This article was downloaded by: [Acadia University]

On: 03 May 2013, At: 05:37

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Psychology, Health & Medicine

Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/cphm20

A review of the affects of worry and

generalized anxiety disorder upon
cardiovascular health and coronary
heart disease
a b a c
Phillip J. Tully , Suzie M. Cosh & Bernhard T. Baune
a
School of Psychology, University of Adelaide, Adelaide, Australia
b
Department of Cardiac and Thoracic Surgery, Flinders Medical
Centre and Flinders University, Bedford Park, Australia
c
Discipline of Psychiatry, University of Adelaide, Adelaide,
Australia
Published online: 16 Jan 2013.

To cite this article: Phillip J. Tully , Suzie M. Cosh & Bernhard T. Baune (2013): A review of the
affects of worry and generalized anxiety disorder upon cardiovascular health and coronary heart
disease, Psychology, Health & Medicine, DOI:10.1080/13548506.2012.749355

To link to this article: http://dx.doi.org/10.1080/13548506.2012.749355

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-

conditions

This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden.

The publisher does not give any warranty express or implied or make any representation
that the contents will be complete or accurate or up to date. The accuracy of any
instructions, formulae, and drug doses should be independently verified with primary
sources. The publisher shall not be liable for any loss, actions, claims, proceedings,
demand, or costs or damages whatsoever or howsoever caused arising directly or
indirectly in connection with or arising out of the use of this material.
 Psychology, Health & Medicine, 2013
http://dx.doi.org/10.1080/13548506.2012.749355

A review of the affects of worry and generalized anxiety disorder

upon cardiovascular health and coronary heart disease
Phillip J. Tullya,b*, Suzie M. Cosha and Bernhard T. Baunec
a
School of Psychology, University of Adelaide, Adelaide, Australia; bDepartment of Cardiac and
Thoracic Surgery, Flinders Medical Centre and Flinders University, Bedford Park, Australia;
c
Discipline of Psychiatry, University of Adelaide, Adelaide, Australia
(Received 6 April 2012; nal version received 9 November 2012)
Downloaded by [Acadia University] at 05:37 03 May 2013

Objective: The aims of this review article are to present psychophysiological and
behavioral pathways for the involvement of worry and generalized anxiety disorder
(GAD) upon cardiovascular function. The review will focus on persons with and
without coronary heart disease (CHD), and encompass etiological and prognostic
studies. Methods: Articles (19752011) reporting on GAD or worry affecting CHD
prognosis or cardiovascular function were found using MEDLINE, EMBASE, SCO-
PUS and PsychINFO database searches, and extracted to form a narrative review.
Results: Available evidence in experimental and observational studies in CHD free
samples consistently showed that worry was associated with diminished heart rate
variability (HRV) and elevated heart rate. Worry and GAD were commonly associated
with blood pressure and diagnosed hypertension or medication use in both disease-
free and established CHD populations. No evidence was found to support worry
being benecial to cardiovascular function or conducive to health promoting behav-
iors. The literature indicated that measures of worry were associated with fatal and
nonfatal CHD in seven etiological studies of initially disease-free individuals; how-
ever, females were underrepresented. Three studies reported that GAD was associated
with poorer prognosis in establish CHD, independent of depression. The median
GAD prevalence was 10.4% in 3266 patients across 15 studies, suggesting that GAD
is marginally less common in CHD samples than is depression. Conclusions: A grow-
ing literature highlights the association between worry and development of CHD. The
association between worry, GAD and CHD risk factors (e.g. blood pressure), and
HRV are leading mechanisms of cardiopathogenesis that may affect cardiovascular
function. Findings regarding worry and GAD in established CHD are less clear.
Keywords: anxiety disorders; heart diseases; worry; depression; review

Introduction
The importance of depression upon coronary heart disease (CHD) prognosis and quality
of life has been extensively documented (Baumeister, Hutter, & Bengel, 2011a; 2011b).
However, that modest impact of depression interventions on cardiovascular disease
(CVD) outcomes suggests that what is understood about the depression-CHD link is
incomplete. Some evidence implicating anxiety in CVD prognosis raises the possibility
that depression is not a discrete psychiatric risk factor CHD. In particular, generalized
anxiety disorder (GAD) commonly co-occurs with depression (Tully & Cosh, in press),

*Corresponding author. Email: phillip.tully@adelaide.edu.au

2013 Taylor & Francis

 2 P.J. Tully et al.

and scholars debate whether these do form separate disorders (Andrews et al., 2010).
The large degree of comorbidity and symptom overlap, at the very least, highlights
possible confounds in the purported depression-CHD link (Frasure-Smith & Lesperance,
2008). Though depression meta-analyses suggest an independent association with CHD,
none of the original empirical studies are adjusted for GAD.
The hallmark clinical feature of GAD is unequivocally excessive and uncontrollable
worry (anxious apprehension) (Andrews et al., 2010). Worry might also emerge as
important in CHD considering that interrelated cognitive processes (e.g. rumination,
worry, and perseverative cognitions) are evident in GAD and depression (Brosschot,
Gerin, & Thayer, 2006; Larsen & Christenfeld, 2009). A critical appraisal and synthesis
of GAD and worry research in CHD may identify common or alternative cardiotoxic
correlates to the depression-CHD association. The role of perseverative cognitions in
somatic diseases has been previously reviewed elsewhere (Brosschot et al., 2006;
Larsen & Christenfeld, 2009). However, no evidence is available to review the effects
of GAD and worry as it relates to CHD aetiology and prognosis. The aims of this
Downloaded by [Acadia University] at 05:37 03 May 2013

review article are to present psychophysiological and behavioral mechanisms for the
involvement of worry and GAD upon cardiopathogenesis in persons with and without
CHD. To cover these aims, we describe the effects of GAD and worry on cardiac func-
tion. This paper also describes evidence for worry and GAD upon health promoting
behaviors. Finally, we conclude with a synthesis of etiological and prognostic studies
between GAD, worry, and CHD; making recommendations for further research.

Methods
A systematic search of the Medline, EMBASE, SCOPUS, and PsycINFO electronic dat-
abases was performed without language restrictions for peer-reviewed papers published
between January 1975 and November 2011. General search terms included GAD and
worry, in combination with; CHD, cardiovascular disease, heart disease, ischemic heart
disease, myocardial infarction (MI), cardiac death, coronary artery bypass graft, percuta-
neous coronary intervention, angioplasty, and heart failure. Initial searching revealed
673 abstracts and 402 included the search term worry. Articles were excluded if they
included anecdotal evidence, did not relate to GAD/worry and CHD, or concerned phar-
macological treatment (e.g. dexamethasone suppression test). Given the emphasis on
CHD, we sought to exclude cardiovascular populations with predominantly noncoronary
aetiologies such as mitral valve prolapse, stroke populations, hereditary cardiac disease
and genetic counseling, pediatric, and palliative populations. Resultantly, 505 abstracts
were excluded. The remaining 168 full-text articles were sought, as were a further
seven that were identied by manual searching. The resulting full-text articles were read
thoroughly and their utilization in this review was based on their journal type (i.e. peer
reviewed) and salience to the aims set forth in this review. Finally, 61 articles were
included in this literature review (Figure 1).

Results
Effects of GAD and worry on cardiovascular function
Altered autonomic nervous system activity, dysregulated hypothalamic pituitary adrenal
axis function, and reduced vagal control have been a focus of research to date
(Brosschot et al., 2006). A summary of psychophysiological ndings is presented for
CHD and nonCHD in Table 1 Studies have suggested that episodes of worry and
 Psychology, Health & Medicine 3

673 articles retrieved from

primary literature search

505 articles were excluded

after a review of abstracts

168 articles subjected to full

text review

+ 7 identified by manual
searching
Downloaded by [Acadia University] at 05:37 03 May 2013

114 articles were excluded

based on criteria of quality
and salience

61 articles retained for this

review

Figure 1. Study inclusion ow chart.

prolonged worry duration are associated with diminished HRV (Brosschot, Van Dijk, &
Thayer, 2007; Pieper, Brosschot, van der Leeden, & Thayer, 2007). Thayer, Friedman,
and Borkovec (1996) showed that exposure to experimental worry conditions was asso-
ciated with shorter cardiac interbeat intervals and lower high-frequency spectral power,
indicative of diminished heart rate variability (HRV). Supporting that worry behaviors
were also associated with decreased vagal activity, Hammel et al.s (2011) experimental
task showed that GAD patients displayed signicantly lower inter-beat heart rate (HR)
intervals, and lower HRV, suggesting decreased parasympathetic inuence and increased
sympathetic activity. Ambulatory echocardiogram recordings of 52 healthy subjects
showed that worry frequency and duration was associated with higher HR and lower
HRV during wakeful periods and extended into subjects sleeping period (Brosschot
et al., 2007). Knepp and Friedman (2008) showed that high worry was associated with
elevated HR but not HRV in various laboratory stressor and worry induction tasks. Ver-
kuil et al.s work (Verkuil, Brosschot, de Beurs, & Thayer, 2009) suggested that recovery
in HRV was slower among high-trait worriers and those with high levels of intrusive
thoughts during worry exposure. Together, the ndings suggest that perseverative nature
of verbal worry, in conjunction with a hypervigilant attentional state, might contribute to
cardiac dysfunction through diminished HRV and higher HR (Brosschot et al., 2006).
The mechanisms of worry and GAD-related cardiopathognesis have been infre-
quently described in established CHD populations. Bankier et al. (2008) found that
GAD diagnosis was associated with greater odds for C-reactive protein > 3 mg/L,
whereas depression and comorbid GAD-depression was not. Among stable CHD
outpatients, no association was evident between GAD and indices of HRV, serotonin,
 Downloaded by [Acadia University] at 05:37 03 May 2013

Table 1. Cardiovascular correlates of worry and GAD in samples with or without CHD.
Psychological
Study Study population Age, M (SD) measure Procedure Biological correlates Behavioural correlates

Bankier et al. (2008) 120 Stable CHD Depression and SCID DSM-IV Structured GAD " CRP, OR 4.8 (95% C
(15 with GAD) anxiety 68 8.0, interview, blood I 1.121.8) P = 0.04
Anxiety assay TnT NRNT-proBNP NR
only = 68.5 9.5
P.J. Tully et al.

Barger and Sydeman 3032 non-CHD Range 2575 CIDI_SF Telephone GAD " HTN
(2005) interview and medication OR 3.10 (CI
postal survey 1.277.56)
GAD " smoking OR
2.28 (95% CI 1.04
5.00)
Brosschot et al. (2007) 52 general 33.8 13.9 PSWQ Worry frequency Worry frequency " HR
population STAI and duration, Worry frequency # HRV during
stressors, sleep waking Trait worry " HR
quality. Trait worry # HRV
Carroll, Phillips, Gale, 4180 Vietnam 38.3 DIS DSM-III Structured GAD " HTN OR 1.48
& Batty (2010) Veterans interview (CI 1.18 1.87)
Frasure-Smith and 804 ACS 60.0 10.6 HADS-A Structured GAD no association with LVEF, occluded GAD # BMI r = .09
Lesperance (2008) interview > 2 vessels > 50%, BP, trigylceride, metabolic GAD # waist
months post syndrome, aspirin, blockers, ACE inhibitors, circumference r = .10
discharge for ACS calcium channel blockers, long-acting nitrates
Hammel et al. (2011) 16 GAD and 19 GAD 20.8 2.9, PSWQ Worry induction GAD # IBI p<.05
non-GAD without non-GAD 20.1 GAD-Q-IV experiment with GAD # HRV HF p < .001
CVD SD 1.3 worry control GAD # HRV LF p < .001
strategies
Hoehn-Saric et al. 40 GAD, 36.0 SCID, DSM-IV 4 days ambulatory GAD " rapid HR, tense, sweating
(2004) 26 PD, monitoring IBI (compared to control group)
24 control Control group " HR IBI (vs. GAD and PD)
Hofmann, Schulz, 39 GAD treatment 28 9.92 ADIS, DSM-IV Structured MDD-GAD " HRV compared to GAD only
Heering, Muench, (14 with MDD) interview, ECG,
& Bufka (2010) relaxation and
worry induction

(continued)
 Downloaded by [Acadia University] at 05:37 03 May 2013

Table 1. (Continued).
Psychological
Study Study population Age, M (SD) measure Procedure Biological correlates Behavioural correlates

Knepp and Friedman 41 female 19.7 PSWQ (high vs. ECG, stressor High worry " HR
(2008) university students low worry) task, worry Worry no association with HRV
imagery,
relaxation
Kuczmierczyk et al. 38 GAD and 21 GAD 40.2 10.0, SCID-DSM-III-R Structured GAD " cholesterol GAD no association
(1996) GAD-MDD GAD-MDD M interview GAD " triglyceride with BMI
36.7 8.8
Martens et al. (2010) 1015 stable CHD NR DIS, DSM-IIIa Structured GAD " LVEF GAD " smoking
(106 with GAD) interview GAD " renin-angiotensin system inhibitor use GAD " medication
GAD no association with cholesterol, HRV, cortisol, non-adherence
norepinephrine, CRP, aspirin, blocker, HTN, MI, GAD # self report
DM, CHF, stroke, physical activity
GAD no association
with BMI,
Muhsen, Lipsitz, 2,082 NHS (53 48.3 16.6 CIDI-SF, DSM-IV Structured GAD # regular
Garty-Sandalon, with GAD) interview, exercise OR 0.46 (CI
Gross, & Green telephone survey 0.220.95)
(2008)
Parker et al. (2011) 436 ACS NR CIDI, DSM-IV Structured GAD " past CAB GAD no association
interview GGAD # creatinine with smoking or visits
GAD no association with HTN, CRP, cholesterol, to physician
diseased vessels, TnT,
Phillips et al. (2009) 4,256 38.3 DSM-III Structured GAD no association with cholesterol, blood glucose, GAD # alcohol use
maleVietnam interview, BP GAD " smoking
veterans, USA telephone survey GAD no association
BMI
Pieper et al. (2007) 73 teachers 46.7 9.5 PSWQ Naturalistic worry Worry episodes " HR 2.00 (CI 0.913.09, p < .05)
WDQ diary (duration, beats/min
Job Content intensity, Future related worry " HR 4.79
Questionnaire controllability) (CI 3.146.44, p < .01)
Worry episodes #
HRV (antilog 1.06; CI 1.04 1.10, p < .05)
Ray et al. (2009) 9 GAD and 9 GAD (M = 36 HAM-D Attention, Control group " vagal tone parasympathetic vs.
matched controls NA) non-GAD HAM-A relaxation, worry sympathetic tasks (control 6.3 vs. 5.7; GAD 5.9 vs.
Psychology, Health & Medicine

without Axis-I (M = 35 NA) PSW induction 6.0, p < .01)

disorders QBDI (parasympathetic
STAI and sympathetic)
5

(continued)
 Downloaded by [Acadia University] at 05:37 03 May 2013

Table 1. (Continued).
Psychological
Study Study population Age, M (SD) measure Procedure Biological correlates Behavioural correlates

Sevincok et al. (2001) 117 mixed MDD-GAD (35.2 GAD-MDD " cholesterol
psychiatric 7.9) GAD only GAD-MDD " triglyceride
disorders and 33.3 8.2
control
P.J. Tully et al.

Thayer et al. (1996) 34 GAD and 32 GAD 35.6 10.2, ADIS-R Relaxation and GAD # IBI p < .05
non-anxious control 35.3 11.2 worry induction GAD # HF power p < .05
controls Worry induction # IBI
p < .05
Worry induction # HF power
p < .05
Verkuil et al. (2009) 59 undergraduate 22.4 3.7 PSWQ Cognitive stress Trait worriers " HR during stressor
students RRS task, implicit Trait worriers " HR during recovery
explicit
perseverative
cognition

Notes: BDI, Beck Depression Inventory; CRP, C-reactive protein; CVD, cardiovascular disease; ECG, electrocardiogram; FQ, fear questionnaire; GAD, generalized anxiety disor-
der; GAD-Q-IV Generalized Anxiety Disorder Questionnaire; HAM-A, Hamilton Anxiety Inventory; HAM-D, Hamilton Depression Inventory; HF, high frequency; HR, heart rate;
HRV, heart rate variability; IBI, interest intervals of heart rate; LF, low frequency; NR, not reported; NT-proBNP, amino-terminal pro-B-type brain natriuretic peptide; PD, panic
disorder; PSWQ, Penn State Worry Questionnaire; RMSSD, root mean square of successive differences of interbeat intervals; RRS, ruminative response scale; STAI, Spielberger
trait anxiety inventory; TnT, Troponin; WDQ, Worry domain questionnaire; WQ, worry questionnaire.
 Psychology, Health & Medicine 7

cortisol, norepinephrine, or C-reactive protein in a sample of more than 1000 patients

(Martens et al., 2010). Together, the studies to date do not support a consistent associa-
tion between GAD and physical mechanisms of cardiopathogenesis in CHD samples,
though few observational studies have been conducted.

Cross-sectional association between GAD and CHD

The prevalence of GAD is shown in Table 2 for studies with veried and self-reported
CHD. There were 418 GAD cases among 3266 patients and the median GAD preva-
lence was 10.4%. There were 221 cases of lifetime GAD among 881 CHD cases and
the median lifetime GAD prevalence was 24.4%. Three large epidemiological studies
reported cross-sectional derived ORs that could not be converted to prevalence esti-
mates in CHD. The rst study by Ormel et al. (2007) showed twofold odds for self-
reported CHD according to GAD status in 85,052 persons across 17 countries. Also, a
survey of 43,093 US civilians showed that the largest effect size for physician-diag-
Downloaded by [Acadia University] at 05:37 03 May 2013

nosed cardiovascular disease was attributable to GAD, as opposed to any other affect or
mood disorder (Goodwin, Davidson, & Keyes, 2009). The Gutenberg Heart Study of
5000 respondents, however, did not support a signicant association between a two-
item GAD questionnaire proxy and CHD or MI (Wiltink et al., 2011).

GAD, worry, and CHD risk factors

Cross-sectional GADCHD associations are potentially mediated by CHD biobehavioral
risk factors such as hypertension (Barger & Sydeman, 2005). In a representative sample
of 3032 adults, Barger and Sydeman (2005) reported that GAD denoted two to three-
fold greater odd for blood pressure medication use, controlling for comorbid depression.
This nding was corroborated elsewhere in samples of Vietnam Veterans (Carroll et al.,
2010). A large survey of 5877 residents in the US National Comorbidity Survey
showed, however, that GAD was not associated with hypertension or cardiac disease
(OR = 1.10, 95% CI 0.621.97), adjusted for demographics and other mental disorders
(Sareen, Cox, Clara, & Asmundson, 2005). A German cross-sectional study among
5000 persons aged 3574 years showed that GAD was associated with increased odds
for obesity (OR = 1.65, 95% CI 1.112.44) (Wiltink et al., 2011). However, only depres-
sion was associated with diabetes and dyslipidemia. Smaller studies among clinical
GAD populations, without known CHD, have suggested signicantly higher cholesterol
and triglyceride levels among pure GAD vs. comorbid GADMDD groups (Kuczmierc-
zyk, Barbee, Bologna, & Townsend, 1996). In contrast, Sevincok, Buyukozturk, Dere-
boy (2001) showed that patients with comorbid GAD and depression were found to
have higher total serum cholesterol, triglyceride, mean high-density lipoprotein, and
mean low-density lipoprotein than patients with GAD alone. Together, the data suggest
that GAD is associated with hypertension and blood pressure medication and largely
independent of depression. However, the independent, conjoint, or mediating effects of
depression on blood pressure are not clear.

GAD, worry, and CHD risk and health promoting behaviors

Some cognitive models assert that GAD patients can hold positive views concerning
worry and their ability to cope and plan for future catastrophe (Dugas, Letarte,
Rhaume, Freeston, & Ladouceur, 1995). Thus, worry may lead to health promoting
behaviors and be benecial to CHD prognosis. With respect to interventions, Lee et al.
 8 P.J. Tully et al.

Table 2. Prevalence of GAD among samples with documented CHD.

Lifetime Current
Age, M Female GAD GAD % GAD%
Study Country Sample (SD) % (N) Criteria (N) (N)

Martens et al. (2010) USA 1015 CHD NR 18.0 DIS, 10.4

(183) DSM-III (106)
a

Frasure-Smith and CAN 804 CAD 60.0 19.3 SCID, 5.3

Lesperance (2008) (10.6) (155) DSM- (43)
IV
Parker et al. (2011) AUS 436 post- 65.7 29.7 CIDI, 29.4 16 (70)
ACS (12.2) (145) DSM- (128
IV
Sherbourne, Jackson, USA 245 MI, HF 61.1 40.0 DIS, 22.8 12.4
Meredith, Camp, (1.0) (98) DSM-III (53) (33)
& Wells (1996)
Downloaded by [Acadia University] at 05:37 03 May 2013

Tully et al. (2011) AUS 158 pre- 64.7 20.9 MINI, 10.1
CABG (10.6) (33) DSM- (16)
IV
Todaro, Shen, Raffa, USA 150 CHD 60.6 32.0 ADIS, 26.0 18.7
Tilkemeier, & rehabilitation (12.3) (48) DSM- (39) (28)
Niaura (2007) IV
Valkamo et al. FIN 144 NR 42.3 SCID, 2.1 (3)
(2003) angiography (36) DSM-
>50% III-R
Fedoroff, Lipsey, USA 129 post-MI 56 (16) NR PSE, 10.1
Starkstein, & DSM-III (13)
f
Forrester (1991)
Bankier et al. (2008) USA 120 stable NR 30.8 SCID, 12.5
CHD (37) DSM- (15)
IV
Bettina Bankier, USA 100 CHD 67.1 31 SCID, 24.0
Januzzi, & (13.6) (31) DSM- (24)
Littman (2004) IV
Haworth et al. UK 98 HF 67.0 (17) SCID, 11.0
(2005) (11.0) DSM- (11)
IV
Vogelzangs et al. NL 97 self- NR NR CIDI, 50.0
(2010) reported DSM- (49)
CHD IV
Birket-Smith, DEN 86 CHD Median 37 PRIME- 4.7 (4)
Hansen, Hanash, 68 (43) MD,
Hansen, & DSM-
Rasmussen (2009) III-R
Fraguas Junior, BRA 50 pre- 54.4 14 (7) DSM- 2.0 (1) 2.0 (1)
Ramadan, Pereira, CABG III-R
& Wajngarten
(2000)
Rothenhausler et al. GER 34 pre- 68.2 25.3 SCID, 5.9 (2)
(2005) cardiac (9.7) (12) DSM-
surgery IV
Notes: ACS, acute coronary syndrome; ADIS, anxiety disorder interview schedule; AUS, Australia; BRA,
Brazil; CABG, coronary artery bypass graft; CAD, coronary artery disease; CAN, Canada; CHD, coronary
heart disease; DISH, Diagnostic Interview Schedule; DSM, Diagnostic and Statistical Manual of Mental Disor-
ders; GER, Germany; MINI, MINI International Neuropsychiatric Interview; NR, not reported; PSE, Present
State Exam; SCID, Structured Clinical Interview for DSM-III-R; USA, United States of America.
 Psychology, Health & Medicine 9

(2011) showed that visual presentation of a persons CHD risk could induce worry,
which, in turn, may play a critical role in motivation for health behavior change. Some
evidence in nonCHD-specic populations revealed that GAD patients are equally as
likely as panic disorder patients to have sought medical consultation and undergone
echocardiogram for chest pain (Logue et al., 1993), though cardiovascular symptoms
are more common in panic disorder than GAD (Hoehn-Saric, McLeod, Funderburk, &
Kowalski, 2004). Also, in Carter and Maddocks (1992) clinical psychiatric sample,
chest pain was a common symptom in GAD patients and 67% of those underwent a
medical evaluation for these symptoms. However, the proportion of GAD patients
meeting physician veried CHD as a consequence of such a proactive approach to
health was not reported. Another cross-sectional study by Barsky et al. (Barsky, Cleary,
Coeytaux, & Ruskin, 1994) comparing general medical patients with a cohort referred
for heart palpitations which found lower GAD prevalence among the palpitation group.
Recently, Parker and colleagues (2011) speculated about the constructive aspects of
worry in relation to medication adherence and a proactive approach to health practitio-
Downloaded by [Acadia University] at 05:37 03 May 2013

ners. However, the authors showed that after acute coronary syndrome, GAD patients
were no more likely than nonGAD patients to have visited their general practitioner or
specialist, receive new scripts for medications, or join a rehabilitation/support group
(Parker et al., 2011). In fact, other ndings suggest around twofold odds for excessive
smoking or tobacco use among GAD patients (Barger & Sydeman, 2005; Grant et al.,
2009; Patten and Liu, 2007; Phillips et al., 2009) including among documented CHD
samples (Martens et al., 2010). Specically, the association between GAD and
behavioral CHD risk factors were evident in the Heart and Soul Study (Martens et al.,
2010), which reported greater smoking, lower physically activity, and less adherence to
prescribed medications in GAD patients. Parallel ndings were evident in a large cohort
study which reported that worry concerning social conditions was signicantly associ-
ated with smoking, alcohol use, and family history of heart disease (Kubzansky et al.,
1997). Moreover, the Scottish Health Survey in 11,905 community dwelling individuals
showed that high worry was associated with smoking, lower physical activity, larger
BMI, HTN, and diabetes (Hamer, Batty, & Kivimaki, 2011).
Other research also did not support health-promoting benets of worry and GAD.
Bosworth et al. (2008) suggested that worry about hypertension was actually associated
with poorer blood pressure control, corroborating earlier reports of an association
between worry and hypertension (Levenstein, Smith, & Kaplan, 2001; Powers &
Jalowiec, 1987). In a diverse ethnic sample of women aged 3691 years (Wilcox,
Ainsworth, LaMonte, & DuBose, 2002), worry-related preventative action was not evi-
dent for cardiovascular conditions, but only for breast cancer (e.g. monthly breast
exams). Ethnicity and socioeconomic factors may also inuence health behavior; in one
study, African-American respondents worry about CHD had a pronounced effect on
health promoting behaviors, but only in those of lower socioeconomic status (Ransford,
1986). By contrast, in white respondents, CHD-related worry had no effect on health
promoting behaviors (Ransford, 1986). Together, these ndings suggest that behavioral
pathways link both GAD and worry with CHD risk, and probable links appear to be
alcohol use, smoking, and lower physical activity in addition to blood pressure.

GAD etiological ndings in initially CHD free individuals

Etiological studies reporting the association between GAD and worry in, initially, CHD-
free individuals with subsequent CHD are reported in Table 3. Scherrer et al. (2010)
 10 P.J. Tully et al.

longitudinally followed-up a large sample of Veterans Affairs and showed a 30%

increase risk of MI among patients with GAD. However, GAD was only associated
with incident MI among nondepressed patients (HR 1.17, 0.981.39) (Scherrer et al.,
2010). Fifteen year follow-up of male Vietnam veterans by Phillips et al. (2009) showed
that GAD diagnosis alone was associated with nearly threefold greater risk for cardio-
vascular disease mortality (HR = 2.89, 95% CI 1.595.23). However, subsequent analy-
ses suggested that the cumulative effect of GAD, depression, and post-traumatic stress
disorder exerted the largest effect for all-cause and CVD mortality, contrasting to the
effect for GAD in nondepressed cases reported by Scherrer et al. (Scherrer et al., 2010).

Worry etiological ndings in initially CHD-free individuals

With respect to worry, Kubzansky et al. (Kubzansky et al., 1997) showed that a high level
of worry about social conditions was associated with an increased risk ratio (RR) for non-
fatal MI (RR = 2.41 95% CI 1.404.13) among initially healthy males. A trend association
Downloaded by [Acadia University] at 05:37 03 May 2013

was also evident between worry about social conditions and incident CHD (Table 3),
though health-related worry was associated with an age-adjusted RR of 2.19 for sudden
cardiac death (95% CI 1.014.76). Two-year follow-up of 33,999 male health profession-
als, aged 4277 years in 1988 (Kawachi et al., 1994), showed that responses to the ques-
tion worrying unduly when relatives are late coming home was associated with fatal
CHD in age-adjusted analysis (RR 2.26, 95% CI 1.224.18) but not nonfatal MI (RR
0.97, 95% CI 0.641.48) or total CHD (RR 1.23, 95% CI 0.871.73) (Kawachi et al.,
1994). Similarly, Hamer et al. (2011) recently showed that sleep loss due to worry was
only marginally associated with incident CVD. In fact, health-related behaviors (smoking,
alcohol, and physical inactivity) accounted for approximately 40% of the sleepCVD
association. Elevated transitory worry on the bradbury worries index was not associated
with CHD after adjustment for covariates such as age, sex, socioeconomic status, and
smoking (Vogt, Pope, Mullooly, & Hollis, 1994). Finally, subsequent to 9/11 terrorist
attacks, a high level of ongoing worry about terrorism was associated with incident CVD
diagnosis at three-year follow-up (Holman et al., 2008).

GAD, worry, and cardiac prognosis in CHD populations

The ndings from four studies reporting the association between GAD and cardiac mor-
bidity among CHD samples are summarized in Table 4. The largest study showed that
GAD increased the risk for subsequent major cardiovascular events between 61 and
74% after adjustment for comorbid depression, indices of cardiac function, and health
behaviors such as medication use and physical inactivity (Martens et al., 2010). Major
depression impacted the strength of GAD association with cardiac outcome by less than
5% and the GAD-depression interaction was nonsignicant. Tully et al. (2011) also
showed that GAD, but not major depression or panic disorder, was associated with a
threefold increased risk of major within-hospital morbidity (e.g. death, stroke, and renal
failure) after cardiac surgery in adjusted analyses.
The two extant acute coronary syndrome studies produced contrasting ndings
(Frasure-Smith & Lesperance, 2008; Parker et al., 2011). The largest study reported by
Frasure-Smith and Lesperance (2008) recruited patients two months after hospitalization
and showed that GAD increased the risk of cardiac death, MI, cardiac arrest, and twofold
nonelective revascularization in adjusted analyses (Frasure-Smith & Lesperance, 2008).
The largest effect size in risk of subsequent cardiac outcome was attributable to any
 Downloaded by [Acadia University] at 05:37 03 May 2013

Table 3. Aetiological and cross-sectional association between worry, GAD and cardiac outcomes in initially disease free individuals .

Age, Female Effect Size

Study Sample M(SD) % (N) Anxiety measure F/U Outcome Adjustment (95% CI)

Scherrer et al. 355,999 55.7 (13.2) 11.8 ICD-9 CM 7 yr Incident MI Age HR 1.28 (1.18
(2010) Veterans (41,907) 1.38)
Administration,
USA
Phillips et al. 4,256 male 38.3 None DSM-III Mean CVD mortality Age, place of service, HR 1.84 (0.98
(2009) Vietnam 14.6 yr ethnicity, marital 3.45)
veterans, USA status, smoking,
alcohol use, IQ,
income, BMI,
cholesterol, BP,
glucose, somatic
illness).
Kubzansky 1,758 21 80 yrs None Worry domains Mean Incident CHD, Age, smoking, blood Incident CHD
et al. (1997) community (range) questionnaire -social 13.7 yr fatal CHD, pressure, cholesterol, RR 1.48 (0.99-
dwelling males, conditions BMI, family history 2.20)
USA CHD (%), alcohol Fatal CHD RR
intake 0.81 (0.45-
1.44)
Kawachi et al. 33,999 male 40 75 yrs None Crown Crisp phobic 2 yr Fatal-CHDTotal Age Fatal CHD RR
(1994) health (range) anxiety scale CHD 2.26 (1.22-
professionals, worrying unduly 4.18)
USA when relatives are late Total CHD RR
coming home 1.23 (0.87-
1.73)
Hamer et al. 11,905 53.4 (12.2) yrs 57.8 Sleep loss due to 8 yr CVD death, MI, Age, sex, BMI, HTN, HR 1.13
(2011) community (6,881) worry (much more coronary DM,socioeconomic (0.871.46)
dwelling adults, than usual) surgical position, marital status,
SCO procedures, antidepressant use,
Psychology, Health & Medicine

stroke, and heart physical activity,

failure smoking, alcohol,
11

(continued)
 Downloaded by [Acadia University] at 05:37 03 May 2013

Table 3. (Continued).
12

Age, Female Effect Size

Study Sample M(SD) % (N) Anxiety measure F/U Outcome Adjustment (95% CI)

Vogt et al. 1,529, USA 1875 + (range) 53.9 Bradburn 15 yr IHD Age, sex, SES, length HR 1.18 (.85 -
(1994) (1386) Worries Index of health plan 1.63)
membership,
subjective health,
P.J. Tully et al.

smoking
Holman et al. 2,729 NR 52.2% I worry that an act of 3 yr ICD coded heart Sex, age, marital High worry
(2008) probability (6,881) terrorism will problems status, race, ethnicity, RR 3.22 (1.05
sample, USA personally affect me education, income, 9.85)
or someone in my prior cardiac, mental Low worry RR
family in the future and endocrine .37 (.10
ailments, exposure to 1.36)
stressful events,
9/11-related exposure,
concurrent mental and
physical health
ailments, post-9/11
somatization
Most adjusted model shown for GAD where available.
Notes: CHD, coronary heart disease; CI, condence interval; CVD, cardiovascular disease; DSM, Diagnostic and Statistical manual; GAD, generalized anxiety disorder; HR, haz-
ard ratio; ICD, International Classication of Diseases; ICD-9CM, International Classication of Diseases Clinical Modication; MI, myocardial infarction; NR, not reported;
SCO, Scotland; SES, socio-economic status; USA, United States of America.
 Psychology, Health & Medicine 13

depression and/or GAD diagnosis. Contrasting results were reported by Parker et al.
(2011) who followed a sample of 436 ACS patients at ve years for cardiac readmission
and death. The multivariate model showed that GAD in isolation was associated with
reduced risk for cardiac outcome (OR = .35, .17.75), though the discrete effects for other
affective disorders were not reported in multivariate analyses. The only study to employ
worry measures suggested that trait worry was not associated with cardiac outcome
(Parker et al., 2011). However, patients reporting worry in the immediate period after
ACS experienced more cardiac events (42.8% vs. 29.8%) (Parker et al., 2011).

Conclusions
A growing body of literature documents the role of GAD and worry in CHD and
cardiovascular risk. In established CHD, GAD increased the risk for major cardiac
events in three data-sets (Frasure-Smith & Lesperance, 2008; Martens et al., 2010; Tully
et al., 2011) and lowered risk in one data-set (Parker et al., 2011). Importantly, there
Downloaded by [Acadia University] at 05:37 03 May 2013

