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Duquenne P, Samieri C, Chambaron S, Brindisi MC, Kesse-Guyot E, Galan P, Hercberg S, Touvier M, Léger D, Fezeu LK, Andreeva VA. Chronic insomnia, high trait anxiety and their comorbidity as risk factors for incident type 2 diabetes mellitus. Sci Rep 2024; 14:11927. [PMID: 38789594 PMCID: PMC11126668 DOI: 10.1038/s41598-024-62675-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/20/2024] [Indexed: 05/26/2024] Open
Abstract
The main objective of this study was to evaluate the association of the insomnia-anxiety comorbidity with incident type 2 diabetes (T2D) in a large prospective cohort. We selected adults without diabetes at baseline from the French NutriNet-Santé cohort who had completed the trait anxiety subscale of the Spielberger State-Trait Anxiety Inventory (STAI-T, 2013-2016) and a sleep questionnaire (2014); insomnia was defined according to established criteria. Using multivariable Cox models, we compared T2D risk across 4 groups: no insomnia or anxiety (reference), insomnia alone, anxiety alone (STAI-T ≥ 40), and comorbid anxiety and insomnia. Among 35,014 participants (mean baseline age: 52.4 ± 14.0 years; 76% women), 378 (1.1%) developed T2D over a mean follow-up of 5.9 ± 2.1 years. Overall, 28.5% of the sample had anxiety alone, 7.5%-insomnia alone, and 12.5%-both disorders. In the fully-adjusted model, a higher T2D risk was associated with anxiety-insomnia comorbidity (HR = 1.40; 95% CI 1.01, 1.94), but not with each disorder separately, compared to the group without insomnia or anxiety. The findings supported a positive association between anxiety-insomnia comorbidity and incident T2D among general-population adults. Future research using clinical diagnoses of mental disorders could confirm the findings and guide diabetes prevention programs.
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Affiliation(s)
- Pauline Duquenne
- INSERM, INRAE, CNAM, Center for Research in Epidemiology and Statistics (CRESS), Nutritional Epidemiology Research Team (EREN), SMBH, Sorbonne Paris Nord University and Paris Cité University, 74 Rue Marcel Cachin, 93017, Bobigny, France.
| | - Cécilia Samieri
- Bordeaux Population Health, INSERM U1219, University of Bordeaux, Bordeaux, France
| | - Stéphanie Chambaron
- Center for Taste and Feeding Behavior, CNRS, INRAE, Agro Dijon Institute, University of Burgundy, Dijon, France
| | - Marie-Claude Brindisi
- Center for Taste and Feeding Behavior, CNRS, INRAE, Agro Dijon Institute, University of Burgundy, Dijon, France
- University Hospital Center, Dijon, France
| | - Emmanuelle Kesse-Guyot
- INSERM, INRAE, CNAM, Center for Research in Epidemiology and Statistics (CRESS), Nutritional Epidemiology Research Team (EREN), SMBH, Sorbonne Paris Nord University and Paris Cité University, 74 Rue Marcel Cachin, 93017, Bobigny, France
| | - Pilar Galan
- INSERM, INRAE, CNAM, Center for Research in Epidemiology and Statistics (CRESS), Nutritional Epidemiology Research Team (EREN), SMBH, Sorbonne Paris Nord University and Paris Cité University, 74 Rue Marcel Cachin, 93017, Bobigny, France
| | - Serge Hercberg
- INSERM, INRAE, CNAM, Center for Research in Epidemiology and Statistics (CRESS), Nutritional Epidemiology Research Team (EREN), SMBH, Sorbonne Paris Nord University and Paris Cité University, 74 Rue Marcel Cachin, 93017, Bobigny, France
- Department of Public Health, AP-HP Paris Seine-Saint-Denis Hospital System, Bobigny, France
| | - Mathilde Touvier
- INSERM, INRAE, CNAM, Center for Research in Epidemiology and Statistics (CRESS), Nutritional Epidemiology Research Team (EREN), SMBH, Sorbonne Paris Nord University and Paris Cité University, 74 Rue Marcel Cachin, 93017, Bobigny, France
| | - Damien Léger
- Université Paris Cité, VIFASOM, APHP Hôtel-Dieu, Centre du Sommeil et de la Vigilance, Paris, France
| | - Léopold K Fezeu
- INSERM, INRAE, CNAM, Center for Research in Epidemiology and Statistics (CRESS), Nutritional Epidemiology Research Team (EREN), SMBH, Sorbonne Paris Nord University and Paris Cité University, 74 Rue Marcel Cachin, 93017, Bobigny, France
| | - Valentina A Andreeva
- INSERM, INRAE, CNAM, Center for Research in Epidemiology and Statistics (CRESS), Nutritional Epidemiology Research Team (EREN), SMBH, Sorbonne Paris Nord University and Paris Cité University, 74 Rue Marcel Cachin, 93017, Bobigny, France.
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.
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Kharwar S, Singh P. Investigating the Role of Anger and Cognitive Malfunction in Mental Health: A Cross-Sectional Exploration Paving the Way for a Subsequent Experiment. THE JOURNAL OF PSYCHOLOGY 2024:1-23. [PMID: 38564674 DOI: 10.1080/00223980.2024.2334289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
The functional outcomes associated with subjective well-being (SWB) and the detrimental aspects of psychological distress (PD) make it essential to explore contributing factors. The present study investigated a model about the existing gap in the determining role of trait anger (TA), state anger (SA), cognitive reappraisal (CR), rumination and cognitive failure (CF) as predictors of SWB and PD. The study contributes by exploring the interaction of dispositional, situation factors and emotional regulation strategies in shaping SWB and PD in the Indian Sample. A cross-sectional survey design was employed wherein 600 young adults aged 18-40 (Mage = 22.13, SDage = 4.06) were recruited from Uttar Pradesh, India using a multi-level cluster sampling method. The data were collected using questionnaires in the field setting during August-December 2021. Regression and path analysis revealed that the proposed predictors explained significant variance in SWB and PD, i.e., R2 = 0.24, F (5, 594) = 38.03, p < 0.01, Cohen f2 =0.31 and R2 = 0.35, F (5, 594) = 66.40, p < 0.01, Cohen f2 = 0.53, respectively. The models also fit well with the statistical indices. Except CR, all predictors emerged as significant risk factors. The findings suggest that the interventions to reduce PD and enhance SWB may consider inculcating CR and reducing higher levels of TA, SA, rumination and CF to enhance an individual's adaptive functioning. The findings pave the way for conducting a pre-planned experiment to study the outcomes of various levels of TA in regulating incidental anger (SA) employing CR and rumination.
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Apenyo T, Taveira TH, Wu WC. Hostility and prevalent diabetes among black adults: The Jackson Heart Study. Nutr Metab Cardiovasc Dis 2023; 33:770-777. [PMID: 36774203 DOI: 10.1016/j.numecd.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 12/11/2022] [Accepted: 01/17/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIMS The relationship between hostility and the prevalence of diabetes mellitus (DM) among black adults was investigated using the Jackson Heart Study (JHS) cohort. We hypothesized that Cook-Medley Hostility scores will be positively related with the prevalence of DM. METHODS AND RESULTS A total of 3232 black adults who completed at least one question for each of the three subscales of the Cook-Medley Hostility Scale and had data available regarding DM status were included. Using multivariate logistic regression, we studied the cross-sectional relationship between the overall Total Cook-Medley Hostility scores and individual subscales, hostile affect (n = 3232), aggression (n = 3119) and cynical distrust (n = 3085), with prevalent DM, adjusting for known DM confounders. Our population was 36% male with a mean age of 53.5 ± 0.9 years. In risk-factor adjusted models, each point higher in the overall Total Cook-Medley Hostility scores was associated with increased odds of having DM [Adjusted OR 1.02, 95%CI 1.00-1.04, P = 0.03]. Higher scores of cynicism were independently associated with prevalent DM [Adjusted OR 1.04, 95%CI 1.01-1.07, p = 0.021]. CONCLUSIONS There was a positive relationship between overall hostility levels and prevalent DM. Future studies should investigate the extent to which additional social determinants may impact the relationship between hostile affect and prevalent DM.
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Affiliation(s)
- Tsikata Apenyo
- Warren Alpert School of Medicine, Brown University, 222 Richmond St., Providence, RI 02903, USA.
| | - Tracey H Taveira
- Warren Alpert School of Medicine, Brown University, 222 Richmond St., Providence, RI 02903, USA; Veterans Affairs Medical Center, Center of Innovation for Long Term Services & Support, 830 Chalkstone Ave., Providence, RI 02908, USA; University of Rhode Island, College of Pharmacy, Avedisian Hall, 7 Greenhouse Rd., Kingston, RI 02881, USA.
| | - Wen-Chih Wu
- Warren Alpert School of Medicine, Brown University, 222 Richmond St., Providence, RI 02903, USA; Veterans Affairs Medical Center, Center of Innovation for Long Term Services & Support, 830 Chalkstone Ave., Providence, RI 02908, USA; University of Rhode Island, College of Pharmacy, Avedisian Hall, 7 Greenhouse Rd., Kingston, RI 02881, USA; Brown University School of Public Health, Department of Epidemiology, 121 South Main St., Providence, RI 02903, USA.
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Carlson SE, Smith TW, Williams PG, Parkhurst KA, Tinajero R, Goans C, Hirai M, Ruiz JM. Partialing Alters Interpersonal Correlates of Negative Affective Symptoms and Traits: A Circumplex Illustration. J Pers 2022; 91:683-699. [PMID: 35988017 DOI: 10.1111/jopy.12767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 04/06/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Negative affective symptoms (e.g., anxiety, depression, and anger) are correlated and have parallel associations with outcomes, as do related personality traits (i.e., facets of neuroticism), often prompting statistical control (i.e., partialing) to determine independent effects. However, such adjustments among predictor variