Coping Styles for Anxiety and Depressive Symptoms in Community-Dwelling Older Adults

Clinical Gerontologist, 37:406–417, 2014Copyright © Taylor & Francis Group, LLCISSN: 0731-7115 print/1545-2301 onlineDOI: 10.1080/07317115.2014.907590

Coping Styles for Anxiety and DepressiveSymptoms in Community-Dwelling

Older Adults

VASILIKI ORGETA, PhD and MARTIN ORRELL, PhD, FRCPsychUniversity College London, London, United Kingdom

The aim of the present study was to examine whether specific copingstyles are associated with self-reported anxiety in a sample of olderadults. A total of 210 community-dwelling older adults completedself-report measures of anxiety and depression and the CopingOrientations to Problems Experienced scale. Results indicated thata tendency to utilize dysfunctional coping strategies predicted anx-iety symptomatology in late life, with older adults who reportedhigh levels of anxiety more likely to report using dysfunctional cop-ing. After controlling for depressive symptoms, use of venting andself-blame made an independent contribution in predicting anx-iety symptoms. Overall, 65% of the variance in anxiety symptomswas explained by education, depressive affect, and use of self-blameand venting as coping strategies. Our findings indicate that spe-cific coping styles such as venting and self-blame are associatedwith experiencing high levels of anxiety symptoms in late life. Theseresults suggest that targeting specific dysfunctional copying stylesmay be useful for prevention strategies and interventions treatinganxiety in late life.

KEYWORDS aging, anxiety, coping style, depression, venting

Late-life anxiety is often subclinical (Bryant, Jackson, & Ames, 2008), whereasthe impact of even mild anxiety symptoms in older adults is comparable tothat seen in depressive disorders, causing significant disability (Wetherellet al., 2004). Anxiety is very common in late life (Wolitzky-Taylor, Castriotta,

Address correspondence to Vasiliki Orgeta, PhD, University College London, Divisionof Psychiatry, 67-73 Riding House Street, 2nd Floor, Charles Bell House, London W1W 7EJ,United Kingdom. E-mail: [email protected]

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mailto:[email protected]

Coping Styles in Late Life 407

Lenze, Stanley, & Craske, 2010), with recent prevalence studies indicatingthat anxiety disorders may in fact be more common compared to depressionor other disorders in late adulthood (Bryant et al., 2008). However, despiteconsistent evidence that anxiety decreases quality of life and social function-ing for older people (Porensky et al., 2009; Wetherell et al., 2004), it is widelyrecognized that the knowledge base about anxiety in late life continues tobe much less developed compared to that of depression (Kogan, Edelstein,& McKee, 2000).

Successful coping with life stressors has long been considered anessential part of aging, defined as a multidimensional process involving cog-nitive, behavioral, and emotional efforts to alter stressful situations (Carver& Scheier, 1994; Folkman & Moskowitz, 2004; Lazarus & Folkman, 1984).Coping is often seen as a psychological and social process (Folkman,Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986) and as a psychologi-cal trait (Endler & Parker, 1994) that may be situational and person-based(Costa, Somerfield, & McCrae, 1996). Although life stressors have beenshown to increase the risk of developing anxiety in late life (Schultz, Hoth,& Buckwalter, 2004), a number of studies investigating coping processesacross the life span show that older adults use coping resources efficientlywhen dealing with stressors (Carstensen, Fung, & Charles, 2003; Carstensen& Mikels, 2005). For example, increasing age is associated with the use ofmore emotion-focused coping (i.e., strategies that involve changing one’sthoughts or feelings about the problem) such as distancing oneself from anegative event (Blanchard-Fields, Mienaltowski, & Seay, 2007; Carstensen& Lockenhoff, 2003), and older adults are better than young people intheir ability to control emotions (Blanchard-Fields et al., 2007; Gross et al.,1997).

In line with coping theories (Carver, Scheier, & Weintraub, 1989; Lazarus& Folkman, 1984) evidence shows that individuals experiencing anxietysymptoms or anxiety disorders are less likely to use coping resources effi-ciently (Garnefski et al., 2002; Grandinetti et al., 2011). In late-life psychiatricdisorders, particularly depression, depressed older adults are more likely toreport using avoidance and emotional discharge (Bjorklof, Engedal, Selbaek,Kouwenhoven, & Helvik, 2013; Foster & Gallagher, 1986), whereas longitudi-nal studies show that cognitive coping strategies such as positive reappraisalare associated with fewer depressive symptoms (Kraaij, Pruymboom, &Garnefski, 2002).

Coping is an important mediator between anxiety and emotional well-being, and given that older adults tend to experience more negative lifeevents, efficient coping is of particular importance. For example, use ofstrategies such as venting on emotions and behavioral disengagement corre-late highly with anxiety symptoms in both clinical (Grandinetti et al., 2011)and nonclinical samples (Liverant, Hoffman, & Litz, 2004). It appears that

408 V. Orgeta and M. Orrell

despite evidence that some dysfunctional coping strategies are related toanxiety symptoms (Garnefski et al., 2002), current research is limited in termsof identifying which specific dysfunctional coping styles are more likely tobe associated with anxiety symptoms in late life. Knowledge about whichdysfunctional coping strategies are more likely to be associated with anxietymay provide insight into how different coping styles may affect the occur-rence and maintenance of anxiety symptoms in older adults and therebyinform interventions by including more effective treatment strategies.

The aim of this study was to examine through correlational analysiswhether specific coping styles are more likely to be related to anxiety symp-toms in community-dwelling older adults. A secondary objective was toexamine the relative contribution of depressive symptoms in the interrelationbetween anxiety and dysfunctional coping, given that depressive symptomsoften coexist with anxiety symptomatology (King-Kallimanis, Gum, & Kohn,2009). In line with coping theory (Carver et al., 1989), and prior research(Garnefski et al., 2002; Grandinetti et al., 2011), we hypothesized that report-ing high levels of anxiety will be associated with greater use of dysfunctionalcoping strategies. Given the paucity of previous research on coping and anx-iety in late life, we did not make any predictions about how various copingstyles might differentially relate to anxiety.

METHOD

Participants

Respondents were 210 community-residing older adults, ranging in age from59 to 96 years, with a mean age of 75.04 years (SD = 8.81), which wererecruited from a university panel of volunteers and were invited to par-ticipate. A total of 53.3% of the sample was female and most were EnglishWhite or European (74.2%), 16.2% were Black, and 9.6% Other or Not Stated.A total of 40.5% lived alone, and 97.5% were retired. Thirty-one percent werewidowed, 43.8% were married, and 25.2% were single, separated, divorced,or in a civil partnership. All participants were screened for possible cogni-tive impairment with the Mini Mental State Examination (Folstein, Folstein,& McHugh, 1975), with a cut-off score of > 25 (Chayer, 2002) (M = 28.10,SD = 1.91). Six participants were excluded from the study on the basis ofthis criterion. The mean years of education was 17.96 (SD = 4.91).

Procedure

After informed consent, all participants completed baseline testing, whichincluded demographic and health information such as age, gender, maritalstatus, years of education, and living status, the self-report measures, and


cognitive tests. The demographic questionnaire was presented first, and theremaining measures were presented in a random order to diminish potentialorder effects. Ethical approval was obtained by the College of Life Sciencesand Medicine Ethics Review Board of University of Aberdeen.

Measures

THE BRIEF VERSION OF THE COPING ORIENTATIONS TO PROBLEMS

EXPERIENCED SCALE

The Coping Orientations to Problems Experienced scale (COPE; Carveret al., 1989) is a 28-item questionnaire measuring coping styles. We usedthe 14 subscales of the brief version of the COPE (Brief COPE; Carver,1997): active coping, planning, positive reframing, acceptance, humor, reli-gion, using emotional support, using instrumental support, self-distraction,denial, venting, substance use, behavioral disengagement, and self-blame.Participants rate their use of each strategy on a 4-point Likert-type scaleranging from 1 (not at all) to 4 (a lot). Consistent with past research (Carver,1997), alpha level for the scales was ≤ .77.

HOSPITAL AND ANXIETY DEPRESSION SCALE

Anxiety and depressive symptoms were measured with the Hospital andAnxiety Depression Scale (HADS; Zigmond & Snaith, 1983), a 14 itemself-report questionnaire designed to assess anxiety and depression astwo distinct dimensions in nonpsychiatric populations. Recent studies haveshown that scoring the HADS as two separate subscales is appropriatein nonclinical populations of older men and women (Cale et al., 2010).A Cronbach’s alpha of .81 was observed for HADS-Anxiety and .87 forHADS-Depression.

PHYSICAL HEALTH

Physical health status was measured by the Visual Analogue Scale of theEQ-5D (EQ-VAS), commonly used to measure self-reported health status(EuroQoL, 1990). The EQ-VAS records the respondent’s self-rated health ona vertical VAS, providing a quantitative measure of health outcome as judgedby the individual respondents. The EQ-VAS scale has been successfully usedby previous research in estimating physical health in older adults (Hulme,Long, Kneafsey, & Reid, 2004), with established psychometric properties inthis population (Holland, Smith, Harvey, Swift, & Lenaghan, 2004).


