Psychoneuroimmunology: psychological influences on immune function and health

Breast Cancer Risk and Immune Responses in Healthy Women

PURPOSE/OBJECTIVES

To summarize the findings of objective and subjective breast cancer risk assessments and their association with psychological distress and immune responses in healthy women with a family history of breast cancer.

DATA SOURCES

Published articles and book chapters.

DATA SYNTHESIS

Healthy women with a family history of breast cancer have shown decreased immune responses (i.e., low natural killer cell activity and low Th1 cytokine production), exaggerated biophysiologic reactivity to stimuli, and increased psychological distress.

CONCLUSIONS

Objective and subjective breast cancer risk is associated with impaired immune responses and exaggerated biophysiologic responses in healthy women with a family history of breast cancer. Increased psychological distress can contribute further to negative immune responses. Additional studies are warranted to substantiate and extend the findings based on more comprehensive assessments of objective and subjective breast cancer risk.

IMPLICATIONS FOR NURSING

Biophysiologic assessment is a useful approach for nurses in early identification of women at risk for breast cancer and developing appropriate strategies to reduce the risk.

Social sensitivity and acne: the role of personality in negative social consequences and quality of life

BACKGROUND

Acne affects a majority of adolescents and a substantial number of adults. The adverse social impact of acne is well documented. Negative social consequences, however, are likely to be determined by personality features as well as acne severity.

PURPOSE

To determine whether a personality trait--dispositional social sensitivity--is associated with the adverse social impact of acne.

METHODS

A survey of 479 acne sufferers between the ages of 16 and 62 was conducted in the Piedmont region of North Carolina, United States. Respondents were classified as either high or low social sensitivity and compared on demographic, disease characteristics, and quality of life. Main and interaction effects were evaluated for acne severity and social sensitivity in relation to global and intimate social concerns and social interference.

RESULTS

Greater acne severity was significantly associated with poorer social outcomes and quality of life (ps < 0.05). For women, higher social sensitivity was independently associated with poorer outcomes (ps < 0.05), while for men, higher social sensitivity interacted with acne severity and was associated with worse social outcomes and life quality (ps < 0.05).

CONCLUSIONS

Acne is a biopsychosocial skin condition. Dispositional social sensitivity is an independent psychological factor associated with poorer social functioning and quality of life. Treatment of the acne patient should consider psychosocial factors as well as biological factors.

The effects of nurses' practicing of the HeartTouch technique on perceived stress, spiritual well-being, and hardiness

PURPOSE

To test the effects of nurses' practicing of the HeartTouch technique (internal method of changing thoughts and feelings) on their perceived stress, hardiness, and spiritual well-being.

METHOD

Experimental (n = 58) and comparison (n = 40) groups received an education session discussing the effects of thoughts and feelings on stress and health, with the experimental group also learning HeartTouch and practicing it for 1 month.

FINDINGS

ANCOVA produced no statistically significant between-group differences. Effect sizes ranged from .14 to .35, indicating practical significance, suggesting that nurses who practiced HeartTouch likely noticed a greater improvement in outcome variables than nurses who did not practice HeartTouch. In the experimental group, statistically significant within-group differences were seen in all variables, with effect sizes ranging from .25 to .89. In the comparison group, statistically significant within-group differences were seen in two variables.

IMPLICATIONS

Learning about the power of thoughts and feelings and using HeartTouch to change them can reduce stress and increase hardiness and spiritual well-being.

Coping, affect, and the metabolic syndrome in older men: how does coping get under the skin?

The metabolic syndrome is a complex construct with interrelated factors of obesity, blood pressure, lipids, and glucose. It is a risk factor for a number of chronic diseases in late life. This study tested a model in which the relationship between stress and the metabolic syndrome was mediated by appraisal, coping, and affect. Data were collected from 518 male participants in the Normative Aging Study (X(age) = 68.17 years). The model was partially confirmed. Relationships among stress, appraisal, coping, and affect were valenced along positive and negative pathways. However, affect was not directly related to the metabolic syndrome. The metabolic syndrome was related to positive coping as operationalized by self-regulatory strategies. The results of this study suggest that the influence of coping on physical health may occur through emotional regulation.

Stress-related cognitive interference predicts cognitive function in old age

Both subjective distress and cognitive interference have been proposed as mechanisms underlying the negative effects of stress on cognition. Studies of aging have shown that distress is associated with lower cognitive performance, but none have examined the effects of cognitive interference. One hundred eleven older adults (M-sub(age)=80) completed measures of working memory, processing speed, and episodic memory as well as self-report measures of subjective distress and cognitive interference. Cognitive interference was strongly associated with poorer performance on all 3 cognitive constructs, whereas distress was only modestly associated with lower working memory. The results suggest that cognitive process related to stress is an important predictor of cognitive function in advanced age.

Effects of spiritual mantram repetition on HIV outcomes: a randomized controlled trial

We examined the efficacy of a psycho-spiritual intervention of mantram repetition--a word or phrase with spiritual associations repeated silently throughout the day--on psychological distress (intrusive thoughts, stress, anxiety, anger, depression), quality of life enjoyment and satisfaction, and existential spiritual well-being in HIV-infected adults. Using a 2-group by 4-time repeated measures design, 93 participants were randomly assigned to mantram (n = 46) or attention control group (n = 47). Over time, the mantram group improved significantly more than the control group in reducing trait-anger and increasing spiritual faith and spiritual connectedness. Actual mantram practice measured by wrist counters was inversely associated with non-HIV related intrusive thoughts and positively associated with quality of life, total existential spiritual well-being, meaning/peace, and spiritual faith. Intent-to-treat findings suggest that a mantram group intervention and actual mantram practice each make unique contributions for managing psychological distress and enhancing existential spiritual well-being in adults living with HIV/AIDS.

