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The influences of anxiety, coping, and social support on physical functioning among heart failure patients

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The influences of anxiety, coping, and social support on physical functioning among heart failure patients

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THE INFLUENCES OF ANXIETY, COPING, AND SOCIAL SUPPORT ON
PHYSICAL FUNCTIONING AMONG HEART FAILURE PATIENTS

by
Stacy Ann Eisenberg

_____________________________________________________________________

A Thesis Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(PSYCHOLOGY)

August 2010

Copyright 2010 Stacy Ann Eisenberg

ii

Table of Contents
List of Tables iii
Abstract iv
Chapter 1: Introduction 1
Anxiety in Heart Failure Patients 1
Anxiety, Coping, and Health 2
Anxiety, Coping, and Cardiovascular Disease Patients 4
Coping and Physical Functioning Among Coronary Artery 4
Disease Patients
Coping and Heart Failure Outcomes 5
Coping Moderates the Effect of Psychosocial Factors on 6
Health Outcomes
Social Support and Disease Outcomes in Heart Failure Patients 7
Theory of Social Support as a Buffer 8
Research Questions and Hypotheses 9

Chapter 2: Method 13
Participants 13
Design and Measures 13
Procedures 17
Statistical Analyses 18
Chapter 3: Results 23
Figure 1 33

Chapter 4: Discussion 34
Bibliography 42

iii

List of Tables

Table 1: Participants’ demographic, medical and psychosocial 24
characteristics and descriptive statistics of study variables

Table 2: Pairwise correlations between study variables 29

Table 3: Association between anxiety and physical functioning 30

Table 4: Interaction between anxiety and avoidant coping in their 32
effect on physical functioning

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Abstract
Previous studies have suggested that negative emotions are associated with morbidity
and mortality in heart failure patients, but the psychosocial mechanisms that explain this
relationship have remained unclear. The present study examined whether anxiety was
associated with poorer physical functioning among heart failure patients and explored coping
strategies and social support as possible explanatory mechanisms. Participants included 262
heart failure patients (mean age = 54 years). Hierarchical multiple regression analyses
adjusting for age, gender, ethnicity, marital status, education, New York Heart Association
(NYHA) class, treatment for depression or anxiety, current smoking status, body mass index
(BMI), and history of myocardial infarction were conducted to examine the study
hypotheses. Among participants, 24% reported borderline and 21% reported severe anxiety
symptoms. Results demonstrated a significant association between anxiety and poorer
physical functioning (  = .43, p<.001). There was also a significant interaction between
avoidant coping and anxiety in their effect on physical functioning, (  = .13, p<.05), whereas
approach coping did not moderate the association between anxiety and physical functioning.
In addition, neither approach nor avoidant coping mediated the relationship between anxiety
and physical functioning. Social support was not directly associated with physical
functioning or a moderator of the relationship between anxiety and physical functioning.
Finally, there was not a significant interaction between approach or avoidant coping and
social support in their effects on physical functioning. Overall, these results indicated that
anxiety was associated with poorer physical functioning in heart failure patients and the use
of avoidant coping strategies exacerbated this detrimental effect.

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Chapter 1: Introduction
Anxiety in Heart Failure Patients
Chronic heart failure is a severe illness with a poor prognosis. Approximately
287,000 individuals die as a result of heart failure each year, and the number of heart
failure deaths is on the rise (American Heart Association, 2009). It is the leading cause
for hospitalization in individuals age 65 years and older, and the most costly
cardiovascular disease in the United States (American Heart Association, 2009; Sullivan
et al., 2002; Thomas et al., 2003).
Many heart failure patients suffer from psychological disorders, such as
depression and anxiety. Anxiety is especially prevalent in heart failure patients, with
reported rates ranging from 18.4-63% (Haworth et al., 2005; Friedmann, et al., 2006; De
Jong et al., 2004). Compared to other cardiac patients and patients with cancer or lung
disease, patients with heart failure have similarly high or worse levels of anxiety
(Riedinger, 2002; De Jong, 2004). Although several studies have suggested that chronic
anxiety was associated with an increased risk of coronary artery disease (Coryell et al.,
1982; Weissman et al, 1990; Coryell et al., 1986; Kawachi et al., 1994; Kubzansky, et al.,
2006; Barger & Sydeman, 2005, Shen et al., 2008), only a few investigators have
examined the association between anxiety and heart failure outcomes (Clarke et al., 2000,
Friedmann et al., 2006). Results from Clark et al. (2000) highlighted anxiety as a
significant predictor of risk for experiencing severe limitation in intermediate and social
activities of daily living at one year among heart failure patients. This relationship
remained significant even after controlling for age and clinical characteristics. In their

2

study of outpatients receiving treatment for chronic heart failure, Friedmann et al. (2006)
found a significant association between anxiety and perceived impairment in functional
status. Additionally, analyses adjusting for treatment (implantable cardioverter
defibrillator, amiodarone, or placebo medication) revealed that anxiety independently
predicted mortality. Anxiety, however, was not associated with mortality when adjusting
for demographics and clinical predictors. Thus, the literature has indicated that anxiety
predicted negative heart failure outcomes, but the anxiety measures employed in these
studies often included somatic items that were confounded with heart failure symptoms.
Therefore, these studies may have overestimated both the severity of anxiety in heart
failure patients and the association between anxiety and clinical outcomes. Additionally,
the mechanisms that explained this relationship have remained unclear.
Anxiety, Coping, and Health
One possible explanation for the relationship between high anxiety and poor
physical functioning was the tendency for anxious patients to employ avoidant coping
strategies and to be less likely to use approach coping strategies. Coping strategies are
the “ongoing cognitive and behavioral efforts to manage specific external and/or internal
demands that are appraised as taxing or exceeding the resources of the person” (Lazarus,
1993). A distinction has often been drawn between approach coping strategies, such as
taking direct action or confronting emotional responses to a stressor, and avoidant coping
strategies, such as withdrawal or denial (Roth & Cohen, 1986). These coping strategies
did not operate in isolation. Instead, they were often conceptualized as mediators that
explained the relationship between other psychosocial constructs, such as stressor

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characteristics or intraindividual factors, and disease outcomes (Taylor & Stanton, 2007).
For example, Carver et al. (1993) found that approach coping strategies mediated the
relationship between optimism and distress among women diagnosed with breast cancer.
This understanding of coping as a mediator can be applied to help explain the relationship
between anxiety and physical functioning among heart failure patients.
Research with community dwelling individuals and chronic pain patients
suggested a tendency for anxious individuals to employ avoidant coping strategies and to
neglect approach coping strategies. A study based on a community sample of 294 adults
facing a wide range of stressors demonstrated a significant positive association between
avoidant coping strategies and anxiety symptoms when controlling for stressful life
events (Billings and Moos, 1980). The investigators also found a negative association
between anxiety symptoms and “active cognitive coping” when controlling for stressful
life events, but they found a positive relationship between anxiety and “active behavioral
coping” (Billings and Moos, 1980). A study exploring chronic abdominal pain among
adolescents found that “secondary control engagement coping” (positive thinking,
cognitive restructuring, acceptance, and distraction) was associated with lower levels of
anxiety symptoms, and disengagement coping (denial, avoidance, wishful thinking) was
related to higher levels of anxiety symptoms (Compas et al., 2006). These studies implied
that individuals who reported higher levels of anxiety had a propensity to use more
avoidant coping strategies and fewer approach coping strategies than their less anxious
counterparts.

4

Anxiety, Coping, and Cardiovascular Disease Patients
Similar results have been demonstrated among heart disease patients. Doering et
al. (2004) investigated the relationship between anxiety and avoidant coping among 84
heart failure patients. Mean anxiety scores were compared between high and low users
of avoidant coping strategies. High users of avoidant coping exhibited significantly
higher levels of anxiety than low users. There were no significant differences in anxiety
levels between high and low users of either active behavioral coping or active cognitive
coping. A longitudinal study with coronary heart disease patients, however, found a
negative relationship between approach coping at the first measurement points and
anxiety at later time points (van Elderen et al., 1999). Thus, cardiovascular disease
patients who used avoidant coping strategies may have been experiencing higher levels of
anxiety, and patients who used approach coping strategies may have felt less anxious.
Additional support for the mediational role of coping strategies in the relationship
between anxiety and physical functioning came from evidence suggesting an association
between coping strategies and disease outcomes.
Coping and Physical Functioning Among Coronary Artery Disease Patients
Research examining the efficacy of approach and avoidance coping strategies has
suggested that the context and characteristics of the stressor may play an important role in
the success or failure of different coping strategies. A meta-analysis conducted by Suls
and Fletcher (1985) revealed that avoidance was related to better outcomes in the short-
run, but attention or approach coping strategies were associated with positive adaptation

5

over time when faced with a persistent stressor such as a chronic illness. Therefore, one
would expect approach coping strategies to be associated with better physical functioning
and avoidance coping strategies to be related to worse physical functioning among heart
disease patients, including those with heart failure.
Studies exploring coping in heart disease patients have indicated this was the
case, with these studies demonstrating significant associations between approach and
avoidant coping and physical functioning or overall well-being. In their longitudinal
study, van Elderen et al. (1999) demonstrated that coronary artery disease patients who
used approach coping strategies reported significantly higher well-being at 12-month
follow-up. Ulvik et al. (2008) also reported a positive association between confronting
coping strategies and overall quality of life among patients admitted for an elective
coronary angiography. Overall, it appeared that heart disease patients reported better
functioning when they were using more approach and less avoidant coping strategies.
Coping and Heart Failure Outcomes
Approach and avoidant coping also predicted disease morbidity in studies
specifically examining heart failure patients. In a daily diary study of 58 heart failure
patients, Carels et al. (2004) found that when individuals engaged in less
action/acceptance coping (approach) and more distraction coping (avoidance) they
experienced greater physical symptoms the following day. Klein et al. (2004) indicated
that avoidant coping strategies including self-distraction, denial, and behavioral
disengagement all demonstrated significant negative correlations with a “clinical scale
composite” (including physical limitation, symptom frequency, and symptom burden),

6

ability to participate in social activities, and overall quality of life among older heart
failure patients. In addition, multiple regression analyses adjusting for the effects of New
York Heart Association (NHYA) class and comorbid illnesses revealed that self-
distraction and denial were still significantly related to poor clinical outcomes, lack of
social participation and overall quality of life.
An additional study investigated the relationship between avoidant coping
strategies and future mortality among heart failure patients (Murberg et al., 2004). The
authors evaluated the effect of avoidance coping (characterized by the denial, mental
disengagement, and behavioral disengagement subscales of the COPE scale) on mortality
among 119 congestive heart failure outpatients. Fifty-one deaths were reported during
the 6-year follow-up period due to cardiac causes. Results indicated that behavioral
disengagement was significantly associated with future mortality whereas mental
disengagement and denial were not. The investigators did not report results of an analysis
with a composite score of “avoidant coping” that combined the behavioral
disengagement, mental disengagement and denial subscales, even though these three
subscales were significantly correlated. Thus, the results from this study demonstrated an
association between one type of avoidant coping, behavioral disengagement, and
mortality among heart failure patients.
Coping Moderates the Effect of Psychosocial Factors on Health Outcomes
In addition to the possibility that anxiety has led to poorer physical functioning
via coping strategies, coping strategies may also be conceptualized as moderators that
either buffer or exacerbate the association between psychosocial factors and clinical

7

outcomes (Taylor & Stanton, 2007). For example, cancer patients who experienced low
social support in combination with the greater use of avoidant coping reported more
severe posttraumatic stress symptoms (Jacobsen et al., 2002). Additionally, healthy
individuals who employed avoidant coping strategies and underwent a stressor
demonstrated an attenuated immune response compared to those who did not use
avoidant coping strategies (Barger et al., 2000). Conversely, breast cancer patients high
in hope who coped through emotional approach reported decreased distress and required
fewer medical appointments for cancer-related morbidities (Stanton et al., 2000).
Therefore, approach and avoidant coping strategies may buffer or exacerbate,
respectively, the association between anxiety and poor physical functioning in heart
failure patients.
Social Support and Disease Outcomes in Heart Failure Patients
The previously discussed studies described the adverse impacts of anxiety on
heart failure outcomes and supported the idea that coping strategies may help to explain
this relationship. Another important psychological construct, social support, may also
play a major part in the physical functioning experienced by heart failure patients. The
literature presented diverse conceptualizations of social support. For the purpose of the
present study, social support was understood as the perceived availability of functional
support through interpersonal relationships. Functional support included (1) emotional
support, (2) instrumental support, (3) affectionate support, (4) informational support, and
(5) positive social interactions (Sherbourne and Stewart, 1991).

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Social support has appeared to have a direct impact on the morbidity and
mortality among heart failure patients. Unmarried patients who received or made visits
to family or friends “hardly ever” have been shown to be at significantly higher risk of
having serious impairment in intermediate and social activities of daily living than those
who reported higher levels of social integration (Clarke et al., 2000). Increases in social
support also predicted improvement in the physical functioning of heart failure patients
(Bennet et al., 2001). Furthermore, several studies have demonstrated social isolation as
a predictor of mortality among heart failure patients (Murburg, 2004; Friedmann et al.,
2006). A lack of social support appeared to contribute to worse outcomes for heart
failure patients, suggesting social support may have been playing a protective role. In
addition to its direct effect on heart failure outcomes, social support may also help to
attenuate some of the negative effects of physical and psychological stressors on well-
being.
Theory of Social Support as a Buffer
Social support has often been conceptualized as a buffer against the detrimental
impact of stressful experiences and negative emotions on physical health (Cohen &
Wills, 1985; Alloway & Bebbington, 1987; Cohen, 2004). A study conducted by
Rosengren et al. (1993) revealed that previously healthy men, ages 50 and over, were at
substantially greater risk for mortality if they experienced a high number of stressful life
events in the year before baseline measurement. However, the effect of stress on
mortality was smaller among those who perceived the availability of high levels of

9

emotional support (Rosengren et al., 1993). The negative effects of stress on physical
health may, therefore, depend on the individual’s level of perceived social support.
Additional evidence suggested that social support also buffered the impact of
negative psychological symptoms on physical health among cardiovascular disease
patients. Frasure-Smith et al. (2000) investigated the moderating effect of social support
on the relationship between depression and mortality in 887 patients during the first year
after myocardial infarction. Results indicated that participants who were depressed at
baseline were at significantly increased risk of one-year cardiac mortality. There was no
significant main effect of perceived social support on cardiac mortality, but there was a
significant interaction between the effect of perceived social support and depression on
mortality. Among participants perceiving the lowest level of social support, the impact
of depression on mortality was significantly larger than the effect of depression on
mortality among patients perceiving the highest amount of support. These results implied
that social support, especially when extremely high, buffered the effect of depression on
mortality for post-myocardial infarction patients. The role of social support as a buffer
against the harmful effects of anxiety and avoidant coping among heart failure patients
remained unclear. The proposed study attempted to gain an improved understanding of
these relationships.
Research Questions and Hypotheses
The current investigation sought to build upon past research in order to better
understand the mechanisms that explain the association between anxiety and physical
functioning among heart failure patients. Individual studies have demonstrated a positive

10

relationship between anxiety and avoidant coping strategies and to a lesser extent, a
negative association between anxiety and approach coping. Additionally, prior research
suggested approach coping strategies were more successful than avoidant coping when
facing a chronic illness. Few studies have looked at coping as a possible mechanism that
affected the association between anxiety and poor physical functioning among heart
failure patients. Additionally, it remained unclear whether approach and avoidant coping
served as mediators that explained the relationship between anxiety and physical
functioning or moderators that buffered or exacerbated this relationship. Furthermore,
although social support has been frequently conceptualized as a “buffer” against the
effects of negative events and emotions on mental and physical health, it was unclear if it
played a similar role in the relationship between anxiety, avoidant coping, and physical
functioning among heart failure patients. The proposed study attempted to address these
remaining issues in the following hypotheses.
Hypothesis 1. There will be a significant negative association between reported
anxiety and physical functioning, such that the higher the anxiety heart failure patients
experience, the lower their reported physical functioning will be.
Hypothesis 2. (a) The effect of anxiety on physical functioning will be mediated
by avoidant coping. There will be a significant positive association between avoidant
coping and anxiety, and a significant negative association between avoidant coping and
physical functioning. In addition, when avoidant coping is taken into account, the
relationship between anxiety and physical functioning will decrease significantly. In
other words, anxious participants will be more likely to use avoidant coping strategies,

11

and will therefore experience worse physical functioning than their less anxious
counterparts. (b) It was also hypothesized that the effect of anxiety on physical
functioning would be mediated by approach coping, such that there would be a
significant negative association between anxiety and approach coping, and a significant
positive association between approach coping and physical functioning. When approach
coping is taken into account, the relationship between anxiety and physical functioning
will decrease. In other words, anxious patients will be less likely to employ approach
coping strategies and will therefore report worse physical functioning than less anxious
patients.
Hypothesis 3. (a) Approach coping will moderate the relationship between
anxiety and physical functioning. Anxiety will have less of an adverse impact on
physical functioning for patients with higher levels of approach coping than those with
lower levels of approach coping. (b) Avoidant coping will moderate the effect of anxiety
on physical functioning, such that patients who use avoidant coping strategies and report
higher levels of avoidant coping will have poorer physical functioning than anxious
patients who use less avoidant coping strategies.
Hypothesis 4. (a) Social support will demonstrate a positive association with
physical functioning, such that patients with higher perceived social support will
experience better physical functioning. (b) In addition to its independent effect on
physical functioning, social support will also moderate the relationship between anxiety
and physical functioning. Anxiety will have a weaker negative impact on physical

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functioning for patients with higher levels of social support than those with lower levels
of social support.
Hypothesis 5. (a) Social support will moderate the relationship between avoidant
coping and heart failure physical functioning. Avoidant coping with have less of an
adverse impact on physical functioning for patients with high levels of social support
than those with low levels of social support. (b) Social support will moderate the effect of
approach coping on physical functioning, such that patients who use approach coping
strategies and report higher levels of social support will have higher physical functioning
than patients using approach coping strategies who have lower levels of social support.

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Chapter 2: Method
Participants
Participants were 262 patients with chronic heart failure who were recruited as
part of a larger research project from the cardiology clinics at the University of Miami in
Miami, FL and Cedars-Sinai Medical Center (CSMC) in Los Angeles, CA. Patients from
this sample of convenience were asked to participate if they had a primary diagnosis of
congestive heart failure, were 18 years or older, and agreed to be available for the entire
two-year study period. Patients were excluded if they were unable to meet the demands
of the project (e.g., responding to questionnaires and assessment) due to neurological
disorders, cognitive impairments, and major psychiatric disorders (e.g., psychotic
disorders, substance dependence) that may have interfered with the validity of self-
reported data. Patients were also excluded if they were pregnant or planned to become
pregnant over the course of the study.
Design and Measures
The hypotheses in this study were tested in a cross-sectional, correlational design
that obtained data from questionnaires, a medical interview, and a medical chart review.
All of the data was collected during the participants’ baseline assessments.
Demographic Information. Demographic information was assessed using a
questionnaire. Information included age, gender, marital status, ethnicity and current
smoking status. In addition, education level was obtained to assess socioeconomic status.
Medical Information. Investigators completed a structured interview to obtain
information regarding the participants’ medical histories. This interview assessed current

14

medical diagnosis, NYHA class and disease severity, comorbid medical illnesses, current
medications, cardiac devices, and past surgeries. It also assessed current and past
psychotherapy treatment for various psychological disorders.
Height and weight were measured by a nurse at the clinical visit. BMI was
calculated by dividing weight in kilograms by the square of height in meters. Additional
medical information was gathered through a review of the participants’ medical charts.
Anxiety. The Hospital Anxiety Depression Scale-Anxiety Subscale consisted of
seven Likert-type items designed to identify anxiety symptoms experienced among
patients in non-psychiatric hospital clinics in the past two weeks (Zigmond & Snaith,
1983). The scale measured symptoms of anxiety such as worry, fear, inability to relax,
and feelings of panic. Intended for medically ill patients, the Hospital Anxiety and
Depression Scale-Anxiety Subscale excluded symptoms of anxiety relating to physical
disorders such as dizziness, heart palpitations, and sweating. The internal consistency
reliability was high in the present study, with Cronbach’s α = .84. A mean score was
used in the regression analysis, and a sum score was also reported to compare the anxiety
symptom severity of the present participants with previously reported cutoff values
(Zigmond & Snaith, 1983).
Social Support. The Medical Outcomes Study Social Support Scale (Sherborne
& Stewart, 1991) was an 18-item instrument designed to measure the perceived
availability and levels of social support among patients with chronic illness. It consisted
of items that measured emotional, informational and tangible support in addition to
positive social interactions. All items were rated on a five-point Likert scale, ranging

15

from one (none of the time) to five (all of the time). The internal consistency for this
instrument was excellent (Cronbach’s α=.97). A mean score was used in the analysis.
Coping. The Brief COPE (Carver, 1997) is a 28-item measure designed to assess
how participants cope with a certain stressor, in this case their physical health problems.
The instrument consists of 14 two-item subscales, each identifying a different coping
strategy. A modified, 14-item version of the Brief COPE was used in the present study,
with one item from each of the 14 subscales. These subscales included active coping,
planning, positive reframing, acceptance, humor, religion, using emotional support, using
instrumental support, self-distraction, denial, venting, substance use, behavioral
disengagement, and self-blame.
These coping strategies can be further grouped into broad categories of coping
strategies, such as approach and avoidant coping (Carver et al., 1989). Based on the
recommendations of Carver et al. (1989) a principal component analysis with varimax
rotation was conducted to examine the factor structure of the amended Brief COPE scale
and to provide information for subscale construction. The analysis identified two major
groups of items likely to remain together without cross-loading on other factors. The first
group consisted of five items tapping coping responses generally conceived as avoidant
including denial, substance use, venting, behavioral disengagement, and self-blame. The
other group comprised of four items that tended to be described as approach coping,
including active coping, positive reframing, planning, and acceptance. Two items,
seeking emotional support and seeking informational support, were excluded from
analyses to prevent confounding with the social support construct. Furthermore, three

16

ambiguous items that loaded on both the approach and avoidant coping components, self-
distraction, humor, and religion, were excluded from further analyses. Participants
evaluated how likely they were to engage in each described coping response ranging
from one (I don’t do this at all) to four (I do this a lot). Mean scores of approach and
avoidant coping items were used in the analysis, with higher scores suggesting a stronger
tendency to adopt the coping behaviors with regard to one’s heart failure. The Brief
COPE has been shown to demonstrate sufficient internal consistency among heart disease
patients (Shen et al., 2004). The internal consistency for the instrument in this study was
acceptable for both approach coping (Cronbach’s α=.73) and avoidant coping
(Cronbach’s α=.71).
Physical Functioning. Physical functioning was measured with the Minnesota
Living with Heart Failure Questionnaire (MLHFQ), designed to assess the patient’s
perception of the effect of heart failure and its treatment on his or her life (Rector et al.,
1987). The MLHFQ assessed the degree to which heart failure impaired one’s life in
physical, emotional, and social domains on a scale from 0 (not at all) to 5 (very much).
This measure has demonstrated acceptable reliability and validity in the literature and is
frequently used to assess functional impairment in heart failure patients (Garin et al.,
2008). Physical functioning (e.g. limited functional capacity) and emotional functioning
(e.g. worry, depressive symptoms) form two of the major components of the MLHFQ
(Rector & Cohen, 1992). The current study examined only the items that measured
physical functioning because the emotional items were confounded with the primary
predictor variable (anxiety). The physical functioning items assessed the degree to which

17

heart failure caused difficulties with sitting or lying down to rest, fatigue, shortness of
breath, climbing stairs, house chores or yard work, sleeping at night, and doing things
with family or friends. The internal consistency of these items was excellent with
Cronbach’s α=.94. The mean score was used in the analysis. Higher scores indicated
poorer physical functioning.
Procedures
Participants were recruited from the University of Miami and CSMC cardiology
clinics. During inpatient and outpatient clinics, the cardiologist first met with the
patients, attended to their clinical needs, and assessed their eligibility for the study. If the
patient was eligible, recruitment staff explained the study purposes and procedures to the
patient and completed the informed consent process if the patient was interested in
participating. Within one week, participants were contacted via telephone to schedule an
appointment at the hospital research lab. Baseline data was only collected if participants
were outpatients at the time of assessment.
When participants arrived in the research lab, a nurse measured their height and
weight. The research assistant then conducted the medical interview and the participant
completed the questionnaire packet. During the structured medical interview, a research
assistant inquired about the participant’s current medical diagnoses, NYHA class and
disease severity, comorbid medical illnesses, current medications, psychological
treatment and past surgeries. The questionnaire packet included the demographic
questionnaire, Medical Outcomes Study-Social Support Scale, modified Brief COPE,
Hospital Anxiety and Depression Scale-Anxiety Subscale, and the MLHFQ instruments.

18

The appointment was estimated to last between 60-90 minutes. The medical chart review
was conducted in the week following the participant’s appointment.
Statistical Analyses
Preliminary and descriptive analyses. All analyses were completed using the
SPSS statistical package 15.0. Due to the possibility that participants were permitted to
skip questions on the questionnaires, the issue of missing data was addressed.
Participants with questionnaire packets that were less than 75% complete were not
included in the analyses. Additional missing data was addressed using pair-wise
deletions. The internal consistency of the primary measures used in this study was
calculated using Cronbach’s alpha.
Descriptive statistics were calculated for the demographic and medical
(cardiovascular risk factors and health behaviors, medical and surgical history, mental
health treatment, and medications) variables, along with the independent and dependent
variables of interest (anxiety, social support, coping and physical functioning).
Regression modeling was used to identify possible covariates of the relationship between
the predictor and outcome variables. Potential covariates based on a priori hypotheses
included age, ethnicity, education, depression, NYHA class, body mass index (BMI),
medications, medical comorbidities, surgeries, cardiac events and cardiac devices.
Physical functioning was regressed on all potential covariates, and individual t-tests were
used to assess the significance of their parameter estimates at the .10 level of
significance. Anxiety was then regressed on all potential covariates that were
significantly associated with physical functioning, and t-tests were used to assess the

19

significance of their parameter estimates at the .10 level of significance. Current
smoking status (p=.019, p=.016), BMI (p=.001, p=.004), and history of myocardial
infarction (p=.063, p=.001) demonstrated statistically significant associations with
anxiety and physical functioning, respectively. Therefore, all analyses were adjusted for
these variables. Additionally, although they were not significantly associated with
physical functioning in the current dataset, all analyses were adjusted for demographic
and medical covariates including age, gender, ethnicity, marital status, education, NYHA
class, and treatment for depression or anxiety because these were common covariates in
prior studies. A correlation matrix was conducted to explore pairwise associations
between all variables that were to be examined in the regression models.
Because 231 participants were recruited from the University of Miami, and 31
were recruited from CSMC, independent samples t-tests and chi-square tests were
conducted to examine the differences in demographic and medical characteristics
between these patient groups.
Analyses for testing study hypotheses. Before testing the primary hypotheses,
examination of the residuals verified that the models satisfied the assumptions of linear
regression (existence, independence, linearity, homoscedasticity and normality). Thus, it
was not necessary to transform any of the variables before testing the hypotheses.
Additionally, no significant outliers were identified.
Variance inflation factors were explored in the regression modeling to confirm
that collinearity was not a problem in any of the proposed models (<10). Hierarchical

20

linear regression was used to test the main hypotheses and statistical significance levels
were set at p< 0.05.
Hypothesis 1. Hypothesis 1 stated that anxiety would be negatively associated
with physical functioning. In hierarchical multiple regression analyses, physical
functioning was regressed on two blocks of predictors. The control variables (age,
gender, ethnicity, marital status, education, current smoking status, BMI, NYHA class,
history of myocardial infarction, and treatment for depression or anxiety) were entered in
block one. Anxiety was entered in block two. A significant, negative regression
coefficient of anxiety in predicting physical functioning was expected.
Hypothesis 2. Hypothesis 2a predicted that avoidant coping would mediate the
relationship between anxiety and physical functioning. Mediation was explored using a
series of regression models based on the parameters outlined by Baron and Kenny (1986).
All regression models contained covariates in the first block and predictor variables in
subsequent blocks. First, avoidant coping was regressed on anxiety. Second, physical
functioning was regressed on anxiety. Third, physical functioning was regressed on both
anxiety and avoidant coping. Parameter estimates for each equation were tested for
significance. Mediation was established if there was a significant relationship between
anxiety and avoidant coping in the first model, anxiety and physical functioning in the
second model, and avoidant coping and physical functioning in the third model.
Additionally, the association between anxiety and physical functioning was expected to
greatly decrease or become insignificant after controlling for the mediator (avoidant
coping) in order to verify a mediation effect. Results of the mediation were tested with

21

an approximate significance test proposed by Sobel (1982). The same steps were
employed to test hypothesis 2b, that approach coping would significantly mediate the
relationship between anxiety and physical functioning.
Hypothesis 3. Approach coping was then tested to see if it was a moderator of the
relationship between anxiety and physical functioning (hypothesis 3a). Hierarchical
multiple regression was used to test hypothesis three in which physical functioning was
regressed on three blocks of predictors. The control variables were entered in block one.
Mean centered anxiety and approach coping were entered in block two. The interaction
term, equal to the product of the centered predictor variables, was entered in block three.
A statistically significant regression coefficient for the interaction term would suggest an
interaction between anxiety and approach coping in their effect on physical functioning.
The same strategy was used to test hypothesis 3b. In this case, mean centered
avoidant coping was entered along with mean centered anxiety in block two, and block
three contained the interaction term that was equal to the product of the mean centered
predictor variables.
Hypothesis 4. Social support was then tested to see if it was a direct predictor of
physical functioning or if it was a moderator of the relationship between anxiety and
physical functioning. Hierarchical multiple regression was used to test hypothesis four in
which physical functioning was regressed on three blocks of predictors. The control
variables were entered in block one. Mean centered anxiety and social support were
entered in block two. The interaction term, equal to the product of the centered predictor
variables, was entered in block three. A statistically significant regression coefficient for

22

the interaction term would suggest an interaction between anxiety and social support in
their effect on physical functioning. Additionally, a statistically significant regression
coefficient for social support would suggest that social support was also directly
associated with physical functioning.
Hypothesis 5. The same strategies were used to test hypothesis 5. In this case,
either mean centered approach or avoidant coping were entered along with social support
in block two. Block three contained the interaction term, equal to the product of the
centered predictor variables. A statistically significant regression coefficient for the
interaction term would suggest an interaction between either approach or avoidant coping
and social support in their effect on physical functioning.
Follow-up analyses for significant interaction. Because there was a significant
interaction between anxiety and avoidant coping in their effect on physical functioning,
the association between anxiety and physical functioning at different levels of avoidant
coping was explored. Three simple regression equations were computed using the mean
of avoidant coping and the values one standard deviation above and below the mean of
avoidant coping. Regression modeling was used to test for the significance of the
difference of each simple slope from zero.

23

Chapter 3: Results
Participant Characteristics
Demographic and clinical characteristics of the study sample are presented in
Table 1. Two hundred and sixty-two participants completed the assessment (30.5%
women). The mean age of participants was 53.63 years (SD=11.18), and approximately
half (55%) were married or partnered. The majority of participants were disabled,
retired, or unemployed (75.6%). The sample was ethnically diverse, such that 29% were
Caucasians, 23.7% African Americans, 48.4% Hispanics, and 6.1% others. Most
participants had completed high school (30.9%) or attended at least some college
(55.34%).
The participants had a mean left ventricular ejection fraction of 27% (SD=13%)
and the majority of participants were in the New York Heart Association (NYHA) classes
I (22.52%), II (42.37%), or III (27.86%). Forty-four percent of participants had a history
of coronary artery disease, and 38.9% have had a myocardial infarction. Approximately
half of participants (51.91%) had an implantable cardioverter defibrillator and 21.4%
have had coronary artery bypass surgery. Sixty percent of participants were taking
angiotensin-converting enzyme (ACE) inhibitor medication. Several cardiovascular risk
factors were elevated in the group with 64.9% being hypertensive, 45.04% dyslipidemic,
42% obese, and 34.4% diabetic.

24

Table 1
Participants’ demographic, medical and psychosocial characteristics and descriptive
statistics of study variables
Variable Mean (SD), Range / Frequency (%)
Participant Characteristics
(N=262)
Demographic Background

Age
53.63 (11.18), 24-85
Gender

Women
80 (30.5%)
Men
182 (69.5%)
Married/partnered
149 (54.8%)
Ethnicity

Caucasian
76 (29%)
African American
62 (23.7%)
Hispanic
108 (48.2%)
Other
16 (6.1%)
Education

< High school
36 (13.7%)
High school
81 (30.9%)
Some college
86 (32.82%)
College or more
59 (22.52%)
Current employment
64 (24.4%)
Cardiovascular Risk Factors
and Health Behaviors

Weight (in kg)
192.53 (40.57), 78-303
BMI (kg/m
2
) 29.71 (6.13), 13-51
SBP (mmHg)
119.39 (22.48), 77-214
DBP (mmHg)
74.99 (12.62), 40-129
Hypertension
170 (64.9%)
Dyslipidemia
118 (45.04%)
Diabetes
90 (34.4%)
Current smoking
14 (5.3%)
Current alcohol use
70 (26.72%)
Medical Characteristics

Left ventricular ejection
fraction (LVEF)
26.78 % (13.12%), 3-70
NYHA class

I
59 (22.52%)
II
111 (42.37%)
III
73 (27.86%)
IV
11 (4.20%)

25

Table 1, Continued
Months since heart failure
diagnosis 63.69 (65.84), 0-345
Medical and Surgical
History

Coronary artery disease
115 (43.9%)
Myocardial infarction
102 (38.9%)
Stroke
20 (7.6%)
Arrhythmia
130 (49.6%)
Peripheral vascular disease
22 (8.4%)
Ischemic cardiomyopathy
99 (37.8%)
Mitral valve regurgitation
173 (66%)
Bypass surgery
56 (21.4%)
Angioplasty/Stenting
50 (19.1%)
Implantable cardioverter
defibrillator 136 (51.91%)
Pacemaker
7 (2.67%)
Valvular surgery
27 (10.3%)
Mental Health Treatment

Treatment for Depression 23(8.78%)
Treatment for Anxiety 24(9.16%)
Treatment for Depression or
Anxiety
42(16.03%)
Medications

ACE Inhibitor 158 (60.3%)
β-Blocker 41 (15.6%)
Angiotensin receptor blocker 62 (23.7%)
Calcium channel blocker 34 (13.0%)
Anti-coagulant 135 (51.5%)
Statins 130 (49.6%)
Diuretics 211 (80.5%)
Physical Health Functioning
and Psychological Measures

Physical functioning
(MLHFQ)
2.52 (1.57), 0-5
Anxiety (HADS-A)
6.86 (4.48), 0-2.71
Approach coping (Brief
COPE) 3.05 (0.76), 0.75-4.00
Avoidant coping (Brief COPE)
1.54 (0.55), 0-4
Social support (MOS-Social
Support Scale) 3.99 (1.02), 1-5

26

Psychosocial Characteristics
Applying the guidelines of the Hospital Anxiety and Depression Scale, (Zigmond
& Snaith, 1983), 55% of the participants showed little or no anxiety symptoms (<8), 24%
indicated borderline anxiety symptoms (8-10), and 21% reported severe anxiety
warranting clinical attention (>10). Approach coping strategies were employed more
frequently (M=3.05, SD=.08) than avoidant coping strategies (M=1.54, SD=0.55). The
mean score for social support was fairly high (M=3.99, SD=1.02). The mean physical
functioning score was 2.52 (SD=1.57), with higher scores representing poorer physical
functioning.
Comparison of University of Miami and CSMC Participants
Of the 262 participants, 231 were recruited from the University of Miami, and 31
were recruited from CSMC. Independent samples t-tests and chi-square tests were
conducted to examine the differences in demographic and medical characteristics
between the two participant groups. The results showed that they did not differ in
psychological factors (anxiety, coping, and social support), physical functioning, marital
status, gender, education, employment status, NYHA class, cardiovascular metabolic risk
factors, cardiac history and medications. However, participants recruited from CSMC
were somewhat younger (p<.05) and were more likely to be Caucasian (p<.01) and less
likely to be Hispanic (p<.01) than those recruited from the University of Miami. CSMC
patients also had had higher left ventricular ejection fractions (p<.001) and higher BMI
(p<.05). Of note, most of these differences appeared clinically trivial and were most
likely due to the relatively large sample size. Because ethnicity was not significantly