RESULTS

Coping Style, Anxiety Symptoms, and Demographic Characteristics

There was no association between age and coping style; however, yearsof education were negatively correlated with use of dysfunctional copingstrategies, indicating that with increasing education use of dysfunctionalcoping in late life decreases (r = −.16, p < .05). Women reported greater useof emotion-focused coping (M = 23.44, SD = 7.18 for men, M = 25.57, SD =7.08 for women, t(178) = −1.99, p < .05), greater use of positive reframing(M = 4.80, SD = 1.77 for men, M = 5.35, SD = 1.94 for women, t(185) =−2.02, p < .05), and reported higher use of religious coping (M = 4.39, SD =2.55 for men, M = 5.46, SD = 2.47 for women, t(183) = −2.90, p < .05).Men reported higher levels of substance use (M = 2.97, SD = 1.54 for men,M = 2.50, SD = 1.21 for women, t(189) = 1.99, p < .05), whereas womenreported greater use of self-distraction as a way of coping with stress (M =4.45, SD = 1.78 for men, M = 5.14, SD = 1.95, for women, t(187) = −2.49,p < .05). Among the demographic variables, only education was correlatedwith anxiety symptoms, showing a modest to small negative association withHADS-Anxiety (r = −.19, p < .05). The relations between age (Pearson’s r),marital and living status (Spearman’s rho), and gender (Spearman’s rho) withanxiety symptoms (HADS-Anxiety) were absent or weak (r values .02 to .11).

Using previous cutoffs for anxiety in the literature, which have beenreported to achieve optimal balance between sensitivity and specificity forclinically significant anxiety (Bjelland, Dahl, Tangen Haug, & Neckelmann,2002; Snaith & Zigmond, 1994), the sample was divided in those reportinghigh (n = 90, M = 9.50, SD = 2.96) versus low anxiety symptoms (n =102, M = 2.44, SD = 1.65). Those reporting high anxiety symptoms reportedhigher levels of depression (M = 7.77, SD = 3.87) and lower physical health(M = 51.70, SD = 18.06) compared to those experiencing low anxiety (M =3.61, SD = 2.72 for depression; M = 63.98, SD = 17.55 for physical health).Descriptive statistics for both groups on the Brief COPE subscales can beseen in Table 1. One-way analyses of variance (ANOVAs) showed that therewere significant differences between the two groups in use of dysfunctionalcoping in all subscales except use of distraction as a coping strategy, withthose experiencing low anxiety less likely to use dysfunctional coping. Thetwo groups also differed in use of dysfunctional coping overall, with thosereporting high anxiety more likely to report greater use.

Coping Style, Physical Health, Depression, and Anxiety Symptoms

Table 2 shows the correlations between coping style, anxiety, depression,and physical health. Use of dysfunctional coping and substance use wereassociated with higher levels of depression and anxiety and lower physical


TABLE 1 Descriptive Statistics on the Brief COPE Subscales by Anxiety Status (Low Anxietyand High Anxiety Group)

Low Anxiety(n = 102)

High Anxiety(n = 90)

Brief COPE Subscales Mean SD Mean SD F value

Problem-focused strategies 14.89 4.89 14.94 3.73 F = .06, p = .937Active coping 4.88 2.13 5.02 1.66 F = .26, p = .612Instrumental support 4.78 1.80 4.75 1.63 F = .01, p = .927Planning 5.11 2.01 5.08 1.62 F = .10, p = .919Emotion-focused strategies 24.68 7.16 24.33 7.21 F = .10, p = .755Acceptance 5.17 2.20 5.59 3.72 F = .91, p = .341Emotional support 5.09 2.03 4.77 2.02 F = 1.19, p = .277Humor 4.11 1.97 4.08 1.91 F = .01, p = .923Positive reframing 5.31 2.03 4.85 1.69 F = 2.73, p = .100Religion 4.89 2.71 5.04 2.38 F = .18, p = .676Dysfunctional coping strategies 17.58 3.65 22.80 5.65 F = 54.30, p < .001Behavioral disengagement 2.41 0.94 3.37 1.51 F = 27.02, p < .001Denial 2.53 1.05 3.36 1.52 F = 18.94, p < .001Self-distraction 4.69 2.13 4.92 1.60 F = .66, p = .417Self-blame 2.80 1.22 3.88 1.60 F = 26.89, p < .001Substance use 2.34 0.89 3.03 1.69 F = 12.59, p < .001Venting 2.96 1.12 4.21 1.58 F = 39.07, p < .001

Note. Brief COPE = brief version of the Coping Orientations to Problems Experienced scale (Carver,1997).

TABLE 2 Correlations between Coping Strategies, Anxiety Symptoms, Depression, andPhysical Health

COPE Subscales HADS-Anxiety HADS-Depression Physical Health

Problem-focused strategies −.05 −.17∗ .03Active coping −.04 −.13 .06Instrumental support −.02 −.06 −.05Planning −.05 −.18∗ .10Emotion-focused strategies −.07 −.12 .03Acceptance .05 .07 −.05Emotional support −.10 −.08 −.02Humor −.03 −.06 .05Positive reframing −.16∗ −.27∗∗ .14Religion −.01 −.08 −.04Dysfunctional coping strategies .57∗∗ .40∗∗ −.23∗∗

Behavioral disengagement .39∗∗ .34∗∗ −.16∗

Denial .42∗∗ .32∗∗ −.21∗

Self-distraction .06 −.06 −.04Self-blame .34∗∗ .22∗∗ −.03Substance use .38∗∗ .39∗∗ −.22∗∗

Venting .48∗∗ .30∗∗ −.16∗

Note. COPE = Coping Orientations to Problems Experienced scale (Carver, 1997); HADS = HospitalAnxiety and Depression Scale (Zigmond & Snaith, 1983). Physical health was measured by the EQ-VisualAnalogue Scale (EQ-VAS) of the EQ-5D (EuroQoL, 1990).∗p < .05; ∗∗p < .01.


health. Positive reframing was negatively correlated with both anxiety anddepression, indicating that those reporting use of this strategy are less likelyto experience psychological distress. Higher scores on the HADS-Anxiety andHADS-Depression were significantly related to higher levels of behavioraldisengagement, self-blame strategies, use of denial, and venting; however,no significant correlations were observed between self-distractive coping andanxiety or depression. Higher levels of self-reported health were associatedwith less use of venting, behavioral disengagement, and denial. Increasingdepression was associated with less use of problem-focused strategies overalland planning.

To determine the relative and unique contribution of education, phys-ical health, coping styles, and depression in predicting anxiety symptoms,multiple regression analyses were conducted (Table 3). Tolerance for mul-ticollinearity and variation inflation among the independent variables waswithin the acceptable range (tolerance .768 – .922; variation inflation factor1.08 – 1.30). A hierarchical multiple regression was conducted with HADS-Anxiety as the criterion variable, and education, physical health, depression,and coping strategies that were found to be significant in the correlationalanalyses, as the predictor variables. In the first step, we entered education,gender, physical health, and depression. Multiple R for the regression was

TABLE 3 Summary of Hierarchical Multiple Regression Analysis of Demographic, PhysicalHealth, and Coping Variables Predicting Anxiety Symptoms

HADS-Anxiety

Variable β p value

Step 1Education −.11∗ .041Gender −.05 .311Physical health −.02 .806HADS-Depression .72∗∗ <.001

Step 2Education −.11∗ .032Gender .05 .343Physical Health −.01 .895HADS-Depression .55∗∗ <.001Positive reframing .01 .889Behavioral disengagement −.01 .915Denial .05 .450Self-blame .11∗ .046Substance use .10 .083Venting .21∗∗ .001

Note. HADS = Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983). Physical health wasmeasured by the EQ-Visual Analogue Scale (EQ-VAS) of the EQ-5D (EuroQoL, 1990). β is the averageincrease in the dependent variable associated with an increase of one unit in the independent variable.R2 = .56, F(4, 159) = 48.88, p < .001 for step 1; R2 = .65, �R2 = 0.63, F -change (9, 159) = 28.01, p <

.001 for step 2; ∗p < .05; ∗∗p < .01.


significantly different from zero, where all variables accounted for 56% of thevariance in anxiety symptoms. Education, and depressive symptoms, madeindependent contributions to the prediction of anxiety symptoms. In Step 2,coping style variables were entered simultaneously, controlling for depres-sion, education, gender, and physical health. Adding type of copying styleresulted in a significant increase in the model, with multiple R significantlydifferent from zero. In this model all variables accounted for 65% of thevariance in anxiety, with depressive affect, education, venting, and use ofself-blame making an independent contribution (Table 3).

DISCUSSION

It has long been postulated that the way individuals cope with problemsand emotions is particularly important in the experience of psychologicaldistress. The aim of our study was to identify whether specific coping styleswere more likely to be associated with experiencing anxiety in a sample ofcommunity-dwelling older adults. We found that older adults reporting highlevels of anxiety were more likely to report using dysfunctional coping. Ourfindings are in line with previous suggestions in the literature that increaseduse of maladaptive coping leads to more negative outcomes, such as anxi-ety, depression, and poor physical health (Garnefski et al., 2002; Roesch &Weiner, 2001; Vinberg, Froekjaer, & Kessing, 2010).

In this study, dysfunctional coping styles independently contributed toexplaining anxiety symptoms after controlling for depressive affect and phys-ical health. Current findings suggest that older adults experiencing high levelsof anxiety are less likely to engage in cognitive, behavioral, and emotionalefforts to manage effectively particular external and/or internal demands,but may be more likely to use dysfunctional coping responses. An implica-tion of these findings is that greater anxiety is likely to hamper the use ofeffective problem solving strategies and therefore negatively influence inter-personal or decision-making processes for older adults (Zermatten, Van derLinden, d’Acremont, Jermann, & Bechara, 2005). Dysfunctional coping stylemay operate across situations to influence psychological outcomes, such asexperiencing anxiety symptoms.

We found that older adults experiencing high levels of anxiety weremore likely to report using venting and self-blame, perhaps as a way ofcoping with the anxiety symptoms. This is consistent with previous studiesshowing that self-blame is associated with state anxiety in both clinical andnonclinical samples (Garnefski, Kraaij, & Spinhoven, 2001; Kraaij, Garnefski,& Van Gerwen, 2003). Our findings are in line with studies showing thatventing and focusing on emotions is uniquely predictive of long-term anx-iety (Liverant et al., 2004). Similarly to prior work increasing anxiety and


depression were also associated with less use of positive reframing (Martin& Dahlen, 2005).

Our results suggest that treatment programs for anxiety-prone olderadults should specifically focus on reducing maladaptive coping strategies.For older adults with significant clinical anxiety it may be useful for psy-chological interventions to specifically target coping mechanisms such asself-blame and venting. For example, changing individuals’ maladaptive stylecan ameliorate the course of an affective disorder (Miklowitz, 2008) and canbe a useful target for prevention of psychological distress (Ingram, Nelson,Steidtmann, & Bistricky, 2007). This is indeed the case with cognitive behav-ioral interventions that aim to help older adults control anxiety symptoms, byplacing emphasis in avoidance of self-blame (Stanley, Diefenbach, & Hopko,2004).

Better coping enables individuals to cope more effectively with stress,therefore understanding the relationship between anxiety and effective cop-ing in late life is particularly important. The findings that have been presentedsuggest that a tendency to utilize dysfunctional coping strategies such asventing and self-blame predict anxiety symptomatology in late life, indica-tive of their predictive utility in understanding psychological distress. Thismay be due to the fact that venting, and self-blame are unlikely to alter any-thing about the stressful situation that the individual is experiencing or theindividual’s adaptation to the stressor, as the stressor and its power to evokedistress remain unchanged (Wadsworth, Gudmundsen, & Raviv, 2004).

There are a number of limitations in this study. This sample consistedof older adults from a panel of university volunteers and may therefore notbe representative of the general ageing population. It is important to con-sider that levels of education were above average for this sample, and thatself-reported anxiety was explained in part by education. For example, mostparticipants reported high levels of education, which limits the generalizabil-ity of our findings and may harm external validity. The use of self-reportmeasures to quantify coping ability is limited, since participants’ perceptionsof their coping skills may not necessarily reflect actual ability. Due to thecross-sectional nature of this study, no conclusions can be drawn regardingthe direction of influence. It is possible that using specific maladaptive cop-ing strategies may be causing anxiety symptoms; however, on the other hand,dysfunctional coping may be an epiphenomenon of experiencing high levelsof anxiety. Research with larger sample sizes using longitudinal designs andclinical populations is needed to address the specific role of coping strategiesin the development and maintenance of anxiety symptoms in older adults.Research in this area may influence the development and refinement of pre-vention and intervention strategies for older adults at risk of experiencinganxiety disorders.

In conclusion, this study advances current literature by linking anxietywith specific dysfunctional coping mechanisms in community-dwelling older


adults, but future research is necessary to assess the ways in which anxietyand coping ability interact. Research investigating individual differences inthe use of different coping strategies may inform models of treatment foranxiety disorders and provide important insights into the maintenance ofanxiety symptomatology. Future research investigating which cognitive pro-cesses are likely to mediate the use of adaptive coping mechanisms couldhave important implications for treating anxiety in late life.

ACKNOWLEDGMENTS

We thank those who kindly volunteered to participate in the study.

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Coping Styles for Anxiety and Depressive Symptoms in Community-Dwelling Older Adults