Sometimes humans are struck by a strange feeling of emptiness causing feelings of discomfort in the thoracic region and the impression of being suffocated. Anguish has a high weight, since its synonyms are agony, affliction, torment, martyrdom, torture, leading to the feeling of oppression, emptiness, hole, sword pain, compression that can present intensity high, however it is not considered a pathology [1].The origin of the word anguish goes back

to the Greek angor that has the meaning of squeezing, compressing, strangling, choking, suffocating [2]. In the scientific field anguish arose with the introduction of angst by Sigmund Freud [3], however angst was translated into anxiety because angst was a term commonly used in German and could be translated by some equally common English words such as fear, fright. alarm [4]. Research on brain function has hypothesized that anguish could have a clinical and neurobiological relevance, that is the feeling of tightness or oppression in the thoracic region could have emotional connection [5]. Over the last decades, conceptual confusions has been observed on concepts such as anguish, anxiety, fear or panic. The feeling of anguish, that foccuses on events occuring in the present, is accompained by sensations in the thoracic region that can present themselves in the form of pain or tightness and due to the fact that many patients with affective and anxiety disorders report this experience, anguish become the target of great clinical concern [6].

The objectives of this research consisted on verifying differences in psychopathological symptoms under the experience of anguish and finding out if anguish is more related to the depression or to anxiety. The following two hypothesis were posed to comprove the objectives of the study:

1. Patients with anguish and patients without anguish are differents in terms of psychological symptoms
2. Patients with depression have more anguish than patients with anxiety.

Participants Data of 100 participants was collected within one large mental health care institucion in Brazil: Institute of psychiatry of clinic’s hospital of medicine’s faculty of São Paulo’s universiry. From the 100 participants 69% self-identified as female, 29% as male and 2% as transexuals. Mean age of the 100 participants was 44,54 years and education level was 42% secondary or lower and 47% graduates. Sample was divided into three groups: Sample 1 participants were 35 patients with anguish. Sample 2 participants were 50 participants without anguish. Sample 3 participants were patients with anguish but without a right description of the feeling when asked in the interview. Measures Sociodemographic questionnaire. Developed with the objective of collecting information regarding the demographic and sociocultural variables of the participants, namely, Age (years), Gender (Male, Female, Other); Education level (Complete Higher Education, Incomplete Higher Education, Complete Secondary Education, Incomplete Secondary Education, Complete Primary Education, Incomplete Primary Education; Marital Status (Single, Married, Divorced, Widowed, No Answer). Brief Symptoms Inventory The Brief Symptom Inventory (BSI) consists of 53 items covering nine symptom dimensions: Somatization, Obsession-Compulsion, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation and Psychoticism; and three global indices of distress: Global Severity Index, Positive Symptom. The authors report good internal consistency reliability for the nine dimensions, ranging from .71 on Psychoticism to .85 on Depression. Good internal consistency reliability is supported by several other independent studies [7, 8]. No alpha reliability is reported for the three global indices. Test-retest reliability for the nine symptom dimensions ranges from .68 (Somatization) to .91 (Phobic Anxiety), and for the three Global Indices from .87 (PSDI) to .90 (GSI). Defense Styles Inventory The Defense Style Questionnaire--40 (DSQ-40) is a modification of the original Defense Style Questionnaire [9], and was developed to create a psychometrically acceptable instrument in which the heterogeneity of defenses measured in the original DSQ was preserved in factor scores, while aiming for internal consistency at the level of the individual defenses. There are two items for each of 20 defenses. Items are rated on a 9-point Likert-style scale (1=strongly disagree; 9=strongly agree). Eight criteria were used to assess the validity and the reliability of each item. The DSQ 40 can yield both individual defense scores and three higher-order factor scores (mature, neurotic, and immature). Psychometric analyses indicated that the instrument possesses reasonable internal consistency and temporal stability appropriate in a trait measure. Correlations among the mature, neurotic, and immature factors derived from the DSQ and the DSQ-40 were .97, .93, and .95, respectively, evidence of the construct validity of the revised instrument. Although very comparable to the 72-item DSQ, the DSQ 40 has yet to be validated against the ratings of skilled clinicians or against other instruments, such as the Defense Mechanism Inventory [10] or the Defense Mechanism Rating Scale [11], as has been done with the original DSQ [9]. Hospital Anxiety and Depression Scale The Hospital Anxiety and Depression Scale (HADS) is commonly used to determine the levels of anxiety and depression that a person is experiencing. The HADS is a 14-item scale, with seven items relating to anxiety and seven relating to depression [12]. The authors created this outcome measure specifically to avoid reliance on aspects of these conditions that are also common somatic symptoms. This, it was hoped, would create a tool for the detection of anxiety and depression in people with physical health problems Twelve studies assessed the psychometric properties of the HADS-Total and its subscales HADS-Anxiety and HADS- Depression. High-quality evidence supported the structural and criterion validity of the HADS-A, the internal consistency of the HADS-T, HADS-A, and HADS-D with Cronbach's alpha values of 0.73-0.87, and before-after treatment responsiveness of HADS-T and its subscales (minimal clinically important difference = 1.4-2; effect size = 0.45-1.40). Moderate quality evidence supported the test-retest reliability of the HADS-A and HADS-D with excellent coefficient values of 0.86-0.90. Hamilton Anxiety Rating Scale The Hamilton Anxiety Rating Scale (HAM-A) is a 14-item instrument that is extensively used in clinical and epidemiological studies to determine the presence of anxiety symptoms. Although the HAM-A generally demonstrates good psychometric properties, including adequate interrater reliability [13, 14, 15], internal consistency [16], and convergent validity [17, 18], several concerns have been raised about the HAM-A that limit its utility [19]. Measurement of anxious features within depressed patients was formalized in the DSM-5 anxious-distress specifier [20] despite an absence of empirical evidence of the validity or utility of the specifier. State-Trait Anxiety Inventory The State-Trait Anxiety Inventory (STAI) is a psychological inventory consisting of 40 self-report items on a 4-point Likert scale . The STAI measures two types of anxiety – state anxiety and trait anxiety. Higher scores are positively correlated with higher levels of anxiety. Its most current revision is Form Y and it is offered in more than 40 languages [21]. For diagnoses of anxiety disorders, the STAI-T demonstrated the best psychometric properties for a cutoff score ≥ 52 with sensitivity of 81.3%, specificity of 77.5%, positive predictive value (PPV) of 41.9%, and negative predictive value (NPV) of 95.4%. Mini International Neuropsychiatric Interview The MINI was developed by researchers at the PitiéSalpêtrière Hospital in Paris and the University of Florida in the United States and consists of a brief questionnaire lasting 15-30 minutes, compatible with the diagnostic criteria of the DSM-III-R and ICD-10 (different versions), which can be used by doctors after a quick training (1h to 3h). The MINI is organized into independent diagnostic modules, designed to optimize the sensitivity of the instrument, despite a possible increase in false positives. Two versions of the MINI were developed to address the specific diagnostic objectives of different contexts of use: 1) intended primarily for use in primary care and clinical trials, the MINI comprises 19 modules exploring 17 DSM-IV Axis I disorders, Suicide Risk and Antisocial Personality Disorder. Procedure While waiting for care, patients were invited to participate in the research, received an explanation about its objective and signed the Free and Informed Consent Form. Patients responded to a Mini International Neuropsychiatric Interview (MINI) diagnostic instrument containing the DSM-5 diagnostic criteria for anxiety disorders and affective disorders and a questionnaire to identify the presence of anguish. Additionally, patients were asked to answer the Brief Inventory of Psychopathological Symptoms (BSI), the Defense Styles Inventory (DSQ-40), the Hospital Anxiety and Depression Scale (HADS), the Hamilton Anxiety Scale (HAM -A) and the State-Trait Anxiety Inventory (STAI). Patients were also asked to record a statement about the experience of anguish. This recording was listened to and analyzed to determine whether the patients were experiencing anguish or not. Data Analysis Data analysis consisted in two phases in which each phase Ch-square test was used in testing nominal variables and Wilcoxon Mann-Whitney test for testing numerical variables. The first phase called descriptive analysis had four steps. The first consisted of comparing the groups with and without anguish with nominal and numerical variables. The second consisted of a descriptive analysis of the sociodemographic variables. The third consisted of a correspondence analysis between the variable anguish and the diagnosis of anxiety, depression or other psychiatric disorder. The fourth sted consisted of a significance comparative test under the variables used in this study between anguish, anxiety and depression. The second phase of the study called inferential analysis had two steps. The first consisted of reducing the size of sellected questionnaires and the construction of latent variables more near to anguish. For this was applicated the item response theory (IRT). Using the logistic regression model, the second step of inferential analysis consisted of identify which variables have the greater predictive power to anguish. Ethical Considerations Ethical aproval was obtained by the Research Ethics Commitee of the Psychiatry’s Institute of Clinic’s hospital of Medicine’s faculty of São Paulo’s University, Brazil, on January 27, 2021. CAAE: 37028419.2.0000.0068.