental health diagnoses commenced the ODA program. Death anxiety was assessed at baseline and at post-intervention. Depression, anxiety and stress were also measured. RESULTS: In total, 50% (10/20) reached the end of the program and completed post-treatment questionnaires. Of these, 60% (6/10) showed a clinically reliable reduction in their overall death anxiety, and 90% (9/10) showed a reduction on at least one facet of death anxiety. There were no adverse events noted. CONCLUSIONS: ODA appears to be a safe and potentially effective treatment for death anxiety. The findings have provided initial evidence to support a randomised controlled trial using a larger sample, to further examine the efficacy of ODA.

Are psychological interventions efficacious for adults with migraine? A systematic review and meta-analysis.

OBJECTIVE: To determine the efficacy of psychological interventions in studies of adults with migraine, in reducing pain, and functional and psychosocial difficulties. BACKGROUND: A recently published Cochrane Review showed no strong evidence for psychological intervention for adults with migraine. However, this review was limited by stringent inclusion criteria, potentially resulting in low power. The current review examines the stability of these findings. METHODS: CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL databases were systematically searched from inception to July 31, 2021. Reviewers independently conducted the search and extraction process. Risk of bias was conducted, and we provide GRADE ratings of our confidence in the evidence. We included 39 randomized controlled trials in the meta-analyses (n = 3155); 31 included data on migraine only and eight combined data from adults with migraine or tension-type headache (TTH). RESULTS: In contrast to the Cochrane Review, for studies including adults with migraine only, we found psychological interventions had a small to medium beneficial effect on improving migraine frequency, pain intensity, and disability post-treatment, compared to controls (Cohen's d range 0.23 to 0.33), and disability at follow-up (d = 0.44). We found no evidence of a beneficial effect on quality-of-life post-treatment, or mood at post-treatment or follow-up. Our sensitivity analyses on studies with mixed headache populations (migraine and combined migraine/TTH) found a similar magnitude of effects for most outcomes (d range 0.25 to 0.36), except for mood, which produced a small to medium beneficial effect (d = 0.32). CONCLUSION: We found evidence that adults with migraine may benefit from psychological intervention, and psychological treatment may equally benefit adults with a range of headache conditions. However, as with previous reviews, quality of the evidence was low, findings should be cautiously interpreted, and this field would benefit from future high-quality trials.

The development and validation of the Death Anxiety Beliefs and Behaviours Scale.

OBJECTIVES: Research spanning the fields of clinical, social and health psychology suggests that death anxiety is an important construct. However, no comprehensive, psychometrically adequate measure of the construct exists. The current studies outline the development of a new measure of death anxiety, the Death Anxiety Beliefs and Behaviours Scale (DABBS), which is the first measure to specifically assess unhelpful beliefs and behaviours that may underlie fears of death. METHODS: In Study 1, items were piloted in a large community sample (N = 505). In Studies 2A and 2B, exploratory and confirmatory factor analyses were performed using a treatment-seeking (N = 200) and non-treatment-seeking sample (N = 200). These analyses resulted in the final 18-item scale. RESULTS: The DABBS demonstrated good construct validity, criterion validity, internal consistency and test-retest reliability. In Study 3, the DABBS effectively distinguished participants with clinically significant death anxiety and distress from those without, demonstrating excellent discriminant validity. CONCLUSIONS: The present data indicate that the DABBS is a valid and reliable measure of affect, beliefs and behaviours relating to death anxiety, in a community sample of adults and among those seeking mental health treatment. Given the increasing recognition of the importance of death anxiety, the DABBS offers a useful research and clinical tool.

A systematic review of the psychometric properties of death anxiety self-report measures.

Recent research suggests that the transdiagnostic construct of death anxiety may be a basic fear underlying a range of anxiety disorders. Although the investigation of death anxiety in clinical populations is relatively recent, the death anxiety literature as a whole has a longer history evidenced by the number of instruments developed to measure this construct. This systematic review aimed to evaluate the evidence supporting the psychometric properties of self-report death anxiety measures. Relevant studies were identified via a systematic search of four electronic databases in addition to reference list searches. Two independent reviewers evaluated relevant studies using the established Terwee et al. quality appraisal tool. Of the 1831 studies identified, 89 met inclusion criteria. These studies investigated the psychometric properties of 21 self-report scales of death anxiety as well as six subscales. No measure was found to possess evidence of adequacy on all evaluated quality criteria. The Templer Death Anxiety Scale, Concerns about Dying Instrument and Death Concern Scale were found to possess the most evidence supporting their validity and reliability. Overall findings suggest that additional research is needed to establish the psychometric adequacy of death anxiety instruments, especially given increased utilization of these measures in both clinical and research settings.

OCD, death anxiety, and attachment: what's love got to do with it?

BACKGROUND: Death anxiety has been empirically implicated in obsessive compulsive disorder (OCD). Research has shown that secure attachments appear to protect against fear of death, and are also associated with reduced risk of mental illness. However, few studies have investigated the moderating effect of attachment style in the relationship between death anxiety and OCD. AIMS: The present study sought to explore whether attachment style moderates the relationship between death anxiety and OCD symptoms among a treatment-seeking sample of individuals diagnosed with OCD. METHOD: Following a structured diagnostic interview, a number of measures were administered to 48 participants. These included the Multidimensional Fear of Death Scale, Vancouver Obsessive Compulsive Inventory, and Experiences in Close Relationships-Revised. RESULTS: As expected, death anxiety was a strong predictor of OCD severity, and other markers of psychopathology. However, contrary to hypotheses, neither anxious nor avoidant attachment style moderated the association between fear of death and OCD severity. CONCLUSIONS: The current findings add further support to the role of death anxiety in OCD. Given the absence of a moderating effect of attachment between death fears and OCD severity, it is possible that this proposed buffer against death anxiety may potentially be insufficient in the presence of this disorder. Further research is needed to clarify whether attachment style may moderate the relationship between death anxiety and symptom severity in other disorders.

Living Authentically in the Face of Death: Predictors of Autonomous Motivation Among Individuals Exposed to Chronic Mortality Cues Compared to a Matched Community Sample.

Despite research demonstrating positive outcomes of conscious death reflection, very little research directly examines a core proposition of existential psychologists-that death reflection provides an opportunity for more authentic living. The current study compared individuals chronically exposed to genuine mortality cues (funeral/cemetery workers, n = 107) to a matched control sample (n = 121) on autonomous motivation. It also assessed the moderating role of six constructs implicated in growth-oriented processing of death reflection: psychological flexibility, curiosity, neutral death acceptance, death anxiety, approach-oriented coping, and avoidant coping. Funeral/cemetery workers were significantly higher on autonomous motivation, and death-related work was found to have a more positive association with autonomous motivation for those higher on flexibility and lower on death anxiety. This has implications for both understanding which individuals are most likely to experience growth motivations when confronting death, and potential avenues for facilitating these motivations to enhance well-being.

Are anxiety disorders a pathway to obsessive-compulsive disorder? Different trajectories of OCD and the role of death anxiety.

OBJECTIVES: A body of research has demonstrated high rates of comorbidity among individuals with obsessive-compulsive disorder (OCD). Further, recent empirical evidence has demonstrated the relevance of death anxiety in OCD. Given that the trajectory towards OCD remains unclear, the current study aimed to examine which disorders individuals typically experience prior to the onset of this disorder. Further, the study aimed to explore the role of death anxiety in the developmental pathways to the disorder. METHODS: The present study involved administering a measure of death anxiety and conducting structured diagnostic interviews among a treatment-seeking sample of 98 individuals with OCD. RESULTS: First, the findings revealed a number of anxiety-related disorders commonly experienced prior to the development of OCD, the most frequent of which were separation anxiety disorder, specific phobias, and generalised anxiety disorder. Second, consistent with hypotheses, individuals with higher death anxiety experienced more disorders prior to the onset of OCD. Conversely, those with lower fears of death were significantly more likely to develop OCD as their first disorder. CONCLUSIONS: These findings support the argument that death anxiety may influence the trajectory towards OCD, and the comorbidity among anxiety-related disorders. However, further research is needed to clarify whether death anxiety plays a causal role in this trajectory.

The relationship between death anxiety and severity of mental illnesses.

OBJECTIVES: Death anxiety has been implicated theoretically and empirically in mental health and has been proposed to be a transdiagnostic construct. However, it has largely been investigated in relation to specific disorders, such as obsessive-compulsive disorder. Few studies have assessed the relationship between death anxiety and psychopathology using heterogeneous treatment-seeking clinical samples. METHODS: In the present study, the relationships between death anxiety and broad markers of psychopathology were explored in 200 treatment-seeking participants with various diagnosed mental disorders. RESULTS: Across the sample, death anxiety was a strong predictor of psychopathology, including the number of lifetime diagnoses, medications, hospitalizations, distress/impairment, depression, anxiety, and stress. This relationship was not accounted for by neuroticism. Large to very large correlations were also consistently found between a measure of death anxiety and the symptom severity of 12 disorders. Neither meaning in life nor attachment style moderated the associations between death fears and psychopathology. CONCLUSIONS: The findings reveal a strong relationship between death anxiety and psychopathology across numerous disorders, further supporting the transdiagnostic role of fears of death. As such, clinical implications revolve around the potential need for innovative treatments which address death fears directly, in order to produce long-term improvements in mental health. However, experimental research is needed to ascertain causal relationships. PRACTITIONER POINTS: Across a large treatment-seeking sample, death anxiety was a significant predictor of broad psychopathology, including distress and number of lifetime diagnoses. Across 12 different disorders, death anxiety significantly predicted symptom severity. Results may suggest the need for novel treatments which specifically target fears of death. Due to the correlational design, future experimental research is needed to establish causal relationships with increased confidence.

Benign or painful? The interpretation of pain and fear of progression in rheumatoid arthritis.

ABSTRACT: People with chronic pain tend to interpret ambiguous information as health-related, more so than people without. In this study, we aimed to investigate whether people with rheumatoid arthritis (RA) exhibit this interpretation bias and whether it is associated with fear of disease progression (FoP). The interpretation biases of people with RA (n = 164) were compared with an age- and gender-matched control group. We hypothesized that (1) people with RA would have larger interpretation biases than people without; (2) those who scored in the clinical range for FoP would have larger interpretation bias than those who did not; (3) interpretation bias would moderate the relationship between pain severity and FoP; and (4) interpretation bias would explain variance in FoP above and beyond other established predictors. Our results confirmed that people with RA were more likely to interpret ambiguous information as health-related compared with people without RA. This effect was more pronounced for the RA subgroup with clinically significant FoP than those scoring in the normal range. We did not find evidence to suggest interpretation bias moderated the relationship between pain and FoP or that FoP added to the variance of other known predictors. Our results indicate that interpretation bias is common amongst people with RA and is associated with FoP. Further research is required to illuminate the exact nature of this relationship.

A synthesis of meta-analyses of mindfulness-based interventions in pain.

ABSTRACT: Mindfulness interventions have become popular in recent decades, with many trials, systematic reviews, and meta-analyses of the impact of mindfulness-based interventions (MBIs) on pain. Although many meta-analyses provide support for MBIs, the results are more mixed than they at first appear. The aim of this umbrella review was to determine the strength of evidence for MBIs by synthesizing available meta-analyses in pain. We conducted a systematic search in 5 databases and extracted data from published meta-analyses as the unit of analysis. For each outcome, we reported the range of effect sizes observed across studies and identified the largest meta-analysis as the "representative" study. We separately analysed effect sizes for different pain conditions, different types of MBIs, different control groups, and different outcomes. We identified 21 meta-analyses that included 127 unique studies. According to Assessment of Multiple Systematic Review ratings, the meta-analyses ranged from very strong to weak. Overall, there was an impact of MBIs on pain severity, anxiety, and depression but not pain interference or disability. When conditions were considered in isolation, only fibromyalgia and headache benefited significantly from MBIs. Mindfulness-based interventions were more efficacious for pain severity than passive control conditions but not active control conditions. Only pain severity and anxiety were affected by MBIs at follow-up. Overall, our results suggest that individual meta-analyses of MBIs may have overestimated the efficacy of MBIs in a range of conditions. Mindfulness-based interventions likely have a role in pain management but should not be considered a panacea.

The development and validation of the Worries About Recurrence or Progression Scale (WARPS).

OBJECTIVES: Worry about recurrence or progression is a common concern among people with chronic physical illnesses. Although there are options to measure the fear of cancer recurrence and other illness-specific measures, there is only one transdiagnostic measure of fear of progression, which does not assess the fear of recurrence or relapse. DESIGN: A multi-phase study outlining the development and validation of a novel transdiagnostic measure of fear of recurrence or progression, the Worries About Recurrence and Progression Scale (WARPS). METHOD: From a prior systematic review, we used quotes from people with lived experience to generate 55 items. Next, we piloted the items with 10 people with a range of chronic conditions, leading to a final total of 57 items. We then recruited four groups of people with cardiac disease, rheumatic disease, diabetes and respiratory disease (n = 804). An exploratory factor analysis in a randomly split sample resulted in an 18 item, single factor scale. We then performed confirmatory factor analysis on these 18 items in the remaining sample. RESULTS: The 18-item WARPS demonstrated good construct validity, internal consistency and test-retest reliability. Specifically, the WARPS was strongly correlated with the Fear of Progression Questionnaire, and with illness-specific fears. Significant, moderate correlations were observed with depression, anxiety, stress, and death anxiety. The WARPS demonstrated the validity and reliability amongst people with four of the most common chronic conditions and the factor structure was invariant across genders. CONCLUSION: The WARPS is a valid and reliable tool to measure transdiagnostic worries about recurrence and progression.

From dread to disorder: A meta-analysis of the impact of death anxiety on mental illness symptoms.

Growing research suggests that death anxiety may be transdiagnostic, playing a key role in the development and symptomology of psychopathology. This meta-analysis examined the relationship between death anxiety and mental illness symptoms. In total, 104 papers were included, representing cross-sectional data from 99 studies (ntotal = 24,434), and experimental data from 11 studies (ntotal = 1372). Meta-analyses of cross-sectional studies indicated a moderate correlation (r = 0.397) between death anxiety and overall mental illness symptoms. The clinical nature of the group emerged as a significant moderator of this effect. In addition, the relationship between death anxiety and mental illness symptoms was larger for clinical samples (r = 0.580), and for anxiety-related symptoms (r = 0.506) than for depression. Additional meta-analyses of 11 mortality salience studies revealed that death reminders had an overall moderate impact on clinical symptoms (Hedge's g = 0.481). The relevance of the sample to the symptom being measured significantly predicted this relationship; that is, the effect was moderate-to-large (Hedge's g = 0.671) when excluding comparison subgroups for which the effect was not predicted by the authors. The clinical nature of the sample did not significantly moderate the effect. The experimental studies were generally of higher quality and lower risk of publication bias compared to cross-sectional studies. These findings support the strong transdiagnostic role of death anxiety across numerous disorders. Clinical implications include the potential need to treat death anxiety directly, to maximise long-term therapy benefits.