Showing papers in "Psychosomatic Medicine in 2005"

DS14 : Standard assessment of negative affectivity, social inhibition, and Type D personality

Abstract: OBJECTIVE Type D personality-a joint tendency toward negative affectivity (NA) and social inhibition (SI)-is related to poor cardiac prognosis, but there is no standard for assessing Type D. This study reports on the Type D Scale-14 (DS14) as a standard measure of NA, SI, and Type D. METHODS The study included 3813 participants (2508 from the general population, 573 cardiac patients, 732 hypertension patients). They all filled out the DS14, containing 7-item NA and SI subscales; 275 subjects also completed the NEO-FFI, and 121 patients filled out the DS14 twice. RESULTS Factor analysis of the DS14 yielded 2 dominant traits; all of the NA and SI items loaded between 0.62 to 0.82 on their corresponding factor (N = 3678). The NA scale covered dysphoria, worry, and irritability; the SI scale covered discomfort in social interactions, reticence, and lack of social poise. The NA and SI scales were internally consistent (alpha = 0.88/0.86; N = 3678), stable over a 3-month period (test-retest r = 0.72/0.82) and not dependent on mood and health status (N = 121). NA correlated positively with neuroticism (r = 0.68); SI correlated negatively with extraversion (r = -0.59/-0.65). Scale-level factor analysis confirmed the construct validity of the DS14 against the NEO-FFI. Using a cutoff of 10 (NA > or =10 and SI > or =10), 1027 subjects (28%) were classified as Type D, 21% in the general population versus 28% in coronary heart disease and 53% in hypertension (p < or = .001). Age, sex, and Type D (odds ratio, 3.98; 95% confidence interval, 3.2-4.6; p <.0001) were independently associated with cardiovascular morbidity. CONCLUSION The DS14 is a brief, psychometrically sound measure of negative affectivity and social inhibition that could readily be incorporated in epidemiologic and clinical research.

Does subjective social status predict health and change in health status better than objective status

Abstract: Objective: To examine, among middle-aged individuals, if subjective socioeconomic status (SES) predicts health status and change in health status over time better than objective SES. Methods: Data are from the Whitehall II study, a prospective study of British civil servants. SES data are drawn from Phase 5 (1997–1999) of the study and health data from Phases 5 and 6 (2000–2001). Physical and mental component scores from the Short Form 36, the General Health Questionnaire, and self-rated health were used to assess health status. Multiple linear regressions were used to examine the relationship between SES and health and change in health status. Results: Complete data were available on 5486 people. Results show both measures of SES to be global measures of SES. Both measures of SES were significantly associated with health outcomes and with decline in health status over time. However, when both objective and subjective measures of SES are entered simultaneously in the model to predict change in health status, it was only the latter that continues to be significantly associated with health and changes in health. Conclusions: Subjective SES is a better predictor of health status and decline in health status over time in middle-aged adults. These results are discussed in terms of three possible explanations: subjective SES is a more precise measure of social position, the results provide support for the hierarchy-health hypothesis, and the results could be an artifact of common method variance.

Depression, the autonomic nervous system, and coronary heart disease.

Abstract: Depression is a risk factor for medical morbidity and mortality in patients with coronary heart disease (CHD). Dysregulation of the autonomic nervous system (ANS) may explain why depressed patients are at increased risk. Studies of medically well, depressed psychiatric patients have found elevated levels of plasma catecholamines and other markers of altered ANS function compared with controls. Studies of depressed patients with CHD have also uncovered evidence of ANS dysfunction, including elevated heart rate, low heart rate variability, exaggerated heart rate responses to physical stressors, high variability in ventricular repolarization, and low baroreceptor sensitivity. All of these indicators of ANS dysfunction have been associated with increased risks of mortality and cardiac morbidity in patients with CHD. Further research is needed to determine whether ANS dysfunction mediates the effects of depression on the course and outcome of CHD, and to develop clinical interventions that improve cardiovascular autonomic regulation while relieving depression in patients with CHD.

Psychiatric and medical comorbidities of bipolar disorder.

Abstract: OBJECTIVES This review summarizes the literature on psychiatric and medical comorbidities in bipolar disorder. The coexistence of other Axis I disorders with bipolar disorder complicates psychiatric diagnosis and treatment. Conversely, symptom overlap in DSM-IV diagnoses hinders definition and recognition of true comorbidity. Psychiatric comorbidity is often associated with earlier onset of bipolar symptoms, more severe course, poorer treatment compliance, and worse outcomes related to suicide and other complications. Medical comorbidity may be exacerbated or caused by pharmacotherapy of bipolar symptoms. METHODS Articles were obtained by searching MEDLINE from 1970 to present with the following search words: bipolar disorder AND, comorbidity, anxiety disorders, eating disorder, alcohol abuse, substance abuse, ADHD, personality disorders, borderline personality disorder, medical disorders, hypothyroidism, obesity, diabetes mellitus, multiple sclerosis, lithium, valproate, lamotrigine, carbamazepine, atypical antipsychotics. Articles were prioritized for inclusion based on the following considerations: sample size, use of standardized diagnostic criteria and validated methods of assessment, sequencing of disorders, quality of presentation. RESULTS Although the literature establishes a strong association between bipolar disorder and substance abuse, the direction of causality is uncertain. An association is also seen with anxiety disorders, attention-deficit/hyperactivity disorder, and eating disorders, as well as cyclothymia and other axis II personality disorders. Medical disorders accompany bipolar disorder at rates greater than predicted by chance. However, it is often unclear whether a medical disorder is truly comorbid, a consequence of treatment, or a combination of both. CONCLUSION To ensure prompt, appropriate intervention while avoiding iatrogenic complications, the clinician must evaluate and monitor patients with bipolar disorder for the presence and the development of comorbid psychiatric and medical conditions. Conversely, physicians should have a high index of suspicion for underlying bipolar disorder when evaluating individuals with other psychiatric diagnoses (not just unipolar depression) that often coexist with bipolar disorder, such as alcohol and substance abuse or anxiety disorders. Anticonvulsants and other mood stabilizers may be especially helpful in treating bipolar disorder with significant comorbidity.

Effects of partner support on resting oxytocin, cortisol, norepinephrine, and blood pressure before and after warm partner contact.

Abstract: Objective: We examined whether the magnitude of plasma oxytocin (OT), norepinephrine (NE), cortisol, and blood pressure (BP) responses before and after a brief episode of warm contact (WC) with the spouse/partner may be related to the strength of perceived partner support. Methods: Subjects were 38 cohabiting couples (38 men, 38 women) aged 20 to 49 years. All underwent 10 minutes of resting baseline alone, 10 minutes of WC together with their partner, and 10 minutes of postcontact rest alone. Results: Greater partner support (based on self-report) was related to higher plasma oxytocin in men and women across the protocol before and after WC. In women, higher partner support was correlated with lower systolic blood pressure (SBP) during solitary rest after WC but not before. Also, higher OT in women was linked to lower BP at baseline and to lower NE at all 4 measurements. Conclusion: Greater partner support is linked to higher OT for both men and women; however, the importance of OT and its potentially cardioprotective effects on sympathetic activity and BP may be greater for women. Key words: warm contact, partner support, oxytocin, norepinephrine, cortisol, blood pressure. ABP ambulatory blood pressure; BMI body mass index; BP blood pressure; CVD cardiovascular disease; DBP diastolic blood pressure; HPA hypothalamic–pituitary–adrenal; HR heart rate; IV intravenous; MI myocardial infarction; NE norepinephrine; OT oxytocin; SBP systolic blood pressure; SNS sympathetic nervous system; SRI Social Relationships Index; WC warm contact.

The Perceived Stress Questionnaire (PSQ) reconsidered: validation and reference values from different clinical and healthy adult samples.

Abstract: Objective The aim was to translate, revise, and standardize the Perceived Stress Questionnaire (PSQ) by Levenstein et al. (1993) in German. The instrument assesses subjectively experienced stress independent of a specific and objective occasion. Methods Exploratory factor analyses and a revision of the scale content were carried out on a sample of 650 subjects (Psychosomatic Medicine patients, women after delivery, women after miscarriage, and students). Confirmatory analyses and examination of structural stability across subgroups were carried out on a second sample of 1,808 subjects (psychosomatic, tinnitus, inflammatory bowel disease patients, pregnant women, healthy adults) using linear structural equation modeling and multisample analyses. External validation included immunological measures in women who had suffered a miscarriage. Results Four factors (worries, tension, joy, demands) emerged, with 5 items each, as compared with the 30 items of the original PSQ. The factor structure was confirmed on the second sample. Multisample analyses yielded a fair structural stability across groups. Reliability values were satisfactory. Findings suggest that three scales represent internal stress reactions, whereas the scale "demands" relates to perceived external stressors. Significant and meaningful differences between groups indicate differential validity. A higher degree of certain immunological imbalances after miscarriage (presumably linked to pregnancy loss) was found in those women who had a higher stress score. Sensitivity to change was demonstrated in two different treatment samples. Conclusion We propose the revised PSQ as a valid and economic tool for stress research. The overall score permits comparison with results from earlier studies using the original instrument.

Social support and coronary heart disease: epidemiologic evidence and implications for treatment.

Abstract: Objective The present paper reviews theories of social support and evidence for the role of social support in the development and progression of coronary heart disease (CHD). Methods Articles for the primary review of social support as a risk factor were identified with MEDLINE (1966-2004) and PsychINFO (1872-2004). Reviews of bibliographies also were used to identify relevant articles. Results In general, evidence suggests that low social support confers a risk of 1.5 to 2.0 in both healthy populations and in patients with established CHD. However, there is substantial variability in the manner in which social support is conceptualized and measured. In addition, few studies have simultaneously compared differing types of support. Conclusions Although low levels of support are associated with increased risk for CHD events, it is not clear what types of support are most associated with clinical outcomes in healthy persons and CHD patients. The development of a consensus in the conceptualization and measurement of social support is needed to examine which types of support are most likely to be associated with adverse CHD outcomes. There also is little evidence that improving low social support reduces CHD events.

Hypercortisolemia and depression.

Abstract: Hypercortisolemia and dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis are often found in severe forms of depression. The authors review the history of techniques used to assess the functions of the HPA axis, evidence for hypercortisolemia as a state rather than trait component of depression, and treatment implications.

Psychosocial factors predict CD4 and viral load change in men and women with human immunodeficiency virus in the era of highly active antiretroviral treatment.

Abstract: Objective Most previous longitudinal studies demonstrating relationships between psychosocial variables and human immunodeficiency virus (HIV) disease progression utilized samples of gay men accrued before the era of highly active antiretroviral treatment (HAART), without including viral load (VL) as an indicator of disease progression or assessing the impact of medication adherence. This study sought to determine whether psychosocial variables would predict both CD4 and VL changes in a diverse sample assessed entirely during the era of HAART and accounting for adherence effects.

Domain and facet personality predictors of all-cause mortality among Medicare patients aged 65 to 100.

Abstract: Objectives: Our objectives were to test whether Conscientiousness, the other 4 domains of the Five-Factor Model, and their facets predicted mortality in older, frail individuals. Methods: Controlling for demographic and health measures, we used Cox regression to test whether the NEO Five-Factor Inventory (NEO-FFI) Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness domains predicted all-cause mortality over 5 years in 1076 65- to 100-year-old participants who took part in a Medicare Demonstration study. Supplementary analyses on 597 participants aged 66 to 102 who were reassessed 2 years later were conducted to determine whether any of the Revised NEO Personality Inventory (NEO-PI-R) facets were related to mortality. Results: When personality domains were treated as continuous variables, NEO-FFI Neuroticism and Agreeableness were significant protective factors. When personality domains were trichotomized, NEO-FFI Conscientiousness was a protective factor. In a third analysis, Agreeableness was not a significant predictor in a model that included the continuous Neuroticism and trichotomized Conscientiousness variables. Analysis of the NEO-PI-R Neuroticism, Agreeableness, and Conscientiousness factors showed that Agreeableness and Conscientiousness were protective and that there was a trend for a similar effect of Neuroticism. Facet-level analyses revealed that the Impulsiveness, Straightforwardness, and Self-Discipline facets of Neuroticism, Agreeableness, and Conscientiousness, respectively, were prospectively related to greater survival over a 3-year interval. Conclusion: The effects of Neuroticism and Agreeableness on mortality are inconsistent across previous studies. This study indicates that, in a sample of older, frail participants, high Neuroticism and Agreeableness scores are protective and that more specific effects are primarily the result of the Impulsiveness and Straightforwardness facet scales. The Conscientiousness findings are consistent with those in earlier studies and demonstrate the importance of the Self-Discipline facet.

The effect of sunlight on postoperative analgesic medication use: a prospective study of patients undergoing spinal surgery.

Abstract: OBJECTIVE Exposure to natural sunlight has been associated with improvement in mood, reduced mortality among patients with cancer, and reduced length of hospitalization for patients who have experienced myocardial infarction. Our aim was to evaluate whether the amount of sunlight in a hospital room modifies a patient's psychosocial health, the quantity of analgesic medication used, and the pain medication cost. METHODS A prospective study of pain medication use was conducted in 89 patients undergoing elective cervical and lumbar spinal surgery where they were housed on either the "bright" or "dim" side of the same hospital unit. Analgesic medication was converted to standard morphine equivalents for interpatient comparison. The intensity of sunlight in each hospital room was measured daily and psychologic questionnaires were administered on the day after surgery and at discharge. RESULTS Patients staying on the bright side of the hospital unit were exposed to 46% higher-intensity sunlight on average (p = .005). Patients exposed to an increased intensity of sunlight experienced less perceived stress (p = .035), marginally less pain (p = .058), took 22% less analgesic medication per hour (p = .047), and had 21% less pain medication costs (p = .047). Age quartile was the only other variable found to be a predictor of analgesic use, with a significant negative correlation (p <.001). However, patients housed on the bright side of the hospital consistently used less analgesic medications in all age quartiles. CONCLUSION The exposure postoperatively of patients who have undergone spinal surgery to increased amounts of natural sunlight during their hospital recovery period may result in decreased stress, pain, analgesic medication use, and pain medication costs.

Psychosocial evaluation of bariatric surgery candidates: a survey of present practices.

Abstract: Objective Successful outcome for bariatric surgery is largely dependent on patients' ability to adhere to postoperative behavior changes A thorough psychological evaluation is often required before patients' approval for surgery In addition to a standard psychiatric interview, assessment of behavioral components specific to this surgery seems indicated No uniform guidelines exist on how to conduct such an evaluation This survey was designed to collect information on the level of involvement of mental health professionals with bariatric surgery programs and their approach to evaluating bariatric surgery candidates Methods Surveys about psychological evaluation practices were mailed to 188 bariatric surgery programs Eighty-one surveys were returned Results Eighty-eight percent of programs require patients to undergo a psychological evaluation and almost half require formal standardized psychological assessment Current illicit drug use, active symptoms of schizophrenia, severe mental retardation, and lack of knowledge about the surgery were the most commonly cited contraindications, preventing patients from gaining approval for surgery Discussion The majority of programs use psychological evaluations; however, the exclusion criteria for surgery vary greatly Establishing uniform guidelines for the screening of bariatric surgery candidates is necessary Suggestions on how to begin this process are provided More research about behavioral and cognitive predictors of postsurgical success is needed

Inflammatory markers and sleep disturbance in major depression.

Abstract: OBJECTIVE: This study was conducted to determine whether immune activation occurs in major depression, and to evaluate the associations between disordered sleep and markers of inflammation in patients with major depressive disorder. METHODS: All-night polysomnography was obtained in patients with acute Diagnostic and Statistical Manual of Mental Disorders, 4th edition major depressive disorder (n = 22) and age-, gender-, and body weight-matched comparison controls (n = 18). After the onset of sleep, nocturnal serum levels of interleukin-6 (IL-6), soluble intercellular adhesion molecule (sICAM), monocyte chemotactic protein (MCP-1), and IL-6 soluble receptor (IL-6sR) were sampled. RESULTS: As compared with matched controls, depressed patients showed significant (p or = 0.30). Backward regression analyses indicated that sleep latency (beta = 0.34, p <.05) and REM density (beta = 0.27, p = .09) were better predictors of IL-6 than depressive status. Similarly, sleep latency (beta = 0.27, p = .06) and REM density (beta = 0.32, p = .02) were also better predictors of sICAM. CONCLUSION: These findings support the hypothesis that sleep disturbance is associated with elevated levels of the inflammatory markers IL-6 and sICAM. This relationship was not accounted for by other confounding factors such as age and body weight. These findings suggest that the elevations in inflammatory markers found in depressive subjects may be partially the result of disturbances of sleep initiation found in this population.

Reflections on depression as a cardiac risk factor

Abstract: Objective:Major North American cardiology organizations do not currently list depression among the officially recognized cardiac risk factors, yet many behavioral medicine specialists believe depression to be an important risk. We wondered what was missing from the available data.Methods:The Medline

The development of persistent pain and psychological morbidity after motor vehicle collision: integrating the potential role of stress response systems into a biopsychosocial model.

Abstract: OBJECTIVES: Persistent pain and psychological sequelae are common after motor vehicle collision (MVC), but their etiology remains poorly understood. Such common sequelae include whiplash-associated disorders (WAD), fibromyalgia, and posttraumatic stress disorder (PTSD). Increasing evidence suggests that these disorders share overlapping epidemiologic and clinical features. A model is proposed in which central neurobiological systems, including physiologic systems and neuroanatomical structures involved in the stress response, are an important substrate for the development of all 3 disorders and interact with psychosocial and other factors to influence chronic symptom development. METHODS: Epidemiologic and clinical characteristics regarding the development of these disorders after MVC are reviewed. Evidence suggesting a role for stress response systems in the development of these disorders is presented. RESULTS: Contemporary evidence supports a model of chronic symptom development that incorporates the potential for interactions between past experience, acute stress responses to trauma, post-MVC behavior, and cognitive/psychosocial consequences to alter activity within brain regions which process pain and to result in persistent pain, as well as psychological sequelae, after MVC. Such a model incorporates factors identified in prior biopsychosocial theories and places them in the landscape of our rapidly developing understanding of stress systems and CNS pain-modulating pathways. CONCLUSION: New models are needed to stimulate deeper examination of the interacting influences of initial tissue damage, acute pain, psychosocial contingencies, and central stress pathways during chronic symptom development after MVC. Deeper understanding could contribute to improved treatment approaches to reduce the immense personal and societal burdens of common trauma-related disorders. Language: en

Sexual abuse history: prevalence, health effects, mediators, and psychological treatment

Abstract: OBJECTIVE: Lifetime history of sexual abuse is estimated to range between 15% and 25% in the general female population. People who are sexually abused are at greater risk for a whole host of physical health disorders that may occur many years after the abusive incident(s). Despite the high prevalence of this trauma and its association with poor health status, abuse history often remains hidden within the context of medical care. The aims of this review are to determine which specific health disorders have been associated with sexual abuse in both women and men, to outline the types of sexual abuse associated with the worst health outcome, to discuss some possible explanations and mediators of the abuse/health relationship, to discuss when and how to talk about abuse within a clinical setting, and to present evidence for which psychological treatments have been shown to improve the mental health of patients with past sexual abuse. METHOD: To meet these objectives, we have reviewed a wide literature on the topic of sexual abuse. RESULTS: We demonstrate that abuse appears to be related to greater likelihood of headache and gastrointestinal, gynecologic, and panic-related symptoms; that the poor health effects associated with abuse are also seen in men; that abuse involving penetration and multiple incidents appears to be the most harmful, and that exposure-type therapies with and without cognitive behavioral therapy hold promise for those with abuse history. CONCLUSION: We need more research examining psychological treatments that might be efficacious in treating the physical health problems associated with sexual abuse history. Language: en

Clinical depression and regulation of the inflammatory response during acute stress.

Abstract: Objective This study examined whether clinical depression is associated with a differential inflammatory response to an acute bout of psychological stress. Methods A total of 72 women participated in the study; half met diagnostic criteria for clinical depression; the others had no history of psychiatric illness. The groups were matched with respect to age and ethnicity. All subjects were exposed to a 17-minute mock-job interview; blood was drawn to assess secretion and regulation of inflammatory molecules. Results The stressor was associated with feelings of shame and anxiety, a mobilization of monocytes, neutrophils, and C-reactive protein into the circulation, and greater endotoxin-stimulated production of interleukin-6 and tumor necrosis factor-alpha by white blood cells in vitro. Depressed subjects began the session with greater sensitivity to the antiinflammatory properties of glucocorticoids than control subjects. Following exposure to the stressor protocol, however, sensitivity decreased among depressed subjects and increased among controls. This was manifest by disparities in interleukin-6 and tumor necrosis factor-alpha production in the presence of dexamethasone. Conclusions These findings suggest that under acutely challenging conditions, depression is associated with greater resistance to molecules that normally terminate the inflammatory cascade. An impaired capacity to regulate inflammation could underlie some of the excess morbidity and mortality that has been associated with depression.

Relationship between work stress and body mass index among 45,810 female and male employees

Abstract: OBJECTIVE: The proportion of overweight and obese people has grown rapidly, and obesity has now been widely recognized as an important public health problem. At the same time, stress has increased in working life. The 2 problems could be connected if work stress promotes unhealthy eating habits and sedentary behavior and thereby contributes to weight gain. This study explored the association between work stress and body mass index (BMI; kg/m2). METHODS: We used cross-sectional questionnaire data obtained from 45,810 female and male employees participating in the ongoing Finnish Public Sector Cohort Study. We constructed individual-level scores, as well as occupational- and organizational-level aggregated scores for work stress, as indicated by the demand/control model and the effort-reward imbalance model. Linear regression analyses were stratified by sex and socioeconomic status (SES) and adjusted for age, marital status, job contract, smoking, alcohol consumption, physical activity, and negative affectivity. RESULTS: The results with the aggregated scores showed that lower job control, higher job strain, and higher effort-reward imbalance were associated with a higher BMI. In men, lower job demands were also associated with a higher BMI. These associations were not accounted for by SES, although an additional adjustment for SES attenuated the associations. The results obtained with the individual-level scores were in the same direction, but the relationships were weaker than those obtained with the aggregated scores. CONCLUSIONS: This study shows a weak association between work stress and BMI.

Prenatal stress alters cytokine levels in a manner that may endanger human pregnancy.

Abstract: Objective Recent data suggest that prenatal stress negatively affects pregnancy and infant outcome. Existing studies implicate dysregulation of the immune and endocrine systems in stress-related increases in premature labor and poor birth outcome, but no published studies have directly addressed the relationships among these variables during pregnancy. We sought to test the hypothesis that high levels of psychosocial stress and low levels of social support during pregnancy alter maternal cytokine profiles in a manner that contributes to poor birth outcomes. Methods Psychosocial stress and social support were measured in 24 women with overtly normal pregnancies once during each trimester of pregnancy. Levels of interleukin-10 (IL-10), IL-6, and tumor necrosis factor-alpha (TNF-alpha) were assessed concurrently with stress and support measurements. Results High social support was associated with low stress scores. Elevated stress scores were positively correlated with higher levels of the proinflammatory cytokines IL-6 and TNF-alpha, and with low levels of the antiinflammatory cytokine IL-10. Conclusions These findings provide initial support for our hypothesis that stress-related neural immune interactions may contribute to pregnancy complications and poor outcome, but require further study to determine the mechanism and significance of these effects.

Psychologic functioning and physical health: a paradigm of flexibility.

Abstract: Recent evidence suggests that positive psychologic factors may be protective against coronary artery disease (CAD). We consider this possibility through a paradigm that explores three interrelated factors that may promote healthy psychologic functioning: vitality, emotional flexibility, and coping flexibility. Vitality is a positive and restorative emotional state that is associated with a sense of enthusiasm and energy. Flexibility is related both to the ability to regulate emotions effectively and cope effectively with challenging daily experiences. A variety of factors may diminish vitality, including chronic stress and negative emotions. Pathophysiologically, chronic stress and negative emotional states can both invoke a "chronic stress response" characterized by increased stimulation of the sympathetic nervous system and hypothalamic-pituitary-adrenal axis, with resultant peripheral effects, including augmented heart rate and blood pressure responsiveness and delayed recovery to stressful stimuli. Research indicates a wide array of stressful conditions--associated with either elements of relative inflexibility in psychologic functioning and/or relatively unabated stressful stimulation--that are associated with this type of exhausting hyperarousal. Conversely, new data suggest that positive psychologic factors, including positive emotions, optimism, and social support, may diminish physiological hyperresponsiveness and/or reduce adverse clinical event rates. Still other positive factors such as gratitude and altruistic behavior have been linked to a heightened sense of well-being but have not yet been tested for beneficial physiological effects. Pending further study, these observations could serve as the basis for expanding the potential behavioral interventions that may be used to assist patients with psychosocial risk factors for CAD.

Altered cortisol response to psychologic stress in breast cancer survivors with persistent fatigue.

Abstract: OBJECTIVE Fatigue is one of the most common and distressing symptoms experienced by cancer patients and survivors. However, the etiology of cancer-related fatigue has not been determined. In previous studies, we have shown alterations in morning serum cortisol levels and diurnal cortisol rhythms in fatigued breast cancer survivors compared with nonfatigued control subjects. The purpose of the current study was to evaluate cortisol responses to an experimental psychologic stressor in fatigued and nonfatigued survivors. METHODS Participants included 27 breast cancer survivors (11 fatigued, 16 nonfatigued). All had completed cancer treatment at least 3 years previously and were currently healthy with no evidence of recurrence. A standardized laboratory stressor, the Trier Social Stress Test (TSST), was administered during a 90-minute afternoon session. Saliva samples and autonomic measures (heart rate, blood pressure) were collected at 15-minute intervals throughout the session. RESULTS Fatigued survivors showed a significantly blunted cortisol response to the stressor compared with nonfatigued survivors, controlling for depression and other potential confounds (p <.05). No differences in autonomic measures were observed. CONCLUSIONS These results, together with our earlier findings, suggest a dysregulation in hypothalamic-pituitary-adrenal (HPA) axis responsiveness among breast cancer survivors with enduring fatigue. Although the sample size was small, results suggest that attention to the HPA axis may be important for understanding cancer-related fatigue.

Electromagnetic hypersensitivity: a systematic review of provocation studies.

Abstract: Objectives: The objectives of this study were to assess whether people who report hypersensitivity to weak electromagnetic fields (EMFs) are better at detecting EMF under blind or double-blind conditions than nonhypersensitive individuals, and to test whether they respond to the presence of EMF with increased symptom reporting. Methods: An extensive systematic search was used to identify relevant blind or double-blind provocation studies. This involved searching numerous literature databases and conference proceedings, and examining the citations of reviews and included studies. The results of relevant studies were tabulated and metaanalyses were used to compare the proportions of “hypersensitive” and control participants able to discriminate active from sham EMF exposures. Results: Thirty-one experiments testing 725 “electromagnetically hypersensitive” participants were identified. Twenty-four of these found no evidence to support the existence of a biophysical hypersensitivity, whereas 7 reported some supporting evidence. For 2 of these 7, the same research groups subsequently tried and failed to replicate their findings. In 3 more, the positive results appear to be statistical artefacts. The final 2 studies gave mutually incompatible results. Our metaanalyses found no evidence of an improved ability to detect EMF in “hypersensitive” participants. Conclusions: The symptoms described by “electromagnetic hypersensitivity” sufferers can be severe and are sometimes disabling. However, it has proved difficult to show under blind conditions that exposure to EMF can trigger these symptoms. This suggests that “electromagnetic hypersensitivity” is unrelated to the presence of EMF, although more research into this phenomenon is required. Key words: electromagnetic hypersensitivity, provocation studies, systematic review. EHS electromagnetic hypersensitivity; EMF electromagnetic field; SMD standardized mean difference; UMTS universal mobile telecommunications system (a “third-generation” mobile phone signal); VDU visual display unit.

Behavioral and emotional triggers of acute coronary syndromes: a systematic review and critique.

Abstract: Objective The objective of this study was to review the evidence that behavioral and emotional factors are triggers of acute coronary syndromes. Method Systematic review of the published literature from 1970 to 2004 of trigger events, defined as stimuli or activities occurring within 24 hours of the onset of acute coronary syndromes. Results There is consistent evidence that physical exertion (particularly by people who are not normally active), emotional stress, anger, and extreme excitement can trigger acute myocardial infarction and sudden cardiac death in susceptible individuals. Many triggers operate within 1 to 2 hours of symptom onset. There are methodologic limitations to the current literature, including sampling, retrospective reporting, and presentation biases, the role of memory decay and salience, and reverse causation because of silent prodromal events. Conclusions Behavioral and emotional factors are probable triggers of acute coronary syndromes in vulnerable individuals, and the pathophysiological processes elicited by these stimuli are being increasingly understood. The benefits to patients of knowledge to these processes have yet to accrue.

How trauma, recent stressful events, and PTSD affect functional health status and health utilization in HIV-infected patients in the south.

Abstract: and utilization of health care may also be important indicators of health status in HIV-infected patients. There is insufficient understanding of the psychosocial predictors of health-related physical functioning and use of health services among those with this chronic disease. Therefore, the current study examines how trauma, severe stressful events, posttraumatic stress disorder (PTSD), and depressive symptoms are related to physical functioning and health utilization in HIV-infected men and women living in rural areas of the South. Methods: We consecutively sampled patients from 8 rural HIV clinics in 5 southern states, obtaining 611 completed interviews. Results: We found that patients with more lifetime trauma, stressful events, and PTSD symptoms reported more bodily pain, and poorer physical, role, and cognitive functioning. Trauma, recent stressful events, and PTSD explained from 12% to 27% of the variance in health-related functioning, over and above that explained by demographic variables. In addition, patients with more trauma, including sexual and physical abuse, and PTSD symptoms were at greater risk for having bed disability, an overnight hospitalization, an emergency room visit, and four or more HIV outpatient clinic visits in the previous 9 months. Patients with a history of abuse had about twice the risk of spending 5 or more days in bed, having an overnight hospital stay, and visiting the emergency room, compared with those without abuse. The effects of trauma and stress were not explained by CD4 lymphocyte count or HIV viral load; however, these effects appear to be largely accounted for by increases in current PTSD symptoms. Conclusion: These findings highlight the importance of addressing past trauma, stress, and current PTSD within clinical HIV care. Key words: HIV, PTSD, trauma, health-related quality of life, sexual abuse. PTSD posttraumatic stress disorder; HIV human immunodeficiency virus; DSM-IV Diagnostic and Statistical Manual of Mental Disorders; OR odds ratio; CI confidence interval; SD standard deviation.

Neuroticism, extraversion, and mortality in a defined population of older persons.

Abstract: Objective The objective of this study was to test the association of the personality traits of neuroticism and extraversion with risk of death in old age. Methods A census was taken of a geographically defined urban community in Chicago, and those aged 65 years or older were invited to participate in an in-home interview; 6158 (79% of those eligible) did so. The interview included brief measures of neuroticism and extraversion, medical history, and questions about current participation in cognitive, social, and physical activities. Vital status was subsequently monitored. The association of each trait with risk of death was examined in a series of accelerated failure-time models that controlled for age, sex, race, and education. Results During a mean of more than 6 years of observation, 2430 persons (39.5%) died. A high level of neuroticism (score = 27; 90th percentile) was associated with a 33% increase in risk of death compared with a low level of neuroticism (score = 9; 10th percentile). A high level of extraversion (score = 33; 90th percentile) was associated with a 21% decrease in risk of death compared with a low level (score = 18; 10th percentile). Adjustment for medical conditions and health-related variables did not substantially affect results, but adjusting for baseline levels of cognitive, social, and physical activity reduced the association of both traits with mortality. Conclusions The results suggest that higher extraversion and lower neuroticism are associated with reduced risk of mortality in old age and that these associations are mediated in part by personality-related patterns of cognitive, social, and physical activity.

Relation of childhood socioeconomic status and family environment to adult metabolic functioning in the CARDIA study

Abstract: OBJECTIVE: Low SES and a conflict-ridden, neglectful, or harsh family environment in childhood have been linked to a high rate of physical health disorders in adulthood. The objective of the present investigation was to evaluate a model of the pathways that may help to explain these links and to relate them to metabolic functioning (MF) in the Coronary Artery Risk Development In Young Adults (CARDIA) dataset. METHODS: Participants (n = 3225) in the year 15 assessment of CARDIA, age 33 to 45 years, completed measures of childhood socioeconomic status (SES), risky early family environment (RF), adult psychosocial functioning (PsyF, a latent factor measured by depression, hostility, positive and negative social contacts), and adult SES. Indicators of the latent factor MF were assessed, specifically, cholesterol, insulin, glucose, triglycerides, and waist circumference. RESULTS: The overall prevalence of metabolic syndrome was 9.7%. Structural equation modeling indicated that childhood SES and RF are associated with MF via their association with PsyF (standardized path coefficients: childhood SES to RF -0.13, RF to PsyF 0.44, PsyF to MF 0.09, all p Language: en

Emotional awareness deficits in inpatients of a psychosomatic ward: a comparison of two different measures of alexithymia.

Abstract: Objective The TAS 20 has demonstrated strong psychometric properties in a broad variety of studies in healthy populations. Much less work has been done in clinical contexts exploring the validity of the TAS 20 as a measure of the cognitive processing of emotions. The TAS 20, a self-report scale, tends to correlate with self-reported negative affect, but in a clinical context it is important to be able to differentiate between negative affect and the cognitive processing of emotion. We therefore used the TAS 20 and a performance measure, the Levels of Emotional Awareness Scale (LEAS), which in previous studies demonstrated no overlap with measures of negative affect, to explore the ability of the two measures to detect deficits in emotional awareness in a clinical sample. Methods Data from inpatients of a psychosomatic ward were collected at onset (N = 394) and at the end of multimodal psychodynamic treatment (N = 249). The sample consisted of six diagnostic groups (depression; anxiety and compulsive-obsessive disorders, adjustment disorders, somatoform disorders, psychological factors related to somatic disorders, eating disorders). Changes in the TAS 20 and LEAS were compared at the two time points controlling for the effects of gender, age, educational level, and associations with self-reported negative affect. Results In contrast to the LEAS, the TAS 20 correlated with negative affect at the onset and the end of treatment. The scores of the TAS 20 decreased with treatment in all diagnostic groups but the change in the TAS 20 was not statistically significant when negative affect was controlled. In contrast, LEAS scores increased with treatment in the groups with somatoform disorders and psychological factors related to somatic disorders, and this change was independent of negative affect. Conclusion The LEAS captured a change in emotional awareness due to treatment, whereas the TAS 20 captured a change in negative affect. The LEAS appears to be a more specific measure of change in emotional awareness in clinical contexts than the TAS 20.

Written emotional expression produces health benefits in fibromyalgia patients.

Abstract: Objective Written expression of traumatic experiences, an intervention found to have health benefits in rheumatoid arthritis, asthma, and breast cancer, was tested in a randomized, controlled trial with female fibromyalgia patients. It was hypothesized that relative to controls, patients engaging in the writing intervention would experience improved status on psychological well-being and physical health variables. Methods Patients (N = 92) were randomized into a trauma writing group, a control writing group, or usual care control group. The two writing groups wrote in the laboratory for 20 minutes on 3 days at 1-week intervals. Psychological well-being, pain, and fatigue were the primary outcome variables. Assessments were made at pretreatment, posttreatment, 4-month follow-up, and 10-month follow-up. Results The trauma writing group experienced significant reductions in pain (effect size [ES] = 0.49) and fatigue (ES = 0.62) and better psychological well-being (ES = 0.47) at the 4-month follow-up relative to the control groups. Benefits were not maintained at the 10-month follow-up. Conclusion Fibromyalgia patients experienced short-term benefits in psychological and health variables through emotional expression of personal traumatic experiences.

Tension and anxiety and the prediction of the 10-year incidence of coronary heart disease, atrial fibrillation, and total mortality: the Framingham Offspring Study.

Abstract: Objective Conflicting research findings regarding the ability of tension or anxiety to predict incident coronary heart disease (CHD) have created uncertainty in the literature. In addition, there are no prospective studies relating these characteristics to the development of atrial fibrillation (AF). Methods From 1984 to 1987, 3682 participants (mean age 48.5 +/- 10.1 year; 52% women) of the Framingham Offspring Study were examined and followed for 10 years for the incidence of CHD, AF, and total mortality. Measures of tension, anxiety, and risk factors for CHD and AF were collected at the baseline examination. Results After adjusting for age, systolic blood pressure, body mass index, current cigarette smoking, diabetes, and total cholesterol/high-density cholesterol in Cox proportional hazards models, increased tension was predictive of 10-year incidence of definite CHD (relative risk (RR) = 1.25 relative to a one SD difference; 95% confidence interval (CI), 1.05-1.49) and total mortality (RR = 1.23; 95% CI, 1.06-1.42) in men. After adjusting for AF risk factors, tension also predicted AF in men (RR = 1.24; 95% CI, 1.04-1.48). Anxiety in men (RR = 1.22; 95% CI, 1.08-1.38), and in women (RR = 1.27; 95% CI, 1.05-1.55) was significantly related to total mortality. Conclusions Tension was observed to be an independent risk factor for incident CHD, AF, and mortality in men. Anxiety was a risk factor for total mortality in men and women. Our findings suggest that further research into the pathophysiology of the excess morbidity and mortality observed with tension and anxiety is merited.

Serum cholesterol and cognitive performance in the Framingham Heart Study.

Abstract: OBJECTIVE The objective of this study was to examine the relationship between total cholesterol (TC) and cognitive performance within the context of the Framingham Heart Study, a large, community-based, prospective investigation of cardiovascular risk factors. METHODS Participants were 789 men and 1105 women from the Framingham Heart Study original cohort who were free of dementia and stroke and who received biennial TC determinations over a 16- to 18-year surveillance period. Cognitive tests were administered 4 to 6 years subsequent to the surveillance period and consisted of measures of learning, memory, attention/concentration, abstract reasoning, concept formation, and organizational abilities. Statistical models were adjusted for multiple demographic and biological covariates. RESULTS There was a significant positive linear association between TC and measures of verbal fluency, attention/concentration, abstract reasoning, and a composite score measuring multiple cognitive domains. Performance levels for three clinically defined groups were examined. Participants with "desirable" TC levels (<200 mg/dL) performed less well than participants with borderline-high TC levels (200-239 mg/dL) and participants with high TC levels (there exists 240 mg/dL). CONCLUSIONS Lower naturally occurring TC levels are associated with poorer performance on cognitive measures, which place high demands on abstract reasoning, attention/concentration, word fluency, and executive functioning.