Showing papers in "Psychosomatic Medicine in 2001"

Association of depression and diabetes complications: A meta-analysis

Abstract: OBJECTIVE The objective of this study was to examine the strength and consistency of the relationship between depression and diabetes complications in studies of type 1 and type 2 adult patients with diabetes. METHOD MEDLINE and PsycINFO databases were searched for articles examining depression and diabetes complications in type 1 and type 2 diabetes samples published between 1975 and 1999. Meta-analytic procedures were used. Studies were reviewed for diabetes type, sample size, statistical tests, and measures of diabetes complications and depression. Significance values, weighted effect sizes r, 95% confidence intervals (CI), and tests of homogeneity of variance were calculated for the overall sample (k = 27) and for subsets of interest. RESULTS A total of 27 studies (total combined N = 5374) met the inclusion criteria. A significant association was found between depression and complications of diabetes (p < .00001, z = 5.94). A moderate and significant weighted effect size (r = 0.25; 95% CI: 0.22-0.28) was calculated for all studies reporting sufficient data (k = 22). Depression was significantly associated with a variety of diabetes complications (diabetic retinopathy, nephropathy, neuropathy, macrovascular complications, and sexual dysfunction). Effect sizes were in the small to moderate range (r = 0.17 to 0.32). CONCLUSIONS These findings demonstrate a significant and consistent association of diabetes complications and depressive symptoms. Prospective, longitudinal studies are needed to identify the pathways that mediate this association.

Validation and utility of the patient health questionnaire in diagnosing mental disorders in 1003 general hospital Spanish inpatients

Abstract: OBJECTIVE To determine whether the Spanish version of the patient health questionnaire (PHQ) has validity and utility for diagnosing mental disorders in general hospital inpatients. METHODS Participants in the study were 1003 general hospital inpatients, randomly selected from all admissions over an 18-month period. All of them completed the PHQ, the Beck Depression Inventory (BDI), and measures of functional status, disability days, and health care use, including length of hospital stay. They also had a structured interview with a mental health professional. RESULTS A total of 416 (42%) of the 1003 general hospital inpatients had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of an independent mental health professional (for the diagnosis of any PHQ disorder, kappa = 0.74; overall accuracy, 88%; sensitivity, 87%; specificity, 88%), similar to the original English version of the PHQ in primary care patients. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (group main effects for functional status measures and disability days, p < .001; group main effects for health care use, p < .01). The group main effect for hospital length of stay was not significant. An index of depression symptom severity calculated from the PHQ correlated significantly both with the number of depressive symptoms detected at interview and the total BDI score. PHQ administration was well accepted by patients. CONCLUSIONS The Spanish version of the PHQ has diagnostic validity in general hospital inpatients comparable to the original English version in primary care.

Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes.

Abstract: Objective The purpose of this study was to examine if depressive symptomatology in pregnancy is associated with adverse obstetric and neonatal outcomes. Method In a prospective observational study, 959 women were followed up longitudinally from early pregnancy to postpartum. The level of depression was measured at baseline (first antepartum visit) and in late pregnancy using the Beck Depression Inventory (BDI). Adverse obstetric and neonatal outcomes were recorded at delivery. Results Depression in late pregnancy was associated with increased risk of epidural analgesia (33% vs. 19%, p =.01, adjusted RR = 2.56, 95% CI 1.24-5.30), operative deliveries (caesarean sections and instrumental vaginal deliveries) (39% vs. 27%, p =.02, adjusted RR = 2.28, 95% CI 1.15-4.53), and admission to neonatal care unit (24% vs. 19%, p =.03, adjusted RR = 2.18, 95% CI 1.02-4.66). These effects remained significant even when controlled for potential confounders, such as antepartum complications. Conclusion Previous studies have shown that antepartum anxiety or stress was associated with growth retardation, premature delivery, and epidural analgesia. Our findings add to this body of evidence, which together suggest an adverse impact of antepartum psychological morbidity on maternal and neonatal well-being.

Word use in the poetry of suicidal and nonsuicidal poets.

Abstract: OBJECTIVE The purpose of this study was to determine whether distinctive features of language could be discerned in the poems of poets who committed suicide and to test two suicide models by use of a text-analysis program. METHOD Approximately 300 poems from the early, middle, and late periods of nine suicidal poets and nine nonsuicidal poets were compared by use of the computer text analysis program, Linguistic Inquiry and Word Count (LIWC). Language use within the poems was analyzed within the context of two suicide models. RESULTS In line with a model of social integration, writings of suicidal poets contained more words pertaining to the individual self and fewer words pertaining to the collective than did those of nonsuicidal poets. In addition, the direction of effects for words pertaining to communication was consistent with the social integration model of suicide. CONCLUSIONS The study found support for a model that suggests that suicidal individuals are detached from others and are preoccupied with self. Furthermore, the findings suggest that linguistic predictors of suicide can be discerned through text analysis.

Attachment and psychosomatic medicine: developmental contributions to stress and disease.

Abstract: Objective The object of this study was to evaluate the evidence linking attachment insecurity to illness. Attachment theory describes lifelong patterns of response to threat that are learned in the interaction between an infant and his or her primary caregiver. Despite its biopsychosocial domain, attachment theory has only recently been applied to psychosomatic medicine. Method MEDLINE and PsychInfo databases were searched from 1966 to 2000 for English language papers with key words "attachment" and "object relations." Papers and their cited references were reviewed if they were directly related to physical illness, symptoms, or physiology. A hypothetical causal model was developed. Results Direct and indirect evidence from survey studies supports an association between attachment insecurity and disease. Animal studies and human experiments suggest that attachment contributes to individual differences in physiological stress response. There is also less robust support for insecure attachment leading to symptom reporting and to more frequent health risk behaviors, especially substance use and treatment nonadherence. Evidence supports the prediction from attachment theory that the benefits of social support derive more from attachment relationships than nonattachment relationships. Conclusions Although the available data are suggestive rather than conclusive, the data can be organized into a model that describe attachment insecurity leading to disease risk through three mechanisms. These are increased susceptibility to stress, increased use of external regulators of affect, and altered help-seeking behavior. This model warrants further prospective investigation.

Interoception: The Inside Story—A Model for Psychosomatic Processes

Abstract: OBJECTIVE: To comprehend psychosomatic processes, it will be necessary to understand the brain's influences on bodily functions and also the body's afferent sensory input to the central nervous system, including the effects of this input on behavior and cognitive functions, especially emotion. The objective of this Presidential Address is to review what is known circa the year 2000 of the processes and mechanisms of visceral sensory psychobiology, often called interoception. METHODS: Over 1000 publications that have appeared since the 19th century were reviewed to prepare this review, including a group that are specifically cited here. RESULTS: Factors and data were reviewed that were identified as germane to understanding interoception. These included definitional issues, historical roots, the neural basis, studies and results in the cardiovascular-respiratory and alimentary-gastrointestinal systems, studies of emotion, and studies in people with mental disorders. Drug and hormone effects, pain, proprioception, and phantom limb or organ factors, and the role of awareness were briefly described. Methodological issues, methods of study including functional imaging, and possible future directions for study were identified. CONCLUSIONS: Understanding the physical basis of psychosomatic processes, including the so-called mind-body problem, will require a detailed understanding the psychobiology of interoception.

Mortality and quality of life 12 months after myocardial infarction: effects of depression and anxiety.

Abstract: OBJECTIVE The purpose of this study was to determine the impact of symptoms of depression and anxiety on mortality and quality of life in patients hospitalized for acute myocardial infarction (MI). METHODS The Beck Depression Inventory and the State-Trait Anxiety Inventory were completed by 288 patients hospitalized for MI. Twelve-month survival status was ascertained, and quality of life among survivors was assessed at 12 months using the Dartmouth COOP charts. RESULTS Thirty-one (10.8%) patients died, 27 of cardiac causes, during the 12-month follow-up. Symptoms of depression and anxiety predicted neither cardiac nor all-cause mortality. Severity of infarction and evidence of heart failure predicted both cardiac and all-cause mortality. The same findings emerged from supplementary analyses of data from patients who died after discharge from the hospital. Symptoms of depression and anxiety, measured at entry, predicted 12-month quality of life among survivors, as did gender, partner status, employment status, living alone, previous frequency of exercise, and indices of disease severity (Killip class and Peel Index). In a multiple regression model in which all of these variables were entered, initial depression scores provided the best independent prediction of quality of life, although living alone, severity of infarction, and state anxiety also entered the model. CONCLUSIONS Symptoms of depression and anxiety did not predict either cardiac or all-cause mortality after MI, but they did predict quality of life among those who lived to 12 months.

Effects of psychological stress and psychiatric disorders on blood coagulation and fibrinolysis: A biobehavioral pathway to coronary artery disease?

Abstract: SUMMARY AND FUTURE DIRECTIONS Although this review cannot exclude the possibilityof a publication bias, the evidence for an associationbetween psychological factors and several hemostaticvariables related to CAD is abundant. Moreover, somepsychological factors appear to show a characteristicpattern of coagulation and fibrinolysis activity. Con-comitant activation of coagulation and fibrinolysispathways in response to acute mental stressors may beharmless or even of evolutionary benefit in healthyindividuals. On the other hand, by eliciting procoagu-lant changes due to impaired endothelial anticoagu-lant function, mental arousal could contribute to CADprogression and acute coronary syndromes in patientswith cardiovascular disease. Much evidence alsopoints to a hypercoagulable state comprising increasedprocoagulant molecules and, to a certain extent, im-paired fibrinolytic capacity, with chronic psychologi-cal distress in particular job strain and low socioeco-nomic status. These associations (ie, with fibrinogen)are partially mediated by cardiovascular risk factorsand demographics. More studies are needed to confirmthrombophilic changes in depressive disorders and toverify occasional reports on increased hemostatic re-activity with type A features (ie, hostility and anger).Because the first studies on this topic were pub-lished many decades ago, the field has generated con-siderable data with strikingly broad methodology. Fu-ture research might be more fruitful if it consideredreplication of previous findings with careful selectionof study populations and by use of established psycho-logical instruments. In addition, focusing on hemo-static changes, in particular on prethrombotic markers,in conjunction with measures of sympathetic nerveactivity and of neuroendocrine hormone profiles,could tremendously advance current knowledge of themechanisms underlying the link between psychologi-cal factors, hemostasis, and coronary artery disease.

Characteristics of socially isolated patients with coronary artery disease who are at elevated risk for mortality.

Abstract: Objectives Social isolation has been linked to poor survival in patients with coronary artery disease (CAD). Few studies have closely examined the psychosocial characteristics of CAD patients who lack social contact. Methods Social isolation was examined as a predictor of mortality in 430 patients with significant CAD. More isolated patients were compared with their less isolated counterparts on factors that might help explain the association between isolation and survival. Results The mortality rate was higher among isolated individuals. Those with three or fewer people in their social support network had a relative risk of 2.43 (p = .001) for cardiac mortality and 2.11 (p = .001) for all-cause mortality, controlling for age and disease severity. Adjustments for income, hostility, and smoking status did not alter the risk due to social isolation. With the exception of lower income, higher hostility ratings, and higher smoking rates, isolated patients did not differ from nonisolated patients on demographic indicators, disease severity, physical functioning, or psychological distress. Isolated patients reported less social support and were less pleased with the way they got along with network members, but they did not report less satisfaction with the amount of social contact received. Conclusions Patients with small social networks had an elevated risk of mortality, but this greater risk was not attributable to confounding with disease severity, demographics, or psychological distress. These findings have implications for mechanisms linking social isolation to mortality and for the application of psychosocial interventions.

Social isolation kills, but how and why?

Abstract: The article by Brummett et al. (1) provides another confirmation of the deleterious effects on health of social isolation, first recognized in epidemiologic research of the late 1970s and 1980s and replicated and extended for more than a decade since then (2–4). Social isolation has been shown repeatedly to prospectively predict mortality and serious morbidity both in general population samples (2) and in individuals with established morbidity (3, 4), especially coronary heart disease (1). The magnitude of risk associated with social isolation is comparable with that of cigarette smoking and other major biomedical and psychosocial risk factors. However, our understanding of how and why social isolation is risky for health—or conversely—how and why social ties and relationships are protective of health, still remains quite limited. Brummett et al. (1) contribute importantly to increasing such understanding, but also fail to capitalize fully on opportunities to contribute even more. This article by Brummett et al. (1) is noteworthy because it shows the impact of social isolation on mortality in an important clinical population with a very extensive set of adjustments for other sociodemographic, psychosocial, and biomedical predictors of mortality. It also carefully explores the functional form of the prospective relationship of social ties to mortality, adding to the evidence that the form of the relationship is nonlinear, with social isolation producing a twoto three-fold increase in risk of mortality, but with little or no variation across moderate to high levels of social relationships. That is, a serious deficiency of social relationships is risky to health, but once the deficiency is removed, adding additional relationships to a social network does not produce substantial or significant increases in health and well-being contrary to the impression left by some arguments for the importance of social relationships to the well-being of individuals and societies (5). Properly understanding the functional form of the relationship has important implications for both social policy and clinical practice. It may be important to try to ensure that all individuals have meaningful social ties with at least one or a few other individuals, and this is especially true of individuals whose health is already compromised by significant morbidity, especially coronary heart disease. However, trying to enhance further the social network of nonisolated individuals is likely to have little or no additional benefits, at least for health. Nor does it seem that any particular type of relationship is crucial. Rather, meaningful social ties seem to be functional alternatives to each other. Where a person has regular interaction with a spouse, other relatives, or friends seems less important than that the person has one or more of these social ties. It is often assumed that it is the supportiveness of social relationships that explains the health-enhancing effects of social relationships. It is certainly reasonable and consistent with existing evidence that the provision of various kinds of emotional and instrumental support is one of the ways in which social relationships benefit health (4, 6). However, most studies of the health impact of social relationships on health fail to evaluate the extent to which support or any other attribute or correlate of relationships can account for the robust and substantial impact of social relationships on health. Brummett et al. (1) seem to have some of the best data yet available for investigating the issue, but fail to capitalize on these data as fully as they could and should. They show that social isolation is unrelated to a wide range of measures of demographic factors, disease severity, physical functioning, and psychological distress. Hence, such factors can not account for or explain the substantial deleterious effects of social isolation. However, they also show that isolated individuals report fewer interactions with others, fewer sources of psychological/emotional and instrumental support, and lower levels of religious activity. The obvious question is whether adjusting for one or more of these factors reduces the association of social relationships/ isolation with health. Which factors constitute the active ingredient in social isolation producing its deleterious effects on health? Few other studies have the combination of measures available to Brummett et al. (1); thus, I hope in the future they will do the type of analyses suggested here. Most of their data seem oriented to testing the hypothesis that it is the supportiveness of relationships that explain their effects. However, there are other plausible hypotheses that also deserve to be tested by Brummett et al. (1) or others (2, 4). First is the idea that isolation from others is anxiety arousing or stressful in and of itself, producing physiological arousal and changes, which if prolonged, can produce serious mor-

The association between emotional well-being and the incidence of stroke in older adults.