27

associated with any of the variables of interest, the differences in ethnicity between the
two groups of participants were not of concern. Additionally, because only 12% of
participants were recruited from CSMC, the reported differences were unlikely to
substantially influence the results. Finally, all regression models were examined
excluding the CSMC participants, and there were no significant differences in the results.
Preliminary Analyses for Regression
Table 2 presents results from the correlation matrix that examined the pairwise
associations between the psychosocial variables, physical functioning, and the
demographic and medical covariates that were to be included in the regression models.
Because all of these values were less than r = 0.52, collinearity was not considered to be
a problem in regression modeling. In all of the hierarchical regression models, variance
inflation factors were all below 2.0, confirming that collinearity was not a problem.
Association between Anxiety and Physical Functioning
Table 3 presents results from the hierarchical multiple regression analyses that
explored the association between anxiety and physical functioning. The analysis,
adjusting for age, gender, ethnicity, marital status, education, NYHA class, BMI, history
of myocardial infarction, current smoking status, and psychotherapy and medications for
depression or anxiety, showed that there was a statistically significant association
between anxiety and poorer physical functioning (  = .43, t[248] = 8.36, p<.001).
Anxiety predicted an additional 14.3% of the variance in physical functioning than the
covariates alone. The model including anxiety and the covariates explained a significant
proportion of variance in physical functioning scores, R
2
=.49, F (13, 248) = 18.57,

28

p<.001. Among the covariates, history of myocardial infarction (  = .11, t[248] = 2.31,
p<.05) and NYHA class (  = .41, t[248] = 8.56, p<.001) were significantly associated
with poorer physical functioning in the final model.
Exploration of Approach and Avoidant Coping as Mediators
Avoidant coping was examined as a mediator that would help to explain the
relationship between anxiety and poorer physical functioning. Adjusting for the
previously mentioned covariates, anxiety ( = .43, t[248] = 6.81, p<.001) was
significantly associated with higher levels of avoidant coping. Avoidant coping,
however, was not significantly related to poorer physical functioning, adjusting for
anxiety and covariates (  = -.04, t[247] = -.69, p = .49). Because this requirement of
mediation outlined by Baron and Kenny (1986) was not satisfied, further steps in the
mediational analyses were not conducted. Thus, avoidant coping did not mediate the
effect of anxiety on physical functioning.
The observed results suggested that anxiety demonstrated a stronger association
with physical functioning than avoidant coping. When adjusting for covariates, avoidant
coping (  = .13, t[248] = 2.38, p<.05) and anxiety (  = .43, t[248]= 8.36, p<.001) were
both significantly associated with poorer physical functioning when tested in separate
models. When tested in the same model, anxiety ( =.45, t[247]=7.94, p<.001) remained
significantly associated with poorer physical functioning, but avoidant coping (  = -.04,
t[247] = -.69, p = .49) no longer demonstrated a significant relationship with physical
functioning.

Table 2
Pairwise correlations between study variables

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1: Age -- .11 -.07 .04 -.10 .08 .09 -.02 .19 .09 -.21** .04 -.01 -.20** -.07 -.12 -.04
2: Gender --- .19** .10 .13* .01 -.04 -.15* .12 .07 -.19** .02 .05 -.04 -.03 .07 -.11
3: Marital
Status --- .11 -.21** .08 .04 -.10 .07 .09 .06 -.08 .08 .06 -.15* -.06 .23**
4: Education
--- -.09 -.12 .09 -.23** -.02 .001 .06 -.03 -.07 -.11 -.15* .04 -.04
5: African
American --- -.47** -.14* .04 -.13* .02 -.04 .02 .05 -.02 .11 .07 .02
6: Hispanic
--- -.22** .10 .08 -.16** -.004 -.09 -.17** -.05 -.04 -.12* -.08
7: Other
--- -.04 .04 -.11 .19** -.10 .06 .08 .02 .10 -.03
8: BMI
--- .06 .07 .07 .04 .19** .20** .13* -.08 -.06
9: History of
MI --- .08 -.15 .01 .22 .14* .07 -.05 -.10
10: NYHA
Class --- -.05 .11 .49** .14* -.03 .10 .01
11: Current
Smoking --- -.02 -.14* -.10 -.05 .02 .03
12:Treatment
for Anxiety or
Depression --- .01 .07 .10 -.03 -.13*
13: Physical
Functioning --- .51** .16** .09 -.05
14: Anxiety
--- .44** .01 -.13*
15: Avoidant
Coping --- .08 -.09
16: Approach
Coping
--- .06
17: Social
Support ---
* p<.05 ** p<.01 *** p<.00
29
9

30

Table 3
Association between anxiety and physical functioning

* p<.05 ** p<.01 ***p<.001

Next, approach coping was examined as a mediator of the relationship between
anxiety and poorer physical functioning. Anxiety ( = -.01, t[247] = -.20, p =.84) was
not significantly associated with approach coping. Additionally, approach coping (  =
.04, t[247] =. 95 p = .35) was not significantly associated with physical functioning,
adjusting for anxiety and covariates. Therefore, additional analyses were not explored to
test approach coping as a mediator of the association between anxiety and poorer
physical functioning. Finally, approach coping (  = .04 t[248] = .71, p = .48) was also
not associated with physical functioning in a model that only adjusted for covariates.

Block 1 β Model 1 β Model 2
BMI 1.60** .08
Age -0.01 .01
Gender 0.002 .02
Marital Status 0.05 .06
Education -0.02 .001
Current Smoking -0.15** -.09
History of MI .16** .11*
Mental Health Treatment .07 -.04
NYHA class 0.46*** .41***
African American Ethnicity 0.05 .05
Hispanic Ethnicity -0.08 -.07
Other Ethnicity 0.12* .08
Block 2
Anxiety .43***
Δ R
2
0.35 0.14
F Change 11.20*** 69.87***
Final R
2
0.35 0.49

31

Examination of Approach and Avoidant Coping as Moderators
Table 4 presents results from the hierarchical multiple regression analyses that
explored an interaction between anxiety and avoidant coping in their effect on physical
functioning. After adjusting for covariates, there was a significant interaction between
avoidant coping and anxiety in their effect on physical functioning (  = .15, t[246] =
2.58, p<.05). Thus, the effect of anxiety on physical functioning depended on the
frequency in which participants used avoidant coping strategies. The interaction term
predicted an additional 1.3% of the variance in physical functioning. The model
including covariates, anxiety, avoidant coping, and the interaction between anxiety and
avoidant coping explained a significant proportion of variance in physical functioning
scores, R
2
=.51, F (15, 246) = 21.88, p<.001.
In order to explore the nature of the significant interaction, the association
between anxiety and physical functioning at different levels of avoidant coping was
explored. Three regression equations were computed to examine the association between
anxiety and physical functioning at the mean of avoidant coping and the values one
standard deviation above and below the mean of avoidant coping. Figure 1 illustrates the
nature of this interaction. At all levels of avoidant coping, anxiety maintained a
statistically significant association with poorer physical functioning. Specifically,
anxiety was significantly associated with poorer physical functioning at one standard
deviation above the mean of avoidant coping (b = 1.40, t[246] = 6.96, p<.001), at the
mean of avoidant coping (b = 1.11, t[246] = 8.12, p<.001), and at one standard deviation
below the mean of avoidant coping (b = .82, t[246] = 4.74, p<.001). Examination of the