Burnout and risk of cardiovascular disease: evidence, possible causal paths, and promising research directions

Burnout is characterized by emotional exhaustion, physical fatigue, and cognitive weariness, resulting from prolonged exposure to work-related stress. The authors review the accumulated evidence suggesting that burnout and the related concept of vital exhaustion are associated with increased risk of cardiovascular disease and cardiovascular-related events. The authors present evidence supporting several potential mechanisms linking burnout with ill health, including the metabolic syndrome, dysregulation of the hypothalamic-pituitary-adrenal axis along with sympathetic nervous system activation, sleep disturbances, systemic inflammation, impaired immunity functions, blood coagulation and fibrinolysis, and poor health behaviors. The association of burnout and vital exhaustion with these disease mediators suggests that their impact on health may be more extensive than currently indicated.

A randomized trial of the efficacy of group therapy in changing viral load and CD4 counts in individuals living with HIV infection

OBJECTIVE

This randomized pilot study evaluates whether seropositive patients who are randomly assigned to receive a supportive-expressive group therapy plus education intervention show greater improvements in increased immune function and decreased viral load compared to those randomly assigned to an education-only intervention.

METHOD

Fifty-nine individuals who had been HIV-seropositive for at least 6 months prior to inclusion in the study and had been receiving standard pharmacologic treatment were entered in a prospective randomized trial of the effects of weekly supportive-expressive group therapy on changes in immune status. Participants were matched for AIDS status and sex and randomized to receive weekly sessions of group psychotherapy plus educational materials on HIV/AIDS, or to receive the educational materials alone. Participants were assessed before treatment and then 12 weeks later.

RESULTS

Individuals who were randomized to group therapy showed a statistically significant increase in CD4 count and decrease in HIV viral load. Among individuals randomized to the education only condition, no significant change occurred in CD4 count or viral load.

CONCLUSIONS

These results provide preliminary data suggesting that HIV-seropositive individuals who receive supportive-expressive group psychotherapy may experience concomitant improvements in CD4 cell count and viral load. Further research with a larger sample should examine the possible underlying mechanisms of such benefits.

Predicting physical health: implicit mental health measures versus self-report scales

Researchers have traditionally relied on self-report questionnaires to assess psychological well-being, but such measures may be unable to differentiate individuals who are genuinely psychologically healthy from those who maintain a facade or illusion of mental health based on denial and self-deception. Prior research suggests that clinically derived assessment procedures that assess implicit psychological processes may have advantages over self-report mental health measures. This prospective study compared the Early Memory Index, an implicit measure of mental health/distress, with a range of familiar self-report scales as predictors of physical health. The Early Memory Index showed significant prospective associations with health service utilization and clinically verified illness. In contrast, self-report measures of mental health, perceived stress, life events stress, and mood states did not predict health outcomes. The findings highlight the limitations of self-report questionnaires and suggest that implicit measures have an important role to play in mental health research.

The urban environment and sexual risk behavior among men who have sex with men

Increasingly, studies show that characteristics of the urban environment influence a wide variety of health behaviors and disease outcomes, yet few studies have focused on the sexual risk behaviors of men who have sex with men (MSM). This focus is important as many gay men reside in or move to urban areas, and sexual risk behaviors and associated outcomes have increased among some urban MSM in recent years. As interventions aimed at changing individual-level risk behaviors have shown mainly short-term effects, consideration of broader environmental influences is needed. Previous efforts to assess the influence of environmental characteristics on sexual behaviors and related health outcomes among the general population have generally applied three theories as explanatory models: physical disorder, social disorganization and social norms theories. In these models, the intervening mechanisms specified to link environmental characteristics to individual-level outcomes include stress, collective efficacy, and social influence processes, respectively. Whether these models can be empirically supported in generating inferences about the sexual behavior of urban MSM is underdeveloped. Conceptualizing sexual risk among MSM to include social and physical environmental characteristics provides a basis for generating novel and holistic disease prevention and health promotion interventions.

Linking Perceived Unfairness to Physical Health: The Perceived Unfairness Model

Can perceiving unfairness influence physical health? To address this question the authors propose the Perceived Unfairness Model, synthesized from psychological and epidemiological research. The model starts from the premise that perceiving unfairness, directed at beings to which the perceiver is emotionally attached, activates a cascade of psychological and physical processes. This cascade may be experienced by low or high status group members, and by the target or observer of the perceived unfairness. With repeated episodes, the effects of perceiving unfairness may accumulate and compromise physical health. Whether perceiving unfairness is potentially toxic or benign is a function of two key components of social location: identity relevance and helplessness to redress the unfairness. The authors conclude by discussing directions for developing the model.

Rethinking gender differences in health: why we need to integrate social and biological perspectives

The complexity of gender differences in health (i.e., men's lower life expectancy and women's greater morbidity) extends beyond notions of either social or biological disadvantage. Gaps remain in understanding the antecedents of such differences and the issues this paradox raises regarding the connections between social and biological processes. Our goals in this analytic essay are to make the case that gender differences in health matter and that understanding these differences requires an explanation of why rational people are not effective in making health a priority in their everyday lives. We describe some salient gender health differences in cardiovascular disease, immune function and disorders, and depression and indicate why neither social nor biological perspectives alone are sufficient to account for them. We consider the limitations of current models of socioeconomic and racial/ethnic health disparities to explain the puzzling gender differences in health. Finally, we discuss constrained choice, a key issue that is missing in the current understanding of these gender differences, and call on the social science community to work with biomedical researchers on the interdisciplinary work required to address the paradoxical differences in men's and women's health.

Stress, social support, emotional regulation, and exacerbation of diffuse plaque psoriasis

The authors' aim was to investigate the role of stressful events, perceived social support, attachment security, and alexithymia in triggering exacerbations of diffuse plaque psoriasis. Inpatients experiencing a recent exacerbation of diffuse plaque psoriasis (N=33) were compared with inpatients with skin conditions believed to have a negligible psychosomatic component (N=73). Stressful events during the last year were assessed with Paykel's Interview for Recent Life Events. Attachment style, alexithymia, and perceived social support were assessed with the Experiences in Close Relationships questionnaire, the Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support, respectively. Multiple logistic regression analysis was used to control for age, gender, education, marital status, and alcohol consumption. In relation to comparison subjects, the patients with psoriasis had lower perceived social support and higher attachment-related avoidance. Also, they were more likely to have high alexithymic characteristics. There were no differences between the patients with psoriasis and the comparison subjects in scores on the Experiences in Close Relationships anxiety scale, the total number of stressful events, and the number of undesirable, uncontrollable, or major events. Although caution should be applied in generalizing these findings to outpatients, this study suggests that alexithymia, attachment-related avoidance, and poor social support might increase susceptibility to exacerbations of diffuse plaque psoriasis, possibly through impaired emotional regulation. Several physiological mechanisms involving the neuroendocrine and the immune system might mediate the interplay between stress, personality, and diffuse plaque psoriasis.

Legal recognition of same-sex relationships in the United States: A social science perspective

Whether and how civil society should recognize committed relationships between same-sex partners has become a prominent, often divisive, policy issue. The present article reviews relevant behavioral and social science research to assess the validity of key factual claims in this debate. The data indicate that same-sex and heterosexual relationships do not differ in their essential psychosocial dimensions; that a parent's sexual orientation is unrelated to her or his ability to provide a healthy and nurturing family environment; and that marriage bestows substantial psychological, social, and health benefits. It is concluded that same-sex couples and their children are likely to benefit in numerous ways from legal recognition of their families, and providing such recognition through marriage will bestow greater benefit than civil unions or domestic partnerships. Trends in public opinion toward greater support for legal recognition of same-sex couples are discussed.

Upregulation of tumor necrosis factor-alpha by stress and substance p in a murine model of allergic airway inflammation

OBJECTIVE

Clinical observation has suggested that stress and asthma morbidity are associated, though underlying mechanisms are not clearly understood. After having established a mouse model of stress-exacerbated allergic airway inflammation, we demonstrated a stress-mediating role for neurokinin-1 receptor, the main substance P (SP) receptor. Here, our aim was to investigate the influence of stress or exogenously applied SP on airway inflammation and on the local cytokine production of immune cells.

METHODS

BALB/c mice were systemically sensitized to ovalbumin (OVA) and repeatedly challenged with OVA aerosol. Sound stress was applied to the animals for 24 h, starting with the first airway challenge. Alternatively, one group of non-stressed mice received intranasal SP before airway challenges. Cell numbers were determined in bronchoalveolar lavage (BAL) fluid. Leukocytes from mediastinal lymph nodes were analyzed by flow cytometry to determine the percentages of T cells producing interleukin-4, interferon-gamma and tumor necrosis factor-alpha.

RESULTS

In BAL fluids of stressed or SP-treated animals, significantly higher total cell counts were found compared to non-stressed mice. In lymph nodes, the percentage of TNF-alpha-positive T cells was higher in stressed mice and mice after application of SP. In contrast, the influence of stress did not increase the percentages of interferon-gamma-positive CD3+ cells, meanwhile the application of SP increased the percentages of T cells positive for this cytokine.

CONCLUSION

Our data provide further evidence for a stress-mediating neuroimmunological pathway that, putatively via SP, is able to influence the composition of immune cells in different compartments of allergic airway inflammation.

Fecal microbiota composition and frailty

The relationship between fecal microbiota composition and frailty in the elderly was studied. Fecal samples from volunteers with high frailty scores showed a significant reduction in the number of lactobacilli (26-fold). At much higher population levels, both the Bacteroides/Prevotella (threefold) and the Faecalibacterium prausnitzii (fourfold) groups showed a significant reduction in percentage of total number of hybridizable bacteria in the elderly with high frailty scores. In contrast to this, the number of Enterobacteriaceae was significantly higher (sevenfold) in samples from very frail volunteers.

A 3-D model of health decline: disease, disability, and depression among Black and White older adults

Much of the research on health decline in older adulthood has specified a single causal direction between two health domains, often measured at the same time point, making it difficult to disentangle the mechanisms of health decline over time. Using three waves of data over seven years from older residents of North Carolina, a 3-D model is used to examine the temporal ordering of general health decline and the pathways of influence across three health domains (disease, disability, and depression). In addition, we test whether the 3-D model of health decline is similar for Black and White older adults. Results indicate that both prevalent and incident disease lead to increases in depression and that prevalent disease leads to greater disability three years later. Depression, in turn, leads to disease, identifying a cycle of health decline that is, for the most part, similar for Black and White older adults. The effect of widowhood is more deleterious to the health of Black older adults than for their White counterparts.

Stress and depression-induced immune dysfunction: implications for the development and progression of cancer

The persistent activation of the hypothalamic-pituitary-adrenal axis and the sympathetic-adrenal-medullary axes in chronic stress response and in depression impairs the immune response and contributes to the development and progression of some types of cancer. This overview presents results from experimental animal models, human studies, and clinical evidence that various cellular and molecular immunological parameters are compromised in chronic stress and depression. At the cellular level, stressed and depressed patients had overall leukocytosis, high concentrations of circulating neutrophils, reduced mitogen-stimulated lymphocyte proliferation and neutrophil phagocytosis. At the molecular level, high levels of serum basal cortisol, acute phase proteins, specific antibodies against herpes simplex virus type 1 and Epstein Barr virus, plasma concentration of interleukins IL-1, IL-6, and TNF-alpha, and a shift in the balance of Th1 and Th2 immune response were observed. Both stress and depression were associated with the decreased cytotoxic T-cell and natural killer cell activities affecting the processes of the immune surveillance of tumours, and the events that modulate the development and the accumulation of somatic mutations and genomic instability. DNA damage, growth and angiogenic factors, proteases, matrix metalloproteinases, and reactive oxygen species were also related to the chronic stress response and depression. Behavioural strategies, psychological, and psychopharmacotherapeutic interventions that enhance effective coping and reduce affective distress showed beneficial effects in cancer patients. A better understanding of the bidirectional communication between the neuroendocrine and immune systems could contribute to novel clinical and treatment strategies in oncology.

Implementing a comprehensive approach to the study of health dynamics using the psychoneuroimmunology paradigm

This article addresses psychoneuroimmunology (PNI) as an integrative paradigm for advancing both theoretical and empirical knowledge of physiological patterns that contribute to the dynamics of health. We depict relationships among relevant psychobehavioral and physiological components in a PNI-based framework. We then provide examples of how this framework guided 2 clinical trials designed to assess the effectiveness of selected nursing interventions to reduce stress and enhance coping, one in persons with human immunodeficiency viral disease and the other in persons with cancer. The examples address disease-specific measures for assessing the components of the PNI-based framework.

Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part II: Immunologic effects

PURPOSE

Cross-sectional studies suggest that clinical insomnia is associated with immune downregulation. However, there is a definite need for experimental studies on this question. The goal of this randomized controlled study was to assess the effect of an 8-week cognitive-behavioral therapy (CBT) for chronic insomnia on immune functioning of breast cancer survivors. Previous analyses of this study showed that CBT was associated with improved sleep and quality of life, and reduced psychological distress.

PATIENTS AND METHODS

Fifty-seven women with chronic insomnia secondary to breast cancer were randomly assigned to CBT (n = 27) or to a waiting-list control condition (WLC; n = 30). Peripheral-blood samples were taken at baseline and post-treatment (and postwaiting for WLC patients), as well as at 3-, 6-, and 12-month follow-up for immune measures, including enumeration of blood cell counts (ie, WBCs, monocytes, lymphocytes, CD3+, CD4+, CD8+, and CD16+/CD56+) and cytokine production (ie, interleukin-1-beta [IL-1beta] and interferon gamma [IFN-gamma]).

RESULTS

Patients treated with CBT had higher secretion of IFN-gamma and lower increase of lymphocytes at post-treatment compared with control patients. Pooled data from both treated groups indicated significantly increased levels of IFN-gamma and IL-1beta from pre- to post-treatment. In addition, significant changes in WBCs, lymphocytes, and IFN-gamma were found at follow-up compared with post-treatment.

CONCLUSION

This study provides some support to the hypothesis of a causal relationship between clinical insomnia and immune functioning. Future studies are needed to investigate the clinical impact of such immune alterations.

Explaining disproportionately high rates of adverse birth outcomes among African Americans: the impact of stress, racism, and related factors in pregnancy

Compared with European Americans, African American infants experience disproportionately high rates of low birth weight and preterm delivery and are more than twice as likely to die during their 1st year of life. The authors examine 5 explanations for these differences in rates of adverse birth outcomes: (a) ethnic differences in health behaviors and socioeconomic status; (b) higher levels of stress in African American women; (c) greater susceptibility to stress in African Americans; (d) the impact of racism acting either as a contributor to stress or as a factor that exacerbates stress effects; and (e) ethnic differences in stress-related neuroendocrine, vascular, and immunological processes. The review of literature indicates that each explanation has some merit, although none is sufficient to explain ethnic disparities in adverse birth outcomes. There is a lack of studies examining the impact of such factors jointly and interactively. Recommendations and cautions for future research are offered.

Biomarkers to assess potential developmental immunotoxicity in children

Clinical tests are readily available for assessing severe loss of immune function in children with diseases such as AIDS or primary immunodeficiency. However tests that could reliably identify subtle immune changes, as might be expected to result from exposure to developmental immunotoxic agents, are not readily available. A number of tests are described which we believe have potential applicability for epidemiological studies involving developmental immunotoxicity. Several of the tests, such as T cell receptor rearrangement excision circles (TRECs) and cytokine measurements, while highly relevant from a biological standpoint, may be precluded from use at the current time, for either technical issues or insufficient validation. Immunophenotyping and measurement of serum immunoglobulin levels, on the other hand, are well validated. Yet they may require extraordinary care in experimental design and technical performance in order to obtain data that would consistently detect subtle changes, as these tests are not generally considered highly sensitive. Quantification of the immune response to childhood vaccine, while up to the present used sparingly, may represent an excellent indicator for developmental immunotoxicity when conducted under appropriate conditions.

Ethnic Variation in the Impact of Emotion and Emotion Regulation on Health: A Replication and Extension

Although emotions and patterns of emotion regulation are central to models linking personality and health, the generalizability of these models to diverse populations of older adults remains untested. In this study, 1,364 community-dwelling women (aged 50-70 years) from six ethnic groups completed self-report measures of trait anger, inhibition, defensiveness, and health. As expected, reports of trait anger and emotion inhibition predicted poorer health (and defensiveness better health), even when demographics and health behaviors were controlled. However, these characteristics related to outcome differently across ethnic groups; greater anger was related to better health in all groups other than U.S-born European Americans, and increased emotion inhibition was associated with better health among immigrant Eastern European women. Results are discussed within a contextualistic model of emotions and health, and directions for future research are given.

Social context in gene-environment interactions: retrospect and prospect

While many behavioral scientists believe that gene-environment (GE) interactions play an important and perhaps pervasive role in human development and aging, little attention has been devoted to a fundamental conceptual issue: What is it about social context that could alter gene expression? We draw on existing examples of GE interactions to formulate a typology that identifies a set of generic mechanisms by which E moderates G. Empirical studies suggest four ideal types: Social context can trigger a genetic diathesis, compensate for a genetic diathesis, act as a control to prevent behaviors for which there is a genetic predisposition, and enhance adaptation through proximal processes. This typology highlights several problems, however, with prior empirical research, which may explain, in part, why so few GE interactions have actually been observed. These problems include inattention to the dynamic nature of social experience, the manifold, often-intercorrelated dimensions of social context ("EE interactions"), mediators that link social context and the genotype, and analytic models that examine GE interactions as processes that characterize individual development. In turn, these insights call for the integration of life course sociology and behavioral genetics to foster ways of studying genes, context, and aging.

Cognitive behavioral stress management effects on mood, social support, and a marker of antiviral immunity are maintained up to 1 year in HIV-infected gay men

Numerous herpesvirus infections are associated with clinically relevant outcomes as well as an accelerated HIV replication rate and subsequent disease progression. Stress management interventions may improve markers of cellular immune control over latent herpesvirus infections and these changes appear to be mediated by perceptions of increased social support availability. We examined the effects of a group-based cognitive behavioral stress management (CBSM) intervention on distress, dysphoria, perceived social support, and herpesvirus immunoglobulin G (IgG) antibody titers during the 6 to 12 months following the intervention. Of those who were initially randomized, 49 HIV-infected men were followed during the 6- to 12-month period after randomization to either a 10-week CBSM intervention (n = 31) or a modified wait-list control condition (n = 18). Measures of distress, dysphoria, social support, and blood samples for herpesvirus IgG titers were taken at baseline, immediately following CBSM and at 6- to 12-month follow-up. Men in CBSM displayed maintenance of previously observed intervention effects on dysphoria, reliable alliance support, and herpesvirus IgG antibody titers (i.e., Epstein-Barr virus capsid antigen; EBV-VCA). Intervention-related changes in EBV-VCA were unrelated to changes in lymphocyte subsets (i.e., CD4+, CD8+, and CD4+:CD8+) or changes in measures of dysphoria and social support during the investigation period. Data indicate that HIV-infected men participating in a CBSM intervention maintain better psychosocial status and immunologic control of latent EBV infection up to 1 year after its conclusion.

Stress, depression, the immune system, and cancer

The links between the psychological and physiological features of cancer risk and progression have been studied through psychoneuroimmunology. The persistent activation of the hypothalamic-pituitary-adrenal (HPA) axis in the chronic stress response and in depression probably impairs the immune response and contributes to the development and progression of some types of cancer. Here, we overview the evidence that various cellular and molecular immunological factors are compromised in chronic stress and depression and discuss the clinical implications of these factors in the initiation and progression of cancer. The consecutive stages of the multistep immune reactions are either inhibited or enhanced as a result of previous or parallel stress experiences, depending on the type and intensity of the stressor and on the animal species, strain, sex, or age. In general, both stressors and depression are associated with the decreased cytotoxic T-cell and natural-killer-cell activities that affect processes such as immune surveillance of tumours, and with the events that modulate development and accumulation of somatic mutations and genomic instability. A better understanding of the bidirectional communication between the neuroendocrine and immune systems could contribute to new clinical and treatment strategies.

Neuroendocrine mechanisms of immune dysregulation: applications to allergy and asthma

OBJECTIVE

To review the current information and hypotheses related to the underlying mechanisms that link psychological stress and asthma activity via a neuroimmune network dysfunction that may manifest as increased morbidity of immune diseases, such as asthma.

DATA SOURCES

Literature searches of MEDLINE for published human and animal studies and review articles published in English-language periodicals. Keywords searched included individual and various combinations of psychoneuroimmunology, neuroimmune, neuroimmunology, stress, immunity, allergy, asthma, and inflammation. Both review articles and specific hypothesis-driven articles that focused on immune effects of stress were included. Manuscripts that focused on animal studies were excluded from this review.

STUDY SELECTION

Representative studies that reflect the consensus of the field based on the expert opinion of the author.

RESULTS

This article demonstrates the established relationships between the neuroendocrine and immune systems and the impact of both acute and chronic psychological stress on neuroendocrine and immune network function. The adverse impact of stress appears to occur more on immune dysregulation rather than immune suppression.

CONCLUSION

Psychological stress, allergy and asthma morbidity, and allergy and asthma incidence are all steadily increasing in our society. Establishing a firm relationship can provide a possible new therapeutic direction for evaluation and management of difficult-to-treat patients and possible prophylactic strategies in susceptible populations.

Psychological, behavioral, and immune changes after a psychological intervention: a clinical trial

PURPOSE

This randomized clinical trial tests the hypothesis that a psychological intervention can reduce emotional distress, improve health behaviors and dose-intensity, and enhance immune responses.

PATIENTS AND METHODS

We studied 227 women who were surgically treated for regional breast cancer. Before adjuvant therapy, women completed interviews and questionnaires assessing emotional distress, social adjustment, and health behaviors. A 60-mL blood sample was drawn for immune assays. Patients were randomly assigned to either the intervention group or assessment only group. The intervention was conducted in small patient groups, with one session per week for 4 months. The sessions included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care. Reassessment occurred after completion of the intervention.

RESULTS

As predicted, patients receiving the intervention showed significant lowering of anxiety, improvements in perceived social support, improved dietary habits, and reduction in smoking (all P <.05). Analyses of adjuvant chemotherapy dose-intensity revealed significantly more variability (ie, more dispersion in the dose-intensity values) for the assessment arm (P <.05). Immune responses for the intervention patients paralleled their psychological and behavioral improvements. T-cell proliferation in response to phytohemagglutinin and concanavalin A remained stable or increased for the Intervention patients, whereas both responses declined for Assessment patients; this effect was replicated across three concentrations for each assay (all P <.01).

CONCLUSION

These data show a convergence of significant psychological, health behavior, and biologic effects after a psychological intervention for cancer patients.

Comprehensive Therapeutic Benefits of Taiji

This literature review offers physical rehabilitation professionals an update on the current breadth and strength of research evidence regarding comprehensive therapeutic benefits of Taiji practice. A critical analysis distinguishes between what is known from controlled clinical research and what is suggested in preliminary research. Of >200 published reports examined, 17 controlled clinical trials were judged to meet a high standard of methodological rigor. Controlled research evidence was found to confirm therapeutic benefits of Taiji practice with regard to improving quality of life, physical function including activity tolerance and cardiovascular function, pain management, balance and risk of falls reduction, enhancing immune response, and improving flexibility, strength, and kinesthetic sense. Preliminary research on implementation feasibility of Taiji programming exists for a variety of clinical populations. Further controlled clinical study is justified for a wide variety of clinical contexts.

Social facilitation of wound healing

It is well documented that psychological stress impairs wound healing in humans and rodents. However, most research effort into influences on wound healing has focused on factors that compromise, rather than promote, healing. In the present study, we determined if positive social interaction, which influences hypothalamic-pituitary-adrenal (HPA) axis activity in social rodents, promotes wound healing. Siberian hamsters received a cutaneous wound and then were exposed to immobilization stress. Stress increased cortisol concentrations and impaired wound healing in isolated, but not socially housed, hamsters. Removal of endogenous cortisol via adrenalectomy eliminated the effects of stress on wound healing in isolated hamsters. Treatment of isolated hamsters with oxytocin (OT), a hormone released during social contact and associated with social bonding, also blocked stress-induced increases in cortisol concentrations and facilitated wound healing. In contrast, treating socially housed hamsters with an OT antagonist delayed wound healing. Taken together, these data suggest that social interactions buffer against stress and promote wound healing through a mechanism that involves OT-induced suppression of the HPA axis. The data imply that social isolation impairs wound healing, whereas OT treatment may ameliorate some effects of social isolation on health.

Alternative modalities for asthma that reduce stress and modify mood states: evidence for underlying psychobiologic mechanisms

OBJECTIVE

To review the evidence supporting a role for psychological interventions in the treatment of asthma, with particular emphasis on underlying psychobiological mechanisms.

DATA SOURCES

Independent literature searches on MEDLINE, PREMEDLINE, Cochrane Library, and PSYCHINFO from their respective inception to 2003 were performed. Separate searches were performed for psychological stress and asthma, psychoneuroimmunology and asthma, stress management, relaxation, asthma, complementary and alternative medicine and asthma, and immune function and psychological intervention. The search was not limited based on language of publication.

STUDY SELECTION

Supportive evidence from overlapping research was included based on the expert opinion of the author and through discussions with consultants in the field.

RESULTS

This review first discusses human and animal studies focused on psychological stress and the effects of stress on the neuroendocrine and immune system, emphasizing the implication of these effects on asthma. Second, studies that evaluated the influence of stress reduction modalities on neuroendocrine and immune function were examined. Existing evidence from human clinical studies that explored the role of psychological interventions for asthma is reexamined in this context.

CONCLUSIONS

A growing appreciation of the interactions among behavioral, neural, endocrine, and immune processes suggests possible mechanisms through which psychological interventions for asthma may be operating. This review provides a framework in which we can begin to see links among these systems that might provide new insights to guide future explorations.

Potential psychosocial mechanisms linking depression to immune function in elderly subjects

Although depression and immune changes in elderly subjects constitute a considerable health risk, mechanisms underlying the association between depression and immune function are unclear. The question of whether personality and social support can explain the variation in immune function during depression was addressed in 21 elderly depressive and 23 control subjects. The following variables were studied: neuroticism, extraversion, received social support, depression-related immune parameters [i.e. numbers of lymphocytes, lymphocyte subsets CD3+, CD8+, natural killer-like T cells (NKT), CD4/CD8 ratio, and interleukin-6 (Il-6)]. We found that neuroticism reduced the association between depression and Il-6 (from 62 to 22.4%) and between depression and CD3+ (from 27.6 to 21.6%), and was also directly related to Il-6 (i.e. adjusted for age and depression). Social support reduced the association between depression and NKT cells from 25 to 18%, while it was also directly related to NKT cells. Extraversion, adjusted for age and depression, was negatively related to CD4/CD8 ratio. Subjects with high extraversion and high social support had more NKT cells. We concluded that changes in immune function during depression can partly be explained by neuroticism and received social support, whereas immune function is also directly related to these psychosocial variables. Neuroticism may exert its contribution to the risk for depression partly via Il-6 production.

Evolution of the biopsychosocial model: prospects and challenges for health psychology

Although advances have been made in specifying connections between biological, psychological, and social processes, the full potential of the biopsychosocial model for health psychology remains untapped. In this article, 4 areas that need to be addressed to ensure the continued evolution of the biopsychosocial model are identified and a series of recommendations concerning initiatives directed at research, training, practice and intervention, and policy are delineated. These recommendations emphasize the need to better understand and utilize linkages among biological, psychological, social, and macrocultural variables. Activities that facilitate the adoption of a multisystem, multilevel, and multivariate orientation among scientists, practitioners, and policymakers will most effectively lead to the kinds of transdisciplinary contributions envisioned by the biopsychosocial perspective.

Major life event -- diagnosis of schizophrenia in offspring and risk for cancer

The overall risk for cancer among 19856 parents of schizophrenic patients in Denmark was not increased; however, a 30% increased risk for lung cancer was observed in mothers (95% confidence interval, 1.03-1.61), suggesting an indirect effect on cancer risk mediated by life-style factors.

Psychosocial predictors of successful delivery after unexplained recurrent spontaneous abortions: a cohort study

OBJECTIVE

To examine psychosocial predictors of successful pregnancy after recurrent spontaneous abortions (RSA).

METHOD

We administered two waves of semi-structured interview and self-report questionnaire battery to a consecutive series of 46 couples who had had two RSAs (baseline before third pregnancy, and immediately after third pregnancy was ascertained), and followed them through their third pregnancy.

RESULTS

Of the 46 couples, four miscarried for karyotypal abnormalities and six without any known cause. When the latter six were compared with the remaining 36 women, they reported less social support satisfaction, a more stable attribution for the causes of past abortions, and more depressed mood in the preceding year. Taken altogether, this psychosocial model was able to predict 93% of the pregnancy outcomes correctly.

CONCLUSION

Psychosocial variables (depression, attribution and social support) are robust predictors of the prospective pregnancy and suggest possible points of intervention in couples with RSA.

Group interventions for patients with cancer and HIV disease: Part II. Effects on immune, endocrine, and disease outcomes at different phases of illness

There has been great interest in the potential impact of group interventions on medical outcomes. This article reviews the effects of professionally-led groups on immune activity, neuroendocrine function, and survival among patients with cancer or HIV disease. We examine findings concerning different types of group services at different phases of illness. Results are mixed, but the most prominent changes in immune and endocrine activity were associated with structured group interventions for patients with early-stage disease. These findings offer provocative illustrations of relevant mind-body interactions, but their clinical importance has yet to be demonstrated empirically. Group interventions have not been tied consistently to improved survival rates for patients with advanced cancer; few studies as yet have focused on survival outcomes among patients with early-stage cancer or HIV disease.

Are there sex differences in emotional and biological responses in spousal caregivers of patients with Alzheimer's disease?

The purpose of this study was to compare emotional and biological responses of men and women who are spousal caregivers of patients with Alzheimer's disease (AD). Quality-of-life measurements, bioinstrumentation data, and immunophenotype assessments were obtained from female and male spousal caregivers of patients with AD. Spousal caregivers (women, n = 45 with average age 69.7; men, n = 16 with average age 71.4 years) completed questionnaires that assessed psychosocial variables. Blood was drawn and lymphocyte subsets (including natural killer [NK] cell number) were determined using flow cytometry. The degree of relaxation was determined measuring muscle tension (EMG) in the frontalis and trapezius muscles, skin conductance, skin temperature, and heart rate. Male spousal caregivers, as compared to female spousal caregivers, had significantly lower levels of stress, depression, caregiver burden (subjective), anxiety, anger-hostility, and somatic symptoms and higher levels of mental health, sense of coherence, NK cell number, and social and physical functioning. There were no statistically significant differences between the 2 groups in social support, coping resources, or T, T suppressor, or activated T cells. Women had more T helper cells and fewer NK cells than men. Men had fewer manifestations of a physiological stress response, as indicated by bioinstrumentation parameters. Unique sex-specific issues need to be considered when strategies are implemented to assist the increasing number of caregivers as our society ages.

Illness perceptions in people with acute bacterial gastro-enteritis

Functional gastro-intestinal disorders (FGID) like irritable bowel syndrome (IBS) are common and can develop after gastro-enteritis. Illness representations may be important influences on the development of post-infectious FGIDs. Here, we studied both the relationship between prior chronic symptoms (FGIDs) and illness perception during an acute illness (bacterial gastro-enteritis) as well as the relationship between illness perception during an acute illness (bacterial gastro-enteritis) and the subsequent development of chronic abdominal symptoms. Two hundred and seventeen people with recent gastro-enteritis completed a questionnaire asking about gut symptoms consistent with a diagnosis of IBS, functional dyspepsia or functional diarrhoea and the Illness Perception Questionnaire. Those without a prior FGID were followed up and completed a similar gut questionnaire at six months. People with a prior FGID had significantly more symptoms and scored significantly higher on the timeline and consequence scores than those without. People who developed a FGID had a non-significantly higher number of symptoms and higher consequence and timeline scores than those who did not. Neither comparative group differed in the control/cure scores or causation scores. The implications of the findings are discussed.

Associating changes in the immune system with clinical diseases for interpretation in risk assessment

This overview unit discusses the relationship between immunosuppression, a potential consequence of immunotoxicity, and disease progression. It also discusses other factors, such as stress and age, that affect disease susceptibility. These factors play an important role in risk assessment for exposures to environmental factors.

The physiology of marriage: pathways to health

Marriage is the central relationship for most adults and has beneficial effects for health. At the same time, troubled marriages have negative health consequences. This review outlines the physiological pathways through which marital relationships influence health based on a stress/social support model. In addition, we review recent findings suggesting that unhappy marriages are associated with morbidity and mortality. We then turn to studies of marital interaction that include assessment of physiological pathways through which marital functioning influences health: the cardiovascular, endocrine, and immune systems. Across these studies, negative and hostile behaviors during marital conflict discussions are related to elevations in cardiovascular activity, alterations in hormones related to stress, and dysregulation of immune function. Using recent conceptualizations of the physiological impact of chronic stress, we illustrate how physiological changes associated with marital functioning in these studies have long-term implications for health outcomes. Finally, we discuss future implications of current research for understanding the relationships among marital functioning, physiology, and health.

Mind matters: cognitive and physical effects of aging self-stereotypes

In the first part of this article, a wide range of research is drawn upon to describe the process by which aging stereotypes are internalized in younger individuals and then become self-stereotypes when individuals reach old age. The second part consists of a review of the author's cross-cultural, experimental, and longitudinal research that examines the cognitive and physical effects of aging self-stereotypes. The final section presents suggestions for future research relating to aging self-stereotypes.

Effects of an exercise intervention on immunologic parameters in frail elderly nursing home residents

BACKGROUND

Aging is associated with decline in both cell-mediated and humoral immunity and may contribute to increased incidence and severity of infections in frail elderly. Exercise, depending on intensity, has significant effects on the immune system. We conducted a randomized, controlled clinical trial of a 32-week functionally oriented exercise program in frail elderly living in nursing homes and determined whether the exercise intervention was associated with a change in immune parameters in this frail elderly nursing home population.

METHODS

Nursing home residents were randomly assigned to an intervention (n = 94) and control group (n = 96). The intervention consisted of a functionally oriented endurance and resistance exercise training that was provided every 2 hours from 8:00 AM to 4:00 PM for 5 days a week for 8 months. Lymphocyte subpopulations, including activation markers (CD28, CD25, HLA-DR), in vitro proliferation, and soluble products of cytokine activity (neopterin and sTNF-RII) in serum were measured by taking blood samples at baseline and after 8 weeks and 32 weeks of the intervention.

RESULTS

Exercise training did not induce changes in lymphocyte subpopulations, activation markers (CD28, CD25, HLA-DR), in vitro proliferation, and soluble products of cytokine activity (neopterin and sTNF-RII) in serum.

CONCLUSIONS

A 32-week exercise intervention did not bring about beneficial or detrimental effects on immune parameters in the frail elderly nursing home population and may explain why the intervention was not associated with a change in the incidence of infections in the intervention group compared with the control group.

Stress, leukocyte trafficking, and the augmentation of skin immune function

Delayed type hypersensitivity (DTH) reactions represent cell-mediated immune responses that exert important immunoprotective (resistance to viruses, bacteria, and fungi) or immunopathologic (allergic or autoimmune hypersensitivity) effects. We have used the skin DTH response as an in vivo model to study neuro-endocrine-immune interactions. We hypothesized that just as an acute stress response prepares the cardiovascular and musculoskeletal systems for fight or flight, it may also prepare the immune system for challenges (e.g., wounding) that may be imposed by a stressor (e.g., an aggressor). Studies showed that acute (2 hours) stress experienced before primary or secondary cutaneous antigen exposure induces significantly enhanced skin DTH. This enhancement involves innate as well as adaptive immune mechanisms. Adrenalectomy eliminates the stress-induced enhancement of DTH. Acute administration of physiological concentrations of corticosterone and/or epinephrine to adrenalectomized animals enhances skin DTH. Compared with those in controls, DTH sites from acutely stressed or hormone-injected animals show significantly greater erythema and induration, numbers of infiltrating leukocytes, and levels of cytokine gene expression. In contrast to acute stress, chronic stress is immunosuppressive. Chronic exposure to corticosterone or acute exposure to dexamethasone significantly suppresses skin DTH. These results suggest that during acute stress, endogenous stress hormones enhance skin immunity by increasing leukocyte trafficking and cytokine gene expression at the site of antigen entry. Elucidation of mechanisms mediating a stress-induced enhancement of skin immune function is important because such immunoenhancement can have protective (wound healing, resistance to infection) or pathological (allergic or autoimmune hypersensitivity) consequences.

The psychology of isolated and confined environments. Understanding human behavior in Antarctica

Psychosocial adaptation to isolated and confined environments exhibits 4 distinct characteristics. First, it is seasonal: Variations in mood are associated with the altered diurnal cycle and psychological segmentation of the mission. Second, it is situational: Concurrent measures of personality, interpersonal needs, and coping styles are better predictors of mood and performance than are predeployment measures. Third, it is social: Members of expeditions with low social coherence report significantly more depression, anxiety, and anger than individuals belonging to expeditions with high social coherence. Fourth, it is salutogenic: Depressed mood is inversely associated with the severity of the physical environment of the station, and the winter-over experience is associated with reduced subsequent rates of hospital admissions, suggesting positive benefits for individuals seeking challenging experiences.

Behavioral medicine and clinical health psychology: introduction to the special issue, a view from the decade of behavior

This collection of articles follows prior special issues on behavioral medicine published in the Journal of Consulting and Clinical Psychology in 1982 and 1992. From the vantage point of the Decade of Behavior, the field has grown in scope, depth of basic science foundations, and evidence of applied utility. Yet many challenges remain-especially in addressing a wide range of health problems across diverse populations and in a health care context characterized by rapid changes in technology and by a growing concern with costs and evidence-based practice.

Behavioral medicine: 2002 and beyond

This article highlights future directions for research and practice in behavioral medicine. Topics addressed include social and environmental issues, the role of technology, translational research, improving and developing interventions, and professional training and retraining.