Abstract: Objective Individuals with high levels of depressive symptoms have an increased risk of many illnesses, including stroke. Measures of depressive symptoms include questions about the presence of negative affect, such as sadness, as well as the absence of positive affect, such as happiness and optimism. We assessed whether positive or negative affect, or both, predicted risk of stroke. Methods Data were from a 6-year prospective cohort study of a population-based sample of 2478 older whites and blacks from five counties in North Carolina who reported no history of stroke at the baseline interview. Baseline, in-person interviews were conducted to gather information on sociodemographic, psychosocial, and health-related characteristics of subjects. Thereafter interviews were conducted annually for 6 years. Results Increasing scores on the modified version of the Center for Epidemiological Studies Depression Scale (CES-D) were significantly associated with stroke incidence for the overall sample (relative risk [RR] = 1.04 for each one-point increase, 95% confidence interval [CI] = 1.01-1.09) over the 6-year follow-up period after adjusting for sociodemographic characteristics, blood pressure, body mass index, smoking status, and selected chronic diseases. Positive affect score demonstrated a strong inverse association with stroke incidence (RR = 0.74, 95% CI = 0.62-0.88). Conclusions Increasing scores on the modified CES-D are related to an increased risk of stroke, whereas high levels of positive affect seem to protect against stroke in older adults.

Is the glass half empty or half full? A prospective study of optimism and coronary heart disease in the normative aging study.

Abstract: OBJECTIVE A sense of optimism, which derives from the ways individuals explain causes of daily events, has been shown to protect health, whereas pessimism has been linked to poor physical health. We examined prospectively the relationship of an optimistic or pessimistic explanatory style with coronary heart disease incidence in the Veterans Affairs Normative Aging Study, an ongoing cohort of older men. METHODS AND RESULTS In 1986, 1306 men completed the revised Minnesota Multiphasic Personality Inventory, from which we derived the bipolar revised Optimism-Pessimism Scale. During an average of 10 years of follow-up, 162 cases of incident coronary heart disease occurred: 71 cases of incident nonfatal myocardial infarction, 31 cases of fatal coronary heart disease, and 60 cases of angina pectoris. Compared with men with high levels of pessimism, those reporting high levels of optimism had multivariate-adjusted relative risks of 0.44 (95% confidence interval = 0.26-0.74) for combined nonfatal myocardial infarction and coronary heart disease death and 0.45 (95% confidence interval = 0.29-0.68) for combined angina pectoris, nonfatal myocardial infarction, and coronary heart disease death. A dose-response relation was found between levels of optimism and each outcome (p value for trend,.002 and.0004, respectively). CONCLUSIONS These results suggest that an optimistic explanatory style may protect against risk of coronary heart disease in older men.

SF-36: evaluation of quality of life in severe and mild insomniacs compared with good sleepers.

Abstract: Objective Despite many studies, the impact of chronic insomnia on daytime functioning is not well understood. The aim of our study was to detect this impact by evaluating quality of life (QoL) using a validated instrument, the 36-item Short Form Health Survey of the Medical Outcomes Study (SF-36), in three matched groups of severe insomniacs, mild insomniacs, and good sleepers selected from the general population. Methods Three matched groups of 240 severe insomniacs, 422 mild insomniacs, and 391 good sleepers were recruited from the general French population after eliminating those with DSM-IV criteria for anxiety or depression. All subjects were asked to complete the SF-36. Scores for each QoL dimension were calculated and compared statistically among the three groups. Results Severe insomniacs had lower QoL scores in eight dimensions of the SF-36 than mild insomniacs and good sleepers. Mild insomniacs had lower scores in the same eight dimensions when compared with good sleepers. No dimension was significantly more altered than the other. Conclusions The mental health status and role of emotional QoL dimensions were worse in severe and mild insomniacs than in good sleepers. This result held even though we screened for psychiatric diseases, which shows a clear interrelation between insomnia and emotional state. General health status was also worse in severe and mild insomniacs than in good sleepers. However, we could conclude only that insomnia was related to a worse health status and not whether it was a cause or consequence of this worse health status. Finally, the degradation of QoL scores was correlated with the severity of insomnia.

Ethnic differences in pain tolerance: clinical implications in a chronic pain population.

Abstract: Objective Although numerous studies have independently examined ethnic differences in clinical and experimental pain, few have investigated differences in both sensitivity to controlled noxious stimuli and clinical pain reports in the same sample. The present experiment examined the effects of ethnicity (African American vs. white) on experimental pain tolerance and adjustment to chronic pain. Methods Three hundred thirty-seven (68 African American and 269 white) patients with chronic pain referred to a multidisciplinary treatment center participated in the study. In addition to completing a number of standardized questionnaires assessing adjustment to chronic pain, participants underwent a submaximal effort tourniquet procedure. This experimental pain procedure yields a measure of tolerance for a controlled noxious stimulus (ie, arm ischemia). Results African American subjects reported higher levels of clinical pain as well as greater pain-related disability than white participants. In addition, substantial group differences were observed for ischemic pain tolerance, with African Americans demonstrating less tolerance than whites. Correlational analyses revealed a small but significant inverse relationship between ischemic pain tolerance and the reported severity of chronic pain. Conclusions Collectively these findings support previous research revealing ethnic differences in responses to both clinical and experimental pain. Moreover, the present results suggest that enhanced sensitivity to noxious stimuli on the part of African Americans may be associated with ethnic differences in reported clinical pain, although the magnitude of ethnic differences was much greater for ischemic pain tolerance than for clinical pain measures.

Pain and emotion: effects of affective picture modulation.

Abstract: Objective and methods Two experiments examined the impact of viewing unpleasant, pleasant, and neutral photographic slides on cold-pain perception in healthy men and women. In each experiment, participants viewed one of three slide shows (experiment 1 = fear, disgust, or neutral; experiment 2 = erotic, nurturant, or neutral) immediately before a cold-pressor task. Skin conductance and heart rate were recorded during the slide shows, whereas visual analog scale ratings of pain intensity and unpleasantness thresholds and pain tolerance were recorded during the cold-pressor task. Results Viewing fear and disgust slides decreased pain intensity and unpleasantness thresholds, but only the fear slides decreased pain tolerance. In contrast, viewing erotic, but not nurturant, slides increased pain intensity and unpleasantness threshold ratings on the visual analog scale in men, whereas neither nurturant nor erotic slides altered pain tolerance. Conclusions These results are consistent with a motivational priming model that predicts that unpleasant affective states should enhance pain and that pleasant affective states should attenuate it.

Cerebral activation in patients with irritable bowel syndrome and control subjects during rectosigmoid stimulation.

Abstract: OBJECTIVE Patients with irritable bowel syndrome (IBS) show evidence of altered perceptual responses to visceral stimuli, consistent with altered processing of visceral afferent information by the brain. In the current study, brain responses to anticipated and delivered rectal balloon distension were assessed. METHODS Changes in regional cerebral blood flow were measured using H2(15)O-water positron emission tomography in 12 nonconstipated IBS patients and 12 healthy control subjects. Regional cerebral blood flow responses to moderate rectal distension (45 mm Hg) and anticipated but undelivered distension were assessed before and after a series of repetitive noxious (60-mm Hg) sigmoid distensions. RESULTS Brain regions activated by actual and simulated distensions were similar in both groups. Compared with control subjects, patients with IBS showed lateralized activation of right prefrontal cortex; reduced activation of perigenual cortex, temporal lobe, and brain stem; but enhanced activation of rostral anterior cingulate and posterior cingulate cortices. CONCLUSIONS IBS patients show altered brain responses to rectal stimuli, regardless of whether these stimuli are actually delivered or simply anticipated. These alterations are consistent with reported alterations in autonomic and perceptual responses and may be related to altered central noradrenergic modulation.

Somatization Symptoms and Hypochondriacal Features in the General Population

Abstract: Objective The principal goal of this study is to examine the base rates of somatoform symptoms and of hypochondriacal features in the general population. Methods A representative sample of 2050 persons in Germany was examined by use of screening for somatoform symptoms and the Whiteley Index. Results The most frequent somatoform symptoms were back pain, joint pain, pain in extremities, and headache, as well as abdominal symptoms (bloating or intolerance of several foods) and cardiovascular symptoms (palpitation). People reported a mean of two somatization symptoms of DSM-IV somatization disorder (SD) during the prior 2 years. Strong age and medium gender effects were found for most somatoform symptoms, as well as for composite indices. However, the sex ratio suggested in DSM-IV for SD seems to be an overestimation. Hypochondriacal features showed only small sex differences but, again, pronounced age effects. In contrast to low rates for SD, the base rates for somatization and hypochondriacal features were high and represented the health care relevance of subthreshold syndromes. Conclusion We present base rates of hypochondriacal and somatization features that may be important facets in the development of classification criteria and in the interpretation of health care expenditure.

Coping with breast cancer: patient, spouse, and dyad models.

Abstract: Objective The objectives of this study were 1) to assess similarities and differences between patients with breast cancer and their spouses in terms of coping strategies and adjustment (psychosocial and psychological) to cancer and 2) to investigate the pattern of relationships between the patients' and spouses' coping strategies and between each of these strategies and the patient's adjustment to the illness using three types of models: patient, spousal, and dyadic coping. Methods Seventy-three patients with breast cancer and their spouses completed questionnaires that measured distress (Brief Symptom Inventory), psychosocial adjustment, and coping strategies. Results The patients' distress was greater than their spouses', but a similar level of psychosocial adjustment was reported. The patients used more strategies involving problem-focused coping than their spouses. The use of emotion-focused coping, which included ventilation and avoidance strategies, was highly related to distress and poor adjustment on the part of the patient. The spouses' emotion-focused coping and distress were related to that of the patients. Dyad emotion-focused coping measures were highly associated with the patients' distress and adjustment. Conclusions Spousal and dyad coping are important factors in a patient's adjustment to breast cancer.

A meta-analytic examination of basal cardiovascular activity in posttraumatic stress disorder

Abstract: Objective The objective of this meta-analytic study was to determine whether individuals with posttraumatic stress disorder (PTSD) have higher levels of basal cardiovascular activity relative to comparable groups of individuals without PTSD. Methods Meta-analytic data methods were applied to 34 studies that gathered indicators of basal cardiovascular activity including: heart rate (HR), systolic blood pressure, and diastolic blood pressure on subjects diagnosed with PTSD and two types of comparison groups. In total, cardiovascular measures were analyzed for 2670 subjects across all studies. Results Results indicate that individuals with a current PTSD diagnosis have higher resting HR relative to both trauma-exposed individuals without a PTSD diagnosis and non-trauma-exposed individuals. The results also suggest that PTSD is associated with elevations in blood pressure; however, the effect sizes were smaller in magnitude than those obtained for heart rate. A subset analysis revealed that the effect sizes for comparisons on basal HR were greatest in studies with the most chronic PTSD samples. Conclusion The meta-analysis supports previous qualitative reviews, finding a positive association between PTSD and basal cardiovascular activity. The discussion addresses possible mechanisms of action and the health-related implications of these findings.

Sex differences in glucocorticoid sensitivity of proinflammatory cytokine production after psychosocial stress.

Abstract: Objective Men and women show marked differences in susceptibility to disorders related to the immune system. These gender differences have been proposed to be mediated by functional interactions of the hypothalamus-pituitary-adrenal (HPA) and hypothalamus-pituitary-gonadal (HPG) axes. A potential mechanism involved in this interaction is the glucocorticoid (GC) sensitivity of relevant target tissues for GC. Therefore, the aim of the study reported here was to investigate the impact of psychosocial stress and HPA axis activation on the GC sensitivity of proinflammatory cytokine production in men and women. Methods A total of 45 healthy subjects were investigated. Eighteen women in the luteal phase of their menstrual cycle and 27 men were exposed to a psychosocial stress test (Trier Social Stress Test). Salivary free cortisol levels were measured repeatedly after exposure to the stressor. GC sensitivity was assessed in vitro by dexamethasone inhibition of lipopolysaccharide-stimulated production of interleukin-6 and tumor necrosis factor-alpha. Results The stress test induced significant increases in salivary free cortisol with no significant differences between men and women. In contrast, GC sensitivity and lipopolysaccharide-stimulated cytokine production showed large gender differences. In men GC sensitivity was markedly increased 1 hour after stress, whereas GC sensitivity decreased significantly in women. Similarly, lipopolysaccharide-induced cytokine production decreased in response to stress in men but increased in women. Conclusions These results demonstrate that despite similar free cortisol responses of men and women (studied in the luteal phase) to psychosocial stress, gender may exert differential effects on the immune system by modulating GC sensitivity of proinflammatory cytokine production.

Psychological stress and antibody response to immunization: a critical review of the human literature.

Abstract: Objective The objective of this review was to evaluate the evidence for the hypothesis that psychological stress influences antibody response to immunization in humans. Methods A critical review of the literature was conducted. Results The evidence supports an association between psychological stress and suppression of humoral immune (antibody) response to immunization. This association is convincing in the case of secondary immune response but weak for primary response. The lack of consistent evidence for a relation with primary response may be attributed to a failure to consider the critical points when stress needs to be elevated in the course of the production of antibody. Lower secondary antibody responses were found among patients with chronically high levels of stress (severe enduring problems or high levels of trait negative affect). These responses were found most consistently among older adults. Lower secondary responses were also found for those reporting acute stress or negative affect, but only in studies of secretory immunoglobulin A antibody in which psychological and antibody measures were linked very closely in time. Health practices did not mediate relations between stress and antibody responses; however, there were indications that elevated cortisol levels among stressed patients could play a role. Evidence also suggests the possible influences of dispositional stress-reactivity and low positive affect in the inhibition of antibody production. Conclusions The literature supports a relationship between psychological stress and antibody responses to immunizations. The data are convincing in the case of secondary response but weak for primary response. More attention to the kinetics of stress and antibody response and their interrelations is needed in future research.

Psychological factors and delayed healing in chronic wounds.

Abstract: Objective Studies have shown that stress can delay the healing of experimental punch biopsy wounds. This study examined the relationship between the healing of natural wounds and anxiety and depression. Methods Fifty-three subjects (31 women and 22 men) were studied. Wound healing was rated using a five-point Likert scale. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HAD), a well-validated psychometric questionnaire. Psychological and clinical wound assessments were each conducted with raters and subjects blinded to the results of the other assessment. Results Delayed healing was associated with a higher mean HAD score (p = .0348). Higher HAD anxiety and depression scores (indicating "caseness") were also associated with delayed healing (p = .0476 and p = .0311, respectively). Patients scoring in the top 50% of total HAD scores were four times more likely to have delayed healing than those scoring in the bottom 50% (confidence interval = 1.06-15.08). Conclusions The relationship between healing of chronic wounds and anxiety and depression as measured by the HAD was statistically significant. Further research in the form of a longitudinal study and/or an interventional study is proposed.

Mechanisms and mediators of psychological stress-induced rise in core temperature.

Abstract: OBJECTIVE Despite numerous case reports on "psychogenic fever," it remains uncertain how psychological stress raises core temperature and whether the rise in core temperature is a real fever or a hyperthermia. This article reviews studies on the psychological stress-induced rise in core temperature (PSRCT) in animals with the aim to facilitate studies on the mechanisms of so-called psychogenic fever in humans. METHODS To address this question, we reviewed the mechanisms and mediators of the PSRCT and classic conditioning of the fever response in animals. RESULTS The PSRCT is not due to the increased locomotor activity during stress, and the magnitude of the PSRCT is the same in warm and cold environments, indicating that it is a centrally regulated rise in temperature due to an elevated thermoregulatory "set point." The PSRCT caused by conventional psychological stress models, such as open-field stress, is attenuated by cyclooxygenase inhibitors, which block prostaglandin synthesis. On the other hand, the PSRCT elicited by an "anticipatory anxiety stress" is not inhibited by cyclooxygenase inhibitors but by benzodiazepines and serotonin Type 1A receptor agonists. The febrile response can be conditioned to neutral stimuli after paired presentation with unconditioned stimuli such as injection of lipopolysaccharide, a typical pyrogen. CONCLUSIONS Most findings indicate that the PSRCT is a fever, a rise in the thermoregulatory set point. The PSRCT may occur through prostaglandin E2-dependent mechanisms and prostaglandin E2-independent, 5-HT-mediated mechanisms. The febrile response can be conditioned. Thus, these mechanisms might be involved in psychogenic fever in humans.

Blood pressure reactions to acute psychological stress and future blood pressure status: a 10-year follow-up of men in the Whitehall II study.

Abstract: Objective The aim of this study was to examine whether blood pressure reactions to mental stress predicted future blood pressure and hypertension. Methods Blood pressure was recorded at an initial medical screening examination after which blood pressure reactions to a mental stress task were determined. A follow-up screening assessment of blood pressure and antihypertensive medication status was undertaken 10 years later. Data were available for 796 male public servants, between 35 and 55 years of age upon entry to the study. Results Systolic blood pressure reactions to mental stress were positively correlated with follow-up screening systolic blood pressure and to a lesser extent, follow-up diastolic pressure. In multivariate tests, by far the strongest predictors of follow-up blood pressures were initial screening blood pressures. In the case of follow-up systolic blood pressure, systolic reactions to stress emerged as an additional predictor of follow-up systolic blood pressure. With regard to follow-up diastolic blood pressure, reactivity did not enter the analogous equations. The same outcomes emerged when the analyses were adjusted for medication status. When hypertension at 10-year follow-up was the focus, both systolic and diastolic reactions to stress were predictive. However, with correction for age and initial screening blood pressure, these associations were no longer statistically significant. Conclusions The results of this study provide modest support for the hypothesis that heightened blood pressure reactions to mental stress contribute to the development of high blood pressure. At the same time, they question the clinical utility of stress testing as a prognostic device.

Depressive symptoms, menopausal status, and climacteric symptoms in women at midlife.

Abstract: OBJECTIVE Previous studies have found increased rates of depression in women aged 45 to 54 years, but the factors that influence these rates are not understood. It was assessed whether higher rates of depressive symptoms were associated with menopausal status, climacteric symptoms, and use of hormone replacement therapy. DESIGN Cross-sectional survey. SETTING Community sample. METHODS Data are from 581 women ages 45 to 54 years who were interviewed by telephone between October 1998 and February 1999. MEASURES Depression was measured with the abbreviated CES-D, a depressive symptoms screening measure. Women's reported perception of menopausal stage, frequency of periods in the preceding 12 months, and history of oophorectomy were used to classify their menopausal status into four categories: (1) no indication of menopause; (2) close to menopause; (3) had begun menopause; and (4) had completed menopause. RESULTS There were 168 women (28.9%) who reported a high level (> or = 10) of depressive symptoms when the abbreviated CES-D was used. In a logistic-regression analysis, significant factors associated with increased depressive symptoms included physical inactivity, inadequate income, use of estrogen/progesterone combination, and presence of climacteric symptoms (trouble sleeping, mood swings, or memory problems). Menopausal status was not associated with depressive symptoms. CONCLUSIONS In this sample of women age 45 to 54 years, climacteric symptoms but not menopausal status were associated with higher rates of depressive symptoms.

Elevated cortisol levels in Cushing's disease are associated with cognitive decrements

Abstract: Objective The objective of this study was to use Cushing's disease as a unique human model to elucidate the cognitive deficits resulting from exposure to chronic stress-level elevations of endogenous cortisol. Methods Forty-eight patients with a first episode of acute, untreated Cushing's disease and 38 healthy control subjects were studied. Results Scores for four of five verbal IQ subtests were significantly lower in patients with Cushing's disease; their scores were significantly lower for only one nonverbal performance IQ subtest (block design). Verbal, but not visual, learning and delayed recall at 30 minutes were significantly decreased among patients with Cushing's disease. Although verbal delayed recall was significantly lower in these patients, the retention index (percentage), which compares the amount of initially learned material to that recalled after the delay, was not significantly decreased. There was no significant association between depression scores and cognitive performance. A higher degree of cortisol elevation was associated with poorer performance on several subtests of learning, delayed recall, and visual-spatial ability. Conclusions Chronically elevated levels of glucocorticoids have deleterious effects on particular domains of cognition. Verbal learning and other verbal functions seem more vulnerable than nonverbal functions. The results suggest that both the neocortex and hippocampus are affected.

Relationship among plasma cortisol, catecholamines, neuropeptide Y, and human performance during exposure to uncontrollable stress.

Abstract: Objective Although many people are exposed to trauma, only some individuals develop posttraumatic stress disorder; most do not. It is possible that humans differ in the degree to which stress induces neurobiological perturbations of their threat response systems, which may result in a differential capacity to cope with aversive experiences. This study explored the idea that differences in the neurobiological responses of individuals exposed to threat are significantly related to psychological and behavioral indices. Methods Individual differences in neurohormonal, psychological, and performance indices among 44 healthy subjects enrolled in US Army survival school were investigated. Subjects were examined before, during, and after exposure to uncontrollable stress. Results Stress-induced release of cortisol, neuropeptide Y, and norepinephrine were positively correlated; cortisol release during stress accounted for 42% of the variance in neuropeptide Y release during stress. Cortisol also accounted for 22% of the variance in psychological symptoms of dissociation and 31% of the variance in military performance during stress. Conclusions Because dissociation, abnormalities in the hypothalamic-pituitary-adrenocortical axis, and catecholamine functioning have all been implicated in the development of stress disorders such as posttraumatic stress disorder, these data suggest that some biological differences may exist before index trauma exposure and before the development of stress-related illness. The data also imply a relationship among specific neurobiological factors and psychological dissociation. In addition, the data provide clues about the way in which individuals' psychobiological responses to threat differ from one another.

Responses to laboratory psychosocial stress in postpartum women.

Abstract: Objective Lactation has been associated with attenuated hormonal responses to exercise stress in humans. This study was designed to determine the effect of lactation on hypothalamic-pituitary-adrenal axis, autonomic nervous system, and anxiety responses to psychological stress. Method The Trier Social Stress Test was administered to 24 lactating women, 13 postpartum nonlactating women, and 14 healthy control women in the early follicular phase of the menstrual cycle. Lactating women were stressed at least 40 minutes after last feeding their infant. Results ACTH, cortisol, heart rate, diastolic blood pressure, systolic blood pressure, and subjective anxiety ratings were all significantly increased in response to the psychological stress (all p Conclusions These results indicate that physiological and subjective responses to social stress are not attenuated in lactating women tested at least one hour after feeding their infant. However, enhanced vagal control of cardiac reactivity was observed in lactating women. In addition, postpartum women who did not lactate showed evidence of increased sympathetic and decreased parasympathetic nervous system tone.

Vagal rebound and recovery from psychological stress.

Abstract: Objective To characterize cardiovascular recovery and examine the possible relationship of vagal activity and reflexes to risk for heart disease. Methods Subjects performed cold pressor and mental arithmetic tasks. Heart rate, heart period variability, and pre-ejection period were obtained for 1 minute before, during, and after each task (Experiment 1). In the second experiment, subjects performed a Stroop color-word task and a mental arithmetic task. Heart rate, heart period variability, blood pressure, and baroreflex sensitivity were obtained during the 5-minute baseline, task, and recovery periods (Experiment 2). Results In Experiment 1, heart rate during recovery was lower than baseline despite continued pre-ejection period shortening, whereas recovery heart period variability was higher than baseline. In Experiment 2, blood pressure increased throughout the session. However, recovery heart rate after mental arithmetic was lower than baseline heart rate, and heart period variability was higher during both recovery periods than during baseline. Vagal rebound, a sharp increase in variability in the first minute of recovery, was reduced in men in Experiment 1 and in individuals with a family history of cardiovascular disease in Experiment 2 and was associated with degree of change in baroreflex sensitivity between task and rest. Conclusions Cardiovascular recovery from stress is associated with increased vagal modulation despite residual sympathetic activation. Vagal rebound may be involved in mechanisms resetting the baroreflex sensitivity at the onset and offset of stress. Diminished vagal rebound during recovery from stress is associated with standard risk factors for cardiovascular disease. The results support an association between attenuated vagal reflexes and risk for cardiovascular disease.

Cardiovascular indices of peripheral and central sympathetic activation.

Abstract: OBJECTIVE A number of sympathetic nervous system (SNS) parameters have been used in cardiovascular psychophysiology. This study aimed to describe the pattern and redundancy of a set of SNS parameters during peripherally induced changes of cardiac sympathetic activation and reflex modulation of central SNS control. Preejection period (PEP) was assessed as a marker of peripheral sympathetic activation. Low-frequency blood pressure variability (BPV) was assessed as an estimate of central SNS control. METHODS Peripheral beta-sympathetic stimulation and blockade were achieved with epinephrine and esmolol hydrochloride (beta1-blockade), respectively. Changes in central SNS output were induced by loading and unloading arterial baroreceptors with norepinephrine and nitroprusside sodium, respectively. This single-blinded, crossover study in 24 healthy men also included two placebo control periods. PEP was derived from impedance cardiography and adjusted individually for heart rate. BPV was calculated by power spectral analyses of beat-to-beat heart rate and systolic blood pressure (Finapres system) data. RESULTS PEP decreased during epinephrine infusion (-40.1 +/- 3.8 ms, p <.0001) and increased during esmolol infusion (+6.6 +/- 3.5 ms, p =.05). PEP was shortened after central SNS activation by nitroprusside (-16.8 +/- 2.9 ms, p < 0.0001). Systolic BPV in the low-frequency range (0.07-0.14 Hz, Mayer waves) increased during nitroprusside infusion (+0.44 +/- 0.19 ln mm Hg(2), p =.03) and decreased during norepinephrine infusion (-0.67 +/- 0.13 ln mm Hg(2), p < 0.0001). Low-frequency BPV did not change significantly during epinephrine or esmolol infusion. CONCLUSIONS Our data provide empirical evidence of separable peripheral and central sympathetic response components. The combined report of low-frequency BPV and PEP gives distinct information on both central SNS control and the level of sympathetic cardiac activation achieved.