32

simple slopes at the various levels of avoidant coping, however, indicated that anxiety
demonstrated a stronger association with poorer physical functioning at higher levels of
avoidant coping. Avoidant coping strategies exacerbated the detrimental effects of
anxiety on heart failure patients’ physical functioning. There was not a significant
interaction between approach coping and anxiety in their effect on physical functioning
(  = .03, t[246] = .57, p = .57). Approach coping did not appear to buffer the association
between anxiety and poor physical functioning.
Table 4
Interaction between anxiety and avoidant coping in their effect on physical functioning
Block 1 β Model 1 β Model 2 β Model 3
BMI 1.60** .10* .08
Age -0.01 .01 .01
Gender 0.002 .02 .01
Marital Status 0.05 .06 .06
Education -0.02 -.004 -.01
Current Smoking -0.15** -.09 -.09
History of MI .16** .11* .10*
Mental Health Treatment .07 -.04 -.03
NYHA class 0.46*** .41*** .42***
African American Ethnicity 0.05 .05 .05
Hispanic Ethnicity -0.08 -.07 -.06
Other Ethnicity 0.12* .08 .10
Block 2
Anxiety .45*** .45***
Avoidant Coping -.04 -.09
Block 3
Anxiety*Avoidant Coping .13*

Δ R
2
0.35 0.14 0.01
F change 11.20*** 35.10*** 6.65*
Final R
2
0.35 0.49 0.51

* p<.05 ** p<.01 ***p<.001

33

Figure 1
Simple slopes of association between anxiety and physical functioning at high, mean, and
low levels of avoidant coping.

Social Support
Multiple regression analyses indicated that there was not a statistically significant
direct association between social support and physical functioning ( = -.03, t[248]= -.57,
p=.57) adjusting for covariates. Additionally, social support did not buffer the
association between anxiety and poorer physical functioning ( =-.003, t[248]= -.07,
p=.95) or avoidant coping and poorer physical functioning ( =.05, t[248]=1.015, p=.31).
Finally, there was not a significant interaction between approach coping and social
support in their effects on physical functioning ( =.01, t[248]=-.11, p=.91).

34

Chapter 4: Discussion
This study demonstrated that anxiety was a common emotional difficulty
experienced by chronic heart failure patients. Approximately half of the participants
reported moderate to severe anxiety symptoms. This result is particularly alarming
considering that the anxiety measure in this study was specifically designed to exclude
the somatic symptoms of anxiety that might falsely inflate its severity when measured in
medical patients.
The current investigation established a significant association between anxiety
and poorer physical functioning, while controlling for demographic and medical
covariates. This relationship supported those found in previous studies (Clarke et al.,
2000; Friedmann et al., 2006; Muller-Tasch et al, 2009; Chung et al., 2009). Unlike the
prior studies, however, the anxiety measure employed in this study did not contain
confounding physical items, thus constituting a more stringent test and providing stronger
evidence for the association between anxiety and poorer physical functioning in chronic
heart failure patients.
Several potential mechanisms may explain the relationship between elevated
anxiety and poorer physical functioning. First, patients with higher anxiety could have
exaggerated their functioning difficulties because of fear. Some studies of very frail
elderly individuals suggested that emotionally distressed patients tended to underestimate
their abilities to perform general activities of daily living (Cress et al., 1995).
Nevertheless, the present study assessed heart failure-specific physical functioning, and
the effect of anxiety remained substantial after adjusting for covariates, such as disease

35

severity. Perception bias alone was not likely to fully explain the observed associations.
Second, the broader literature in psychosocial factors and heart disease have suggested
several physiological mechanisms that may help to explain the relationship between
anxiety and impaired physical functioning, including sympathetic hyper-arousal, reduced
heart rate variability, impaired platelet functioning, elevated inflammation, and
hypercortisolemia (Kubzansky et al., 1998; Rozanski et al., 2005). Lastly, patients with
high anxiety have previously been shown to neglect self-care, engage in health-
compromising behaviors, and fail to adhere to the demanding dietary and medical
regimen for heart failure (Rozanski et al., 2005, DiMatteo et al., 2000), all of which may
have led to poorer functioning.
Of note, the significant direct effect of anxiety on physical functioning should be
interpreted in light of the statistically significant interaction between anxiety and avoidant
coping. Employing avoidant coping strategies exacerbated the detrimental effects of
anxiety on physical functioning. This relationship coincided with the literature that
reported significant associations between both anxiety (Clarke et al., 2000; Friedmann et
al., 2006) and avoidant coping (Carels et al., 2004; Klein et al., 2004; Murberg et al.,
2004) and poorer physical functioning and mortality in heart failure patients. These
results also supported findings from previous studies in cancer patients that demonstrated
interactions between psychosocial factors and avoidant coping in their effects on patients’
distress (Jacobsen et al., 2002) and an interaction between stress and avoidant coping on
physiological measures of heart disease risk (Barger et al., 2000). Therefore, anxious

36

heart failure patients who adopt avoidant coping strategies may be particularly at risk for
experiencing adverse psychological and physical functioning.
Contrary to the model proposed by Taylor and Stanton (2007), avoidant coping
did not mediate the association between anxiety and poorer physical functioning.
Avoidant coping was significantly related to both higher levels of anxiety, and poorer
physical functioning adjusting for covariates. When anxiety was added to the model,
however, avoidant coping was no longer significantly associated with physical
functioning. Therefore, anxiety did not affect physical functioning indirectly via
avoidant coping.
The combination of the significant moderation and the lack of significant
mediation implied that anxious heart failure patients varied in the degree to which they
adopted avoidant coping strategies. Anxious patients that chose to cope through
avoidance tended to report poorer physical functioning than those who avoided less
frequently. These results were congruent with the research that identified lack of self-
care and failure to adhere to the strict dietary and medical treatment for heart failure
(Rozanski et al., 2005, DiMatteo et al., 2000) as mechanisms that explained the
association between anxiety and poorer physical functioning among heart failure patients.
Perhaps anxious participants who adopted avoidant coping strategies were less likely to
adhere to their doctors’ treatment recommendations and therefore experienced poorer
physical functioning.
Approach coping did not mediate or moderate the association between anxiety
and physical functioning. Higher levels of anxiety were not significantly associated with

37

lower levels of approach coping. Additionally, approach coping was not significantly
related to physical functioning, adjusting for anxiety and covariates. Therefore, approach
coping did not satisfy the requirements for mediation of the association between anxiety
and physical functioning. In other words, anxiety did not detrimentally affect physical
functioning through lower levels of approach coping. Approach coping also did not
buffer the association between anxiety and poorer physical functioning.
Of note, these results did not directly contradict the literature, which has failed to
demonstrate a consistent association between lower use of approach coping strategies and
poorer physical functioning or increased distress among patients with chronic illness
(Doering et al., 2004; Taylor & Stanton, 2007). A few explanations have been identified
in an attempt to clarify these inconsistent results. For example, some approach coping
strategies, such as problem solving, have not been found to be useful for coping with
facets of a stressor that are not perceived to be amenable to change (Park et al., 2001).
Additionally, previous research has indicated that approach and avoidant coping
strategies may differentially predict negative and positive indicators of adjustment to
chronic illness, with approach coping demonstrating a stronger association with positive
affect than negative affect (Billings et al., 2000). This hypothesis was supported by the
result that anxiety demonstrated a stronger association with avoidant coping than
approach coping strategies. Finally, the high levels of approach coping reported by this
study’s participants may have restricted its variability and predictive utility.
Social support was not significantly associated with physical functioning,
adjusting for covariates. Additionally, social support did not buffer the association