was insufcient evidence to suggest that GAD is merely a marker for other known
CVD mechanisms in persons with established CHD. With respect to etiological follow-
up of initially disease-free individuals, data showed that worry was associated with sub-
sequent CHD and fatal and nonfatal cardiovascular outcomes (Hamer et al., 2011;
Holman et al., 2008; Kawachi et al., 1994; Kubzansky et al., 1997; Phillips et al.,
2009; Scherrer et al., 2010; Vogt et al., 1994). There was insufcient evidence to sug-
gest a doseresponse relationship whereby GAD might exert greater cardiotoxic effects
than worry. Limitations of interpreting the literature to date include that ndings are
predominantly among male samples and generalization to females is dually problematic,
for GAD appears to disproportionately affect females (Andrews et al., 2010).
The most prominent biological mechanisms of cardiopathogenesis in worry were
diminished HRV in nonCHD samples, a nding yet to be consistently demonstrated in
persons with documented CHD. Clarication of the impact of worry and GAD upon car-
diovascular function in CHD will be informative to the design of psychological treatment
strategies and to rule out possible adverse cardiotoxic effects. For example, in vivo expo-
sure to worry imagery, an accepted psychotherapeutic treatment modality for GAD in
nonCHD patients (Borkovec & Ruscio, 2001), is potentially associated with greater
autonomic response and change in HRV that may have adverse cardiovascular implica-
tions for a person with GAD and comorbid CHD. Associations between GAD and CHD
risk factors such as smoking, excess alcohol use, and hypertension belie the suggestion
that excessive and uncontrollable worry (e.g. clinical GAD) might be benecial to pro-
mote cardiovascular health. In fact, worry was reportedly not related to CVD reducing
behavior changes (e.g. physical activity). Given that GAD research has lagged behind
other anxiety disorder research in the past decade (Dugas, Anderson, Deschenes, & Done-
gan, 2010), the recommendation for further GAD research in CHD cannot be understated.
A likely explanation for the limited GAD research in CHD samples is that studies,
published only since 2008, were preceded by an extensive literature documenting the
depression-CHD association. Frasure-Smith and Lesprance (2008), whom led the way
in depression research post-MI, concluded that the effects of depression and anxiety on
CHD might promote research into common genetic, environmental, and pathophysiolog-
ical pathways and treatments. Broader cognitive processes, such as rumination, observed
across a range of affective disorders may underlie associations with CHD (Larsen &
Christeneld, 2009) and medical illnesses generally (Brosschot, Gerin, & Thayer,
2006).
 Downloaded by [Acadia University] at 05:37 03 May 2013

Table 4. Prognostic association between GAD and cardiac outcomes in CHD populations.
14

Reference Sample F/U Outcome Adjustment Effect Size (95% CI)

Martens et al 1015 5.6 yrs stroke, heart failure, MI, transient Age, sex, MI, diabetes, LVEF, exercise Adjusted HR = 1.74
(Martens et al., stable ischemic attack, death, n = 371 capacity metabolic equivalent task, renin- (1.13 - 2.67)
2010) CHD (36.6%) angiotensin system inhibitor, tricyclic
antidepressant, antidepressant, medication
nonadherence, physical inactivity, HRV, C-
P.J. Tully et al.

reactive protein
Frasure-Smith & 804 2 yrs cardiac death, MI, cardiac arrest, Age, female, education, smoking, previous Adjusted OR = 2.29
Lesperance post- non-elective revascularization, MI, CABG or angiography, LVEF, coronary (1.07 - 4.88)
(Frasure-Smith ACS n = 115 (14.3%) artery bypass graft surgery during index
and Lesperance, hospitalization, 1 coronary vessels with
2008) 50% blockage after index revasculariza-
tion, BMI, triglyceride level, blood pressure,
calcium channel blockers, angiotensin-con-
verting enzyme inhibitors, statins
Tully et al (Tully 158 30 days Death, stroke/CVA, renal failure, Major depression, panic disorder, age, time Adjusted OR = 3.57
et al., 2011) pre- after ventilation > 24 h, deep sternal spent on cardiopulmonary bypass, elective (1.10 - 11.56)
CABG discharge wound infection, reoperation, vs. urgent surgery, MI<30 days, congestive
incident arrhythmia, n = 59 (37.3%) heart failure, hypertension
Parker et al 436 5 yrs Cardiac admission, death or event, Post-ACS depression, CABG, diabetes, GAD OR = .35 (.17.75)
(Parker et al., post n = 162 (37.2%) LVEF, CVA/TIA, non-GAD anxiety, GAD Trait worry p >.05 in logistic
2011) ACS and other anxiety disorder regression, OR NRWorry post-
ACS cardiac events (42.8%
vs. 29.8%, p <.001).
Most adjusted model shown for GAD where available.
Notes: ACS, acute coronary syndrome; CABG, coronary artery bypass graft; CHD, coronary heart disease; CI, condence interval; CVA, cerebrovascular accident; GAD, general-
ized anxiety disorder; HR, hazard ratio; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NR, not reported; OR, odds ratio; RR, risk ratio.
 Psychology, Health & Medicine 15

Limitations
This review should be interpreted while bearing in mind several limitations. Publication
bias may play a part in research documenting a positive role for GAD and worry upon
CHD and cardiovascular function. The lack of consistent denition and measurement of
worry would likely lead to heterogeneity in these results, whilst we did not include
studies assessing rumination or other perseverative cognitions. The qualitative nature of
this review is also potentially biased; however, we have outlined the literature search
strategy for clarity, and null ndings were described. Finally, it is plausible that the
affects of GAD and worry, like depression, are not completely understood and perhaps,
are merely markers for more severe cardiac disease severity.
In conclusion, evidence to date showed that the hallmark feature of GAD and worry
was associated with CHD risk factors such as HRV and blood pressure. Worry was also
associated with incident CHD, and some evidence suggested that the combined effect
of GAD and depression exerted the largest effect sizes upon incident CHD & CHD
Downloaded by [Acadia University] at 05:37 03 May 2013

prognosis (Frasure-Smith & Lesperance, 2008; Scherrer et al., 2010). Like depression,
behavioral pathways including excessive alcohol and tobacco use may partly explain
the link between GAD, worry, and CHD. The paucity of research into the effects of
GAD and worry require further empirical investigation in CHD samples, particularly
among females.

References
Andrews, G., Hobbs, M.J., Borkovec, T.D., Beesdo, K., Craske, M.G., Heimberg, R.G., Stan-
ley, M.A. (2010). Generalized worry disorder: A review of DSM-IV generalized anxiety dis-
order and options for DSM-V. Depression and Anxiety, 27(2), 134147.
Bankier, B., Barajas, J., Martinez-Rumayor, A., & Januzzi, J.L. (2008). Association between C-
reactive protein and generalized anxiety disorder in stable coronary heart disease patients.
European Heart Journal, 29(18), 22122217. doi:10.1093/eurheartj/ehn326
Bankier, B., Januzzi, J.L., & Littman, A.B. (2004). The high prevalence of multiple psychiatric
disorders in stable outpatients with coronary heart disease. Psychosomatic Medicine, 66(5),
645650. doi:10.1097/01.psy.0000138126.90551.62
Barger, S.D., & Sydeman, S.J. (2005). Does generalized anxiety disorder predict coronary heart
disease risk factors independently of major depressive disorder? Journal of Affective Disor-
ders, 88(1), 8791. doi:10.1016/j.jad.2005.05.012
Barsky, A., Cleary, P., Coeytaux, R., & Ruskin, J. (1994). Psychiatric disorders in medical outpa-
tients complaining of palpitations. Journal of General Internal Medicine, 9(6), 306313.
doi:10.1007/bf02599176
Baumeister, H., Hutter, N., & Bengel, J. (2011). Psychological and pharmacological interventions
for depression in patients with coronary artery disease. Cochrane Database Syst. Rev., 9,
CD008012. doi: 10.1002/14651858.CD008012.pub3
Baumeister, H., Hutter, N., Bengel, J., & Hrter, M. (2011). Quality of life in somatically ill per-
sons with comorbid mental disorders: A systematic review and meta-analysis. Psychotherapy
and Psychosomatics, 80, 275286.
Birket-Smith, M., Hansen, B.H., Hanash, J.A., Hansen, J.F., & Rasmussen, A. (2009). Mental
disorders and general well-being in cardiology outpatients-6-year survival. Journal of Psycho-
somatic Research, 67(1), 510.
Borkovec, T.D., & Ruscio, A.M. (2001). Psychotherapy for generalized anxiety disorder.
Journal of Clinical Psychiatry, 62(Suppl. 11), 3742; discussion 4335.
Bosworth, H.B., Powers, B., Grubber, J.M., Thorpe, C.T., Olsen, M.K., Orr, M., & Oddone, E.Z.
(2008). Racial differences in blood pressure control: Potential explanatory factors. Journal of
General Internal Medicine, 23(5), 692698. doi:10.1007/s11606-008-0547-7
Brosschot, J.F., Gerin, W., & Thayer, J.F. (2006). The perseverative cognition hypothesis: A
review of worry, prolonged stress-related physiological activation, and health. Journal of Psy-
chosomatic Research, 60(2), 113124. doi:10.1016/j.jpsychores.2005.06.074
 16 P.J. Tully et al.

Brosschot, J.F., Van Dijk, E., & Thayer, J.F. (2007). Daily worry is related to low heart rate vari-
ability during waking and the subsequent nocturnal sleep period. International Journal of
Psychophysiology, 63(1), 3947. doi:10.1016/j.ijpsycho.2006.07.016
Carroll, D., Phillips, A.C., Gale, C.R., & Batty, G.D. (2010). Generalized anxiety and major
depressive disorders, their comorbidity and hypertension in middle-aged men. Psychosomatic
Medicine, 72(1), 1619.
Carter, C.S., & Maddock, R.J. (1992). Chest pain in generalized anxiety disorder. International
Journal of Psychiatry in Medicine, 22(3), 291298.
Dugas, M.J., Anderson, K.G., Deschenes, S.S., & Donegan, E. (2010). Generalized anxiety disorder
publications: Where do we stand a decade later? Journal of Anxiety Disorders, 24(7), 780784.
Dugas, M., Letarte, H., Rhaume, J., Freeston, M., & Ladouceur, R. (1995). Worry and problem
solving: Evidence of a specic relationship. Cognitive Therapy and Research, 19(1),
109120. doi:10.1007/bf02229679
Fedoroff, J.P., Lipsey, J.R., Starkstein, S.E., & Forrester, A. (1991). Phenomenological compari-
sons of major depression following stroke, myocardial infarction or spinal cord lesions. Jour-
nal of Affective Disorders, 22(12), 8389. doi:10.1016/0165-0327(91)90088-a
Fraguas Junior, R., Ramadan, Z.B., Pereira, A.N., & Wajngarten, M. (2000). Depression with irri-
tability in patients undergoing coronary artery bypass graft surgery: the cardiologists role.
Downloaded by [Acadia University] at 05:37 03 May 2013

General Hospital Psychiatry, 22(5), 365374.

Frasure-Smith, N., & Lesperance, F. (2008). Depression and anxiety as predictors of 2-year car-
diac events in patients with stable coronary artery disease. Archives of General Psychiatry, 65
(1), 6271. doi:10.1001/archgenpsychiatry.2007.4
Goodwin, R.D., Davidson, K.W., & Keyes, K. (2009). Mental disorders and cardiovascular dis-
ease among adults in the US. Journal of Psychiatric Research, 43(3), 239246. doi:10.1016/j.
jpsychires.2008.05.006
Grant, B.F., Goldstein, R.B., Chou, S.P., Huang, B., Stinson, F.S., Dawson, D.A., Comp-
ton, W.M. (2009). Sociodemographic and psychopathologic predictors of rst incidence of
DSM-IV substance use, mood and anxiety disorders: Results from the wave 2 national
epidemiologic survey on alcohol and related conditions. Molecular Psychiatry, 14(11),
10511066.
Hamer, M., Batty, G. D., & Kivimaki, M. (2011). Sleep loss due to worry and future risk of car-
diovascular disease and all-cause mortality: the Scottish Health Survey. Eur J Cardiovasc
Prev Rehabil, 19(6), 14371443. doi: 10.1177/1741826711426092
Hammel, J.C., Smitherman, T.A., McGlynn, F.D., Mulnger, A.M., Lazarte, A.A., & Gothard, K.
D. (2011). Vagal inuence during worry and cognitive challenge. Anxiety Stress Coping, 24
(2), 121136. doi:922954656 [pii]
Haworth, J.E., Moniz-Cook, E., Clark, A.L., Wang, M., Waddington, R., & Cleland, J.G.F.
(2005). Prevalence and predictors of anxiety and depression in a sample of chronic heart fail-
ure patients with left ventricular systolic dysfunction. European Journal of Heart Failure, 7
(5), 803808.
Hoehn-Saric, R., McLeod, D.R., Funderburk, F., & Kowalski, P. (2004). Psychophysiological cor-
relates of generalized anxiety disorder with or without comorbid depression. Archives of Gen-
eral Psychiatry, 61(9), 913921.
Hofmann, S.G., Schulz, S.M., Heering, S., Muench, F., & Bufka, L.F. (2010). Psychophysiologi-
cal correlates of generalized anxiety disorder with or without comorbid depression. Interna-
tional Journal of Psychophysiology, 78(1), 3541.
Holman, E.A., Silver, R.C., Poulin, M., Andersen, J., Gil-Rivas, V., & McIntosh, D.N. (2008).
Terrorism, acute stress, and cardiovascular health: A 3-year national study following the sep-
tember 11th attacks. Archives of General Psychiatry, 65(1), 7380.
Kawachi, I., Colditz, G.A., Ascherio, A., Rimm, E.B., Giovannucci, E., Stampfer, M.J., & Willett,
W.C. (1994). Prospective study of phobic anxiety and risk of coronary heart disease in men.
Circulation, 89(5), 19921997.
Knepp, M.M., & Friedman, B.H. (2008). Cardiovascular activity during laboratory tasks in
women with high and low worry. Biological Psychology, 79(3), 287293. doi:10.1016/j.bio-
psycho.2008.07.002
Kubzansky, L.D., Kawachi, I., Spiro, A.3rd, Weiss, S.T., Vokonas, P.S., & Sparrow, D. (1997). Is
worrying bad for your heart? A prospective study of worry and coronary heart disease in the
normative aging study Circulation, 95(4), 818824.
 Psychology, Health & Medicine 17

Kuczmierczyk, A.R., Barbee, J.G., Bologna, N.A., & Townsend, M.H. (1996). Serum cholesterol
levels in patients with generalized anxiety disorder (GAD) and with GAD and comorbid
major depression. The Canadian Journal of Psychiatry, 41(7), 465468.
Larsen, B.A., & Christenfeld, N.J. (2009). Cardiovascular disease and psychiatric comorbidity:
The potential role of perseverative cognition. Cardiovascular Psychiatry and Neurology,
2009, 791017. doi:10.1155/2009/791017
Lee, T.J., Cameron, L.D., Wunsche, B., & Stevens, C. (2011). A randomized trial of computer-
based communications using imagery and text information to alter representations of heart
disease risk and motivate protective behaviour. British Journal of Health Psychologys, 16(Pt
1), 7291. doi:10.1348/135910710x511709
Levenstein, S., Smith, M.W., & Kaplan, G.A. (2001). Psychosocial predictors of hypertension in
men and women. Archives of Internal Medicine, 161(10), 13411346.
Logue, M.B., Thomas, A.M., Barbee, J.G., Hoehn-Saric, R., Maddock, R.J., Schwab, J., & Beit-
man, B.D. (1993). Generalized anxiety disorder patients seek evaluation for cardiological
symptoms at the same frequency as patients with panic disorder. Journal of Psychiatric
Research, 27(1), 5559.
Martens, E.J., de Jonge, P., Na, B., Cohen, B.E., Lett, H., & Whooley, M.A. (2010). Scared to
death? generalized anxiety disorder and cardiovascular events in patients with stable coronary
Downloaded by [Acadia University] at 05:37 03 May 2013

heart disease: The heart and soul study Archives of General Psychiatry, 67(7), 750758.
doi:10.1001/archgenpsychiatry.2010.74
Muhsen, K., Lipsitz, J., Garty-Sandalon, N., Gross, R., & Green, M. (2008). Correlates of gener-
alized anxiety disorder: Independent of co-morbidity with depression. Social Psychiatry and
Psychiatric Epidemiology, 43(11), 898904. doi:10.1007/s00127-008-0379-0
Ormel, J., Von Korff, M., Burger, H., Scott, K., Demyttenaere, K., Huang, Y.Q., & Kessler,
R. (2007). Mental disorders among persons with heart disease results from World Men-
tal Health surveys. General Hospital Psychiatry, 29(4), 325334. doi:S01638343(07)
00061-8 [pii]
Parker, G., Hyett, M., Hadzi-Pavlovic, D., Brotchie, H., & Walsh, W. (2011). GAD is good? Gen-
eralized anxiety disorder predicts a superior ve-year outcome following an acute coronary
syndrome Psychiatry Research, 188(3), 383389. doi:10.1016/j.psychres.2011.05.018
Patten, S.B., & Liu, M.F. (2007). Anxiety disorders and cardiovascular disease determinants in a
population sample. Internet Journal of Mental Health, 4(1).
Phillips, A.C., Batty, G.D., Gale, C.R., Deary, I.J., Osborn, D., MacIntyre, K., & Carroll, D.
(2009). Generalized anxiety disorder, major depressive disorder, and their comorbidity as pre-
dictors of all-cause and cardiovascular mortality: The Vietnam experience study. Psychoso-
matic Medicine, 71(4), 395403. doi:10.1097/PSY.0b013e31819e6706
Pieper, S., Brosschot, J.F., van der Leeden, R., & Thayer, J.F. (2007). Cardiac effects of momen-
tary assessed worry episodes and stressful events. Psychosomatic Medicine, 69(9), 901909.
doi:10.1097/PSY.0b013e31815a9230
Powers, M.J., & Jalowiec, A. (1987). Prole of the well-controlled, well-adjusted hypertensive
patient. Nursing Research, 36(2), 106110.
Ransford, H.E. (1986). Race, heart disease worry and health protective behavior. Social Science
& Medicine, 22(12), 13551362. doi:10.1016/0277-9536(86)90099-7
Ray, W.J., Molnar, C., Aikins, D., Yamasaki, A., Newman, M.G., Castonguay, L., & Borkovec, T.D.
(2009). Startle response in generalized anxiety disorder. Depression and Anxiety, 26(2), 147154.
Rothenhausler, H.B., Grieser, B., Nollert, G., Reichart, B., Schelling, G., & Kapfhammer, H.P.
(2005). Psychiatric and psychosocial outcome of cardiac surgery with cardiopulmonary
bypass: A prospective 12-month follow-up study. General Hospital Psychiatry, 27(1), 18
28.
Sareen, J., Cox, B.J., Clara, I., & Asmundson, G.J.G. (2005). The relationship between anxiety
disorders and physical disorders in the US National Comorbidity Survey. Depression and
Anxiety, 21(4), 193202.
Scherrer, J.F., Chrusciel, T., Zeringue, A., Gareld, L.D., Hauptman, P.J., Lustman, P.J., & True,
W.R. (2010). Anxiety disorders increase risk for incident myocardial infarction in depressed
and nondepressed veterans administration patients. American Heart Journal, 159(5), 772779.
Sevincok, L., Buyukozturk, A., & Dereboy, F. (2001). Serum lipid concentrations in patients with
comorbid generalized anxiety disorder and major depressive disorder. Canadian Journal of
Psychiatry, 46(1), 6871.
 18 P.J. Tully et al.

Sherbourne, C.D., Jackson, C.A., Meredith, L.S., Camp, P., & Wells, K.B. (1996). Prevalence of
comorbid anxiety disorders in primary care outpatients. Archives of Family Medicine, 5(1),
2734; discussion 35.
Thayer, J.F., Friedman, B.H., & Borkovec, T.D. (1996). Autonomic characteristics of generalized
anxiety disorder and worry. Biological Psychiatry, 39(4), 255266. doi:0006-3223(95)00136-0
[pii]
Todaro, J.F., Shen, B.J., Raffa, S.D., Tilkemeier, P.L., & Niaura, R. (2007). Prevalence of anxiety
disorders in men and women with established coronary heart disease. Journal of Cardiopulmo-
nary Rehabilitation & Prevention, 27(2), 8691. doi:10.1097/01.HCR.0000265036.24157.e7
Tully, P.J., & Cosh, S.M. (in press). Generalized anxiety disorder prevalence and comorbidity
with depression in coronary heart disease: a meta-analysis. Journal of Health Psychology.
Tully, P.J., Pedersen, S.S., Wineeld, H.R., Baker, R.A., Turnbull, D.A., & Denollet, J. (2011).
Cardiac morbidity risk and depression and anxiety: A disorder, symptom and trait analysis
among cardiac surgery patients. Psychology, Health & Medicine, 16(3), 333345.
Valkamo, M., Koivumaa-Honkanen, H.T., Hintikka, J., Niskanen, L., Honkalampi, K., & Viina-
maki, H. (2003). Life satisfaction in patients with chest pain subsequently diagnosed as coro-
nary heart diseaseconnection through depressive symptoms? Quality of Life Research, 12(8),
10991105.
Downloaded by [Acadia University] at 05:37 03 May 2013

Verkuil, B., Brosschot, J.F., de Beurs, D.P., & Thayer, J.F. (2009). Effects of explicit and implicit
perseverative cognition on cardiac recovery after cognitive stress. International Journal of
Psychophysiology, 74, 220228.
Vogelzangs, N., Seldenrijk, A., Beekman, A.T.F., Van Hout, H.P.J., De Jonge, P., & Penninx, B.
W.J.H. (2010). Cardiovascular disease in persons with depressive and anxiety disorders. Jour-
nal of Affective Disorders, 125(13), 241248.
Vogt, T.M., Pope, C., Mullooly, J., & Hollis, J.F. (1994). Mental health status as a predictor of
morbidity and mortality: A 15 year follow-up of members of a health maintenance organiza-
tion. American Journal of Public Health, 84(2), 227231. doi:10.2105/ajph.84.2.227
Wilcox, S., Ainsworth, B.E., LaMonte, M.J., & DuBose, K.D. (2002). Worry regarding major dis-
eases among older African-American, native-American and Caucasian women. Women &
Health, 36(3), 8399. doi:10.1300/J013v36n03_06
Wiltink, J., Beutel, M.E., Till, Y., Ojeda, F.M., Wild, P.S., Mnzel, T., & Michal, M. (2011).
Prevalence of distress, comorbid conditions and well being in the general population. Journal
of Affective Disorders, 130(3), 429437. doi:10.1016/j.jad.2010.10.041