A healthy mix of emotions: underlying biological pathways linking emotions to physical health

Interparental Positivity Spillover Theory: How Parents' Positive Relational Interactions Influence Children

Interparental interactions have an important influence on child well-being and development. Yet prior theory and research have primarily focused on interparental conflict as contributing to child maladjustment, which leaves out the critical question of how interparental positive interactions-such as expressed gratitude, capitalization, and shared laughter-may benefit child growth and development. In this article, we integrate theory and research in family, relationship, and affective science to propose a new framework for understanding how the heretofore underexamined positive interparental interactions influence children: interparental positivity spillover theory (IPST). IPST proposes that, distinct from the influence of conflict, interparental positive interactions spill over into children's experiences in the form of their (a) experience of positive emotions, (b) beneficially altered perceptions of their parents, and (c) emulation of their parents' positive interpersonal behaviors. This spillover is theorized to promote beneficial cognitive, behavioral, social, and physiological outcomes in children in the short term (i.e., immediately after a specific episode of interparental positivity, or on a given day) as well as cumulatively across time. As a framework, IPST generates a host of novel and testable predictions to guide future research, all of which have important implications for the mental health, well-being, and positive development of children and families.

Examining Relationships between Cognitive Flexibility, Exercise Perceptions, and Cardiovascular Disease Risk Factors

Adults do not engage in enough physical activity. Investigating cognitive and physiological factors related to improving this behavior-and reducing health risks-remains a public health priority. Our objective was to assess whether cognitive flexibility influenced perceptions and choice of exercise programs and whether flexibility was associated with cardiovascular disease (CVD) risk factors. Independent sample groups of college-aged adults (18-24 yrs) participated in two studies. Data were collected on individuals' degree of cognitive flexibility (both self-reported and objectively measured), perceptions and choice of exercise programs, and health status markers known to be associated with CVD (vascular function, muscular strength, and body composition). Vascular function was assessed with a near-infrared spectroscopy device, strength was defined as handgrip, and body composition was estimated via digital circumferences. Self-reported flexibility reliably predicted individuals' choice of exercise program and perceptions of effort required for success on an exercise program. The relationships among CVD risk factors and objectively measured cognitive flexibility were not significant, demonstrating that identifying a healthy individual's degree of performance-based cognitive flexibility does not predict health status. Furthermore, although greater self-reported trait flexibility (rigidity) is known to predict higher (lower) likelihood of physical activity, this finding should not be extrapolated to also assume that flexibility (rigidity), as measured by objective cognitive tests, is associated with reduced CVD risk in healthy adults. We posit a rationale for how understanding cognitive flexibility and rigidity can play an impactful role in improving adherence to exercise prescriptions targeted to reducing risks.

Association Between Distress at Diagnosis and Disease-free Survival Among Patients With Resectable Colon Cancer: A Large Cohort Study

OBJECTIVE

This study aimed to evaluate the association between distress at initial diagnosis and disease-free survival in patients with resectable colon cancer.

SUMMARY BACKGROUND DATA

Considerable research has examined the psychological impact of having a confirmed diagnosis of cancer, but relatively limited research has examined the impact of distress during the diagnostic phase on oncological outcomes.

METHODS

This is a retrospective cohort study. We included newly diagnosed colon cancer patients who had resectable surgery and underwent distress screening between July 2014 and July 2021 (N=1,362). The Korean versions of the Distress Thermometer were used to assess distress and related problems. Patients were categorized into 3 groups based on distress score: low (<4), moderate (4-7), and severe (≥8). The primary outcome was disease-free survival.

RESULTS

The mean distress was 5.1 (SD=2.4) and 61%, and 15% of patients had moderate and severe distress at diagnosis, respectively. The severe distress group was more likely to report fear, sadness, and concerns regarding insurance/finance, work, and childcare than the low distress group. Compared with the low distress group, the severe distress group had worse disease-free survival (Hazard Ratio=1.84, 95% CI=1.03, 3.29). The association was more evident in patients with stage IV disease (Hazard Ratio=2.53, 95% CI=1.02, 6.25).

CONCLUSIONS

A substantial number of patients with colon cancer experience distress at diagnosis, and severe distress has a negative impact on oncologic outcomes. Active monitoring and appropriate management of distress at diagnosis should be adopted at clinical settings.

Insight into the causality between basal metabolic rate and endometrial and ovarian cancers: Analysis utilizing systematic Mendelian randomization and genetic association data from over 331,000 UK biobank participants

BACKGROUND

Observational studies have demonstrated that basal metabolic rate (BMR) is associated with the risk of endometrial cancer (EC) and ovarian cancer (OC). However, it is unclear whether these associations reflect a causal relationship.

OBJECTIVE

To reveal the causality between BMR and EC and OC, we performed the first comprehensive two-sample Mendelian randomization (MR) analyses.

METHODS

Genetic variants were used as proxies of BMR. GWAS summary statistics of BMR, EC and OC were obtained from the UK Biobank Consortium, Endometrial Cancer Association Consortium and Ovarian Cancer Association Consortium respectively. The inverse variance weighted method was employed as the main approach for MR analysis. A series of sensitivity analyses were implemented to validate the robustness and reliability of the results.

RESULTS

BMR was significantly related to an increased risk of EC (OR_SD  = 1.49; 95% CI: 1.29-1.72; p-Value < .001) and OC (OR_SD  = 1.21; 95% CI: 1.08-1.35; p-Value < .001). Furthermore, the stratified analysis indicated that BMR was positively associated with endometrioid endometrial cancer (EEC) (OR_SD  = 1.45; 95% CI, 1.23-1.70; p-Value < .001), clear cell ovarian cancer(CCOC) (OR_SD  = 1.89; 95% CI:1.35-2.64; p-Value < .001) and endometrioid ovarian cancer risk (EOC) (OR_SD  = 1.45; 95% CI: 1.12-1.88; p-Value = .005). However, there were no significant associations of BMR with invasive mucinous ovarian cancer (IMOC), high-grade serous ovarian cancer (HGSOC) and low-grade serous ovarian cancer (LGSOC). The robustness of the above results was further verified in sensitivity analyses.

CONCLUSION

The MR study provided etiological evidence for the positive association of BMR with the risk of EC, EEC, OC, CCOC and EOC. But this study did not provide enough evidence suggesting the causal associations of BMR with IMOC, HGSOC and LGSOC.

Are coping strategies and variability in their use associated with lifespan?

OBJECTIVES

Some stress-related coping strategies contribute to survival among medical populations, but it is unclear if they relate to longevity in the general population. While coping strategies are characterized as being adaptive or maladaptive, whether capacity to tailor their implementation to different contexts (i.e., flexibility of use) may influence lifespan is unknown.

METHOD

In 2004-2006, participants from the Midlife Development in the United States study completed a validated coping inventory including 6 strategies and provided information on sociodemographics, health status, and biobehavioral factors (N = 4398). Deaths were ascertained from death registries with follow-up until 2018. Accelerated failure time models estimated percent changes and 95% confidence intervals (CI) in predicted lifespan associated with use of individual coping strategies. As a proxy for flexibility, participants were also classified as having lower, moderate, or greater variability in strategies used, using a standard deviation-based algorithm.

RESULTS

After controlling for sociodemographics and health status, maladaptive strategies (e.g., per 1-SD increase in Denial = -5.50, 95%CI = -10.50, -0.21) but not adaptive strategies (e.g., Planning) were related to shorter lifespan. Greater versus moderate variability levels were related to a 15% shorter lifespan. Estimates were somewhat attenuated when further controlling for lifestyle factors.

CONCLUSION

Although most associations were of modest magnitude, use of some maladaptive coping strategies appeared related to shorter lifespan. Compared to moderate levels, greater coping variability levels were also clearly detrimental for lifespan. Although adaptive strategies were unrelated to longevity, future work should examine other favorable strategies (e.g., acceptance) and more direct measures of flexibility (e.g., experience sampling methods).

Unraveling the Relationship between Sleep Problems, Emotional Behavior Disorders, and Stressful Life Events in Preschool Children

Objectives: The aims of this study were to: (1) explore sleep problems in preschool children with generalized anxiety disorder (GAD), selective mutism (SM), and oppositional defiant disorder (ODD) and (2) examine the relationship between stressful life events, sleep problems, and emotional behavior disorders in preschoolers. Methods: The parents of 213 preschool children with SM, GAD, ODD, and TD (typical development, age range 2–6 years) completed the Children’s Sleep Habits Questionnaire (CSHQ), the Coddington Life Events Scale, preschool version (CLES-P), and the CBCL 1½–5. Results: Eighty-three subjects reported sleep problems before the age of 2 years. Seventy-five children (86.14%) with a clinical diagnosis and eight children with TD (8.4%) exceeded the threshold level on the CSHQ. For the bedtime resistance (p = 0.042) and sleep duration subscales (p = 0.038), the SM group had significantly higher scores in comparison to the ODD group. The same pattern was also true for the sleep onset (p = 0.024) and sleep anxiety subscales (p = 0.019). The linear regression analysis model showed that the impact of stressful life events and internalizing problems could predict sleep habits in children. Conclusions: Emotional behavior disorders and stress factors should be regularly investigated in children who are referred to clinics for sleep problems. Clinicians should consider how these symptoms may exacerbate sleep problems and/or interfere with treatment.

Noncausal effects of genetic predicted depression and colorectal cancer risk: A Mendelian randomization study

Depression has been associated with colorectal cancer (CRC) in observational studies. However, the causality of depression on CRC risk remained unknown. This study aimed to evaluate the potential causal association between genetic variants related to depression and the risk of CRC using Mendelian randomization (MR). Two-sample MR analysis using summary data was performed to examine whether depression was causally associated with CRC risk. We used 2 sets of instrumental variables (IV) from the genome-wide association study results for analysis. A set of IV related to major depressive disorder contain 44 single-nucleotide polymorphisms. Another set of IV was related to major depression, including 53 single-nucleotide polymorphisms. Summary data of CRC was from the FinnGen consortium. Based on the results of MR using inverse-variance weighted method, we found that genetically determined major depressive disorder (odds ratio = 1.06, 95% confidence interval = 0.77-1.45) or major depression (odds ratio = 0.77, 95% confidence interval = 0.57-1.04) did not causally increase CRC risk. The results of MR-Egger and the weighted median method are consistent with the inverse-variance weighted method. The two-sample MR analysis showed that depression is not causally associated with CRC risk. Further research is needed to investigate the association between depression and CRC.

A bidirectional Mendelian randomization study supports the causal effects of a high basal metabolic rate on colorectal cancer risk

Purpose

We conducted a bidirectional two-sample Mendelian randomization (MR) study to determine whether genetically predicted basal metabolic rate (BMR) was a causal risk factor for colorectal cancer (CRC) or whether a genetically predicted CRC risk can influence the BMR level (i.e., reverse causation).

Methods

We employed 1,040 genetic variants as proxies for BMR to obtain effect estimates on CRC risk. Another 58 CRC-associated variants were used to estimate effects on BMR levels. Stratified analysis by tumor site was used to examine the causal associations between BMR and colon/rectal cancer risk.

Results

The inverse variance weighted (IVW) method indicated a significant causal effect of genetically determined BMR on CRC risk (OR_SD = 1.27, 95% CI = 1.07–1.51). No significant reverse causal association was identified between genetically increased CRC risk and BMR levels [IVW (β = 0, 95% CI = -0.01 to 0)]. The results of MR-Egger and the weighted median method were consistent with the IVW method. Stratified analysis by CRC sites identified significant causal associations between BMR and colon cancer [IVW (OR_SD = 1.45, 95% CI = 1.16-1-80)], and null evidence of a causal association between BMR and rectal cancer risk was found (p > 0.05).

Conclusion

Our findings add to the current literature by validating a positive relationship between high BMR levels and CRC risk instead of reverse causality. The genetically predicted BMR level was causally associated with colon cancer risk but not rectal cancer risk.

Physicians, emotion, and the clinical encounter: A survey of physicians' experiences

OBJECTIVES

Training in emotion management is not a standard part of medical education. This study's objective was to understand physicians' challenges navigating emotion (their own and their patients') and identify areas for intervention to support physician wellness and enhance patient care.

METHODS

In 2019, we surveyed 103 physicians in emergency medicine, internal medicine, family medicine, and neurology. Participants quantitatively reported emotion training, emotions that were challenging, and barriers to addressing emotion. They provided qualitative examples of emotion challenges and successes that we analyzed using an inductive thematic analysis.

RESULTS

There were no significant differences in responses by specialty. Only 10% reported receiving emotion management training, with no evidence that more recently trained physicians received more. Those who had received training on emotion reported greater comfort in dealing with patients' emotions and were more likely to engage in teaching on emotion. There were gender and career stage differences regarding which emotions physicians found most challenging. The authors identified central themes of emotion-related challenges and successes.

CONCLUSIONS

Targeted educational initiatives are needed to advance physicians' ability to navigate emotion in clinical encounters.

PRACTICE IMPLICATIONS

Developing strategies for managing patients' emotions may better prepare physicians for navigating the emotional demands of practicing medicine.

An Empirical Study on the Evaluation of Emotional Complexity in Daily Life

Emotional complexity means diversity, universality, and differentiation of individual emotions. This research consisted of two studies to demonstrate the constitution of the emotional complexity. In Study 1, the participants were asked to use 10 emotional words to record the variation of emotions over 30 days in daily life. In Study 2, the experimental materials were enriched. The participants were required to note the emotions with the Positive and Negative Affect Schedule in a 3-day holiday—all the individuals in the two studies needed to record the most important emotional event. As a result, the youth experienced complex emotions every day. Emotional complexity indicators included covariation index (r), component index (C_pc and C_unshared), granularity index (G_e, G_p, and G_n), and variability index (V_p and V_n). A four-factor model reflected a good model fit, with 𝜒²/df = 0.33, CFI = 1.00, TLI = 1.03, RMSEA = 0.000 (0.00, 0.20), SRMR = 0.003, including positive differentiation, covariation of positive affect and negative affect, negative differentiation, and emotional variation. These indicators may reflect the complex experiences in everyday life. The results shed light on the emotional experience that can change greatly within 1 day and on episodes of emotional disruption resulting from an important event coupled with excessive excitement or extreme tension.

Anxiety, Depression, and Colorectal Cancer Survival: Results from Two Prospective Cohorts

Given the unalterable nature of most risk factors for colorectal cancer (CRC) survival (e.g., disease stage), identifying modifiable determinants is critical. We investigated whether anxiety and depression were related to CRC survival using data from the Nurses' Health Study (NHS) and Health Professional Follow-up Study (HPFS). Participants who received a CRC diagnosis and provided information about anxiety (nNHS = 335; nHPFS = 232) and depression (nNHS = 893; nHPFS = 272) within 4 years of diagnosis were included. Cox regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) of overall mortality, while controlling for covariates (sociodemographics, cancer characteristics, and lifestyle factors). Pooled risk estimates were derived from fixed effects meta-analyses of the cohorts. Among 1732 CRC patients, 814 deaths occurred during the 28-year follow-up. Each 1 standard deviation increase in anxiety or depression symptoms was associated with a similar 16% higher mortality risk (anxiety: 95% CI = 1.05-1.29; depression: 95% CI = 1.07-1.26). Comparable results were observed across all sensitivity analyses (introducing a 1-year lag, restricting to CRC-related mortality, considering potential behavioral pathways) and stratified models (cancer stage, sex). Our findings suggest greater anxiety and depression symptoms can not only impede adherence to healthy habits and reduce quality of life in cancer patients but could also be a marker for accelerated CRC progression.

Psychological well-being as part of the public health debate? Insight into dimensions, interventions, and policy

BACKGROUND

Increasing evidence suggests that psychological well-being (PWB) is associated with lower disease and mortality risk, and may be enhanced with relatively low-cost interventions. Yet, dissemination of these interventions remains limited, in part because insufficient attention has been paid to distinct PWB dimensions, which may impact physical health outcomes differently.

METHODS

This essay first reviews the empirical evidence regarding differential relationships between all-cause mortality and multiple dimensions of PWB (e.g., life purpose, mastery, positive affect, life satisfaction, optimism). Then, individual-level positive psychology interventions aimed at increasing PWB and tested in randomized-controlled trials are reviewed as these allow for easy implementation and potentially broad outreach to improve population well-being, in concert with efforts targeting other established social determinants of health.

RESULTS

Several PWB dimensions relate to mortality, with varying strength of evidence. Many of positive psychology trials indicate small-to-moderate improvements in PWB; rigorous institution-level interventions are comparatively few, but preliminary results suggest benefits as well. Examples of existing health policies geared towards the improvement of population well-being are also presented. Future avenues of well-being epidemiological and intervention research, as well as policy implications, are discussed.

CONCLUSIONS

Although research in the fields of behavioral and psychosomatic medicine, as well as health psychology have substantially contributed to the science of PWB, this body of work has been somewhat overlooked by the public health community. Yet, the growing interest in documenting well-being, in addition to examining its determinants and consequences at a population level may provoke a shift in perspective. To cultivate optimal well-being-mental, physical, social, and spiritual-consideration of a broader set of well-being measures, rigorous studies, and interventions that can be disseminated is critically needed.

Emotions in Social Relationships and Their Implications for Health and Disease: Introduction to the Special Issue of Psychosomatic Medicine

Social relationships and emotions are important to health and disease, but research in this area has largely progressed along parallel and distinct historical paths. These areas are critically linked because relationships are among the most powerful elicitors of health-relevant emotions and emotions can in turn influence relationships for better or worse. Conceptually, relationships and emotions can have mediational, reciprocal, and interactive influences on health outcomes, associations that seem dependent on the broader sociocultural context. The articles in this issue of Psychosomatic Medicine are based on a joint meeting of the American Psychosomatic Society and the Society for Affective Science titled "Emotions in social relationships: implications for health and disease." Recent research and conceptual models that fall at the interface of relationships, emotions, and health are highlighted in this special issue. Future work that capitalizes on these links will be critical if this area is to fulfill its potential in terms of new scientific insights and intervention opportunities.

Feedforward Neural Network-Based Architecture for Predicting Emotions from Speech

We propose a novel feedforward neural network (FFNN)-based speech emotion recognition system built on three layers: A base layer where a set of speech features are evaluated and classified; a middle layer where a speech matrix is built based on the classification scores computed in the base layer; a top layer where an FFNN- and a rule-based classifier are used to analyze the speech matrix and output the predicted emotion. The system offers 80.75% accuracy for predicting the six basic emotions and surpasses other state-of-the-art methods when tested on emotion-stimulated utterances. The method is robust and the fastest in the literature, computing a stable prediction in less than 78 s and proving attractive for replacing questionnaire-based methods and for real-time use. A set of correlations between several speech features (intensity contour, speech rate, pause rate, and short-time energy) and the evaluated emotions is determined, which enhances previous similar studies that have not analyzed these speech features. Using these correlations to improve the system leads to a 6% increase in accuracy. The proposed system can be used to improve human–computer interfaces, in computer-mediated education systems, for accident prevention, and for predicting mental disorders and physical diseases.

Coping, mood and health-related quality of life: a cross-sectional study in Chinese patients with advanced lung cancer

OBJECTIVES

The ways patients cope with advanced cancer can influence their health-related quality of life (HRQoL). This study aims to examine the mediating role of positive and negative mood in the relationship between coping and HRQoL in patients with advanced lung cancer.

METHODS

A consecutive sample of 261 patients (mean age: 59.99±9.53) diagnosed with stage III or IV lung cancer was recruited from the inpatient unit in a hospital that specialises in chest-related disease in Shanghai, China. Participants completed measurements including Medical Coping Modes Questionnaire, Positive and Negative Affect Schedule, and 5-level EuroQol 5-dimension instrument.

RESULTS

Although the total effects of confrontation on HRQoL were not significant, competing indirect effects via mood were identified: (1) positive indirect effects through positive mood were found for confrontation on mobility, usual activities, pain/discomfort and overall utility index (indirect effect=0.01, 95% CI 0.003 to 0.03); (2) negative indirect effects through negative mood were found for confrontation on mobility, pain/discomfort, anxiety/depression and overall utility index (indirect effect=-0.01, 95% CI -0.03 to -0.001). Resigned acceptance was negatively associated with HRQoL, and indirect effects via mood were identified: (1) negative indirect effects through positive mood were found for resigned acceptance on mobility, self-care, usual activities, pain/discomfort and overall utility index (indirect effect=-0.01, 95% CI -0.03 to -0.003); (2) negative indirect effects through negative mood were found for resigned acceptance on domains of HRQoL and overall utility index (indirect effect=-0.04, 95% CI -0.06 to -0.02).

CONCLUSIONS

Confronting advanced lung cancer can fuel ambivalent emotional experiences. Nevertheless, accepting the illness in a resigned way can be maladaptive for health outcomes. The findings suggest interventions that facilitate adaptive coping, reduce negative mood and enhance positive mood, as this could help to improve or maintain HRQoL in patients with advanced lung cancer.

The Mind-Body Study: study design and reproducibility and interrelationships of psychosocial factors in the Nurses' Health Study II

PURPOSE

Associations between psychosocial factors and biomarkers are increasingly investigated in studies of cancer incidence and mortality. Documenting optimal data/biospecimen collection protocols and scale properties are fundamental for elucidating the impact of psychosocial factors on biologic systems and ultimately cancer development/progression.

METHODS

Between 2013 and 2014, 233 Nurses' Health Study II women (mean age: 60.6) participated in the Mind-Body Study. Participants completed a detailed online psychosocial assessment and provided hair, toenail, timed saliva over 1 day, urine and fasting blood twice, 1 year apart. Additionally, two separate microbiome collections for stool and saliva were conducted between the psychosocial assessments. We assessed correlations between various psychosocial measures and evaluated their 1-year reproducibility using intraclass correlations (ICC).

RESULTS

Compliance with the protocols was high among participants. Psychosocial measures showed moderate-to-high reproducibility over 1 year (ICCs = 0.51-0.81). There was clear clustering of psychosocial factors according to whether they were querying positive (e.g., optimism, mastery, mindfulness) or negative (e.g., anxiety, depression, discrimination) emotion-related or social constructs.

CONCLUSION

Results suggest feasibility for self-administered collection of various biospecimens and moderate-to-high reproducibility of psychosocial factors. The Mind-Body Study provides a unique resource for assessing inter-relationships between psychosocial factors and biological processes linked with long-term health outcomes, including carcinogenesis.

Placing prostate cancer disparities within a psychosocial context: challenges and opportunities for future research

Black men are more likely to be diagnosed with prostate cancer compared with White men. Despite advances in prevention and treatment strategies, disparities in prostate cancer among Black men persist. While research on the causes of higher incidence and mortality is ongoing, there is limited evidence in the existing literature that clearly speaks to the potential psychological or social factors that may contribute to disparities in prostate cancer incidence. Given the lack of attention to this issue, we review scientific evidence of the ways in which social factors, including socioeconomic status and racial segregation, as well as psychological factors, like depression and anxiety, are related to subsequent prostate cancer risk, which could occur through behavioral and biological processes. Our objective is to illuminate psychosocial factors and their context, using a racial disparity lens, which suggests opportunities for future research on the determinants of prostate cancer. Ultimately, we aim to contribute to a robust research agenda for the development of new prostate cancer prevention measures to reduce racial disparities.

Emotional processes and stress in children affected by hereditary angioedema with C1-inhibitor deficiency: a multicenter, prospective study

Background

Hereditary angioedema with C1-inhibitor deficiency (C1-INH-HAE) is characterized by recurrent edema of unpredictable frequency and severity. Stress, anxiety, and low mood are among the triggering factors most frequently reported. Impaired regulation and processing of emotions, also known as alexithymia, may influence outcomes. The aim of this study was to confirm the presence of alexithymia and stress in children with C1-INH-HAE, to determine whether they are also present in children affected by other chronic diseases, and to investigate their relationship with C1-INH-HAE severity. Data from children with C1-INH-HAE (n = 28) from four reference centers in Italy were compared with data from children with type 1 diabetes (T1D; n = 23) and rheumatoid arthritis (RA; n = 25). Alexithymia was assessed using the Alexithymia Questionnaire for Children scale; perceived stress was assessed using the Coddington Life Event Scale for Children (CLES-C).

Results

Mean age (standard deviation [SD]) in the C1-INH-HAE, T1D, and RA groups was 11.8 (3.3), 11.7 (2.9), and 11.1 (2.6) years, respectively. Mean C1-INH-HAE severity score was 5.9 (2.1), indicating moderate disease. Alexithymia scores were similar among disease groups and suggestive of difficulties in identifying and describing emotions; CLES-C scores tended to be worse in C1-INH-HAE children. C1-INH-HAE severity was found to correlate significantly and positively with alexithymia (p = 0.046), but not with perceived stress. Alexithymia correlated positively with perceived stress.

Conclusions

Alexithymia is common in children with chronic diseases. In C1-INH-HAE, it may result in increased perceived stress and act as a trigger of edema attacks. Comprehensive management of C1-INH-HAE children should consider psychological factors.

Electronic supplementary material

The online version of this article (10.1186/s13023-018-0871-x) contains supplementary material, which is available to authorized users.