38

between anxiety, avoidant coping, or approach coping and physical functioning. Though
this finding was contradictory to hypotheses, it was not inconsistent with prior research
(Clarke et al., 2000, Bennett et al., 2001; Friedmann et al., 2006) in which studies either
did not demonstrate an association or reported significant attenuation in the strength of
the relationship after adjustment for covariates. A possible explanation for the results in
the present study may be that the participants reported fairly strong social support in
general, thus restricting its range and predictive ability. Those with low social support
may not have successfully managed their heart failure, which could have resulted in
severe impairments or even premature death and prevented them from participating in
this study. In addition, social support is a complicated construct, with variable definitions
and measurements (House et al., 1988). The present study explored heart failure patients’
perceived availability of functional support, including the emotional, informational, and
instrumental subcomponents. Other types of social support, such as an objective measure
of received support, social network size, and relationship quality were not investigated.
Additionally, the social support scale did not differentiate between sources of support.
Further research is needed to explore whether certain facets of social support may
demonstrate a more influential role in predicting physical functioning or buffering against
the effects of negative emotions and maladaptive coping strategies in heart failure
patients.
The previously discussed results must also be interpreted in light of study
limitations. One limitation is that the cross-sectional, correlational design did not allow
the investigators to draw causal inferences based on the results. Although several

39

longitudinal investigations have shown baseline anxiety to predict the decline in physical
functioning among heart failure patients (e.g. Clarke et al., 2000), there are other possible
interpretations of the present results. Perhaps heart failure patients became highly
anxious in response to their poorer physical functioning. In addition, there could have
been a third unmeasured variable that caused both anxiety and low physical functioning,
though the examination of many possible demographic, medical, and behavioral
covariates limited this possibility. The cross-sectional nature of the study also didn’t
allow the investigators to look at the change in the primary variables and their
relationships over time.
The applicability of the results to the general heart failure population may also be
limited. The mean age of participants in the present study appeared to be younger than
the mean age that tended to be reported in the literature. This may partly be due to the
fact that the participants were recruited from tertiary care cardiology clinics that treated
patients who tended to be sicker than traditional heart failure patients. Additionally, the
participants were recruited from a convenience sample, and there were some eligible
patients who declined to participate. Data regarding the demographic and medical
composition of the non-participants and their reasons for non-participation were not
collected. The results obtained from this sample of heart failure patients may therefore
lack some degree of external validity.
Another limitation was related to the measures. Because the participants were
patients whose health was severely compromised, it was necessary to limit the length of
the assessment in order to avoid placing undue burden on the participants. Thus, the

40

primary variables of interest were measured with self-report questionnaires that may be
subject to biases. Moreover, the Hospital Anxiety and Depression Scale did not allow
investigators to distinguish between different anxiety disorder diagnoses in the same way
that one can with a structured interview that is based on DSM-IV diagnostic criteria. The
modified Brief COPE included only one item per subscale. The measures of approach
and avoidant coping were comprised of only four and five items respectively and
demonstrated only moderate internal consistency. Therefore, the study may have
underestimated the effects of approach and avoidant coping on physical functioning due
to lower power. Additionally, it was not possible to examine the relationships of
individual coping strategies, such as acceptance or denial, and physical functioning.
Future studies should explore similar hypotheses in a longitudinal design in order
to bolster the interpretation of the present results. Additionally, a measure of coping
strategies with more than one item per strategy could be employed to investigate the
relationship between anxiety, physical functioning, and specific coping strategies.
Additional conceptualizations, measurements, and sources of social support should be
examined in order clarify which aspects of social support are related to physical
functioning among heart failure patients. Finally, additional physiological and behavioral
mechanisms should be explored as explanations for the association between anxiety and
poorer heart failure related physical functioning and possible points of future
interventions.
In sum, the present study demonstrated that moderate to severe anxiety is a
common emotional difficulty experienced by heart failure patients, and is associated with

41

poorer physical functioning, beyond the effects of demographic and medical variables.
Importantly, this study reduced the possibility that this relationship was inflated by the
somatic symptoms of anxiety that were confounded with symptoms of heart failure. The
present study also examined three explanatory mechanisms of this relationship, social
support, approach coping, and avoidant coping. Adopting avoidant coping strategies
exacerbated the detrimental effects of anxiety on physical functioning. These results
suggested the importance of assessing and managing heart failure patients’ anxiety
symptoms. They also implied that assisting patients in decreasing the amount of avoidant
coping strategies that they use in favor of more adaptive strategies may be an additional
focus for intervention. Managing anxiety and avoidant coping strategies may have
important implications for patients’ physical health in addition to their psychological
functioning.

42

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Abstract (if available)

Abstract Previous studies have suggested that negative emotions are associated with morbidity and mortality in heart failure patients, but the psychosocial mechanisms that explain this relationship have remained unclear. The present study examined whether anxiety was associated with poorer physical functioning among heart failure patients and explored coping strategies and social support as possible explanatory mechanisms. Participants included 262 heart failure patients (mean age = 54 years). Hierarchical multiple regression analyses adjusting for age, gender, ethnicity, marital status, education, New York Heart Association (NYHA) class, treatment for depression or anxiety, current smoking status, body mass index (BMI), and history of myocardial infarction were conducted to examine the study hypotheses. Among participants, 24% reported borderline and 21% reported severe anxiety symptoms. Results demonstrated a significant association between anxiety and poorer physical functioning (beta = .43, p<.001). There was also a significant interaction between avoidant coping and anxiety in their effect on physical functioning, (beta = .13, p<.05), whereas approach coping did not moderate the association between anxiety and physical functioning. In addition, neither approach nor avoidant coping mediated the relationship between anxiety and physical functioning. Social support was not directly associated with physical functioning or a moderator of the relationship between anxiety and physical functioning. Finally, there was not a significant interaction between approach or avoidant coping and social support in their effects on physical functioning. Overall, these results indicated that anxiety was associated with poorer physical functioning in heart failure patients and the use of avoidant coping strategies exacerbated this detrimental effect.

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Asset Metadata

Creator Eisenberg, Stacy Ann (author)

Core Title The influences of anxiety, coping, and social support on physical functioning among heart failure patients

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 06/14/2010

Defense Date 05/07/2010

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag anxiety,coping,heart failure,OAI-PMH Harvest,physical functioning,social support

Place Name California (states), Florida (states), Los Angeles (city or populated place), Miami (city or populated place)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Shen, Biing-Jiun (committee chair), Dawson, Michael E. (committee member), Meyerowitz, Beth (committee member)

Creator Email saeisenb@usc.edu,stacyeisenberg@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m3129

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Legacy Identifier etd-Eisenberg-3774.pdf

Dmrecord 349031

Document Type Thesis

Rights Eisenberg, Stacy Ann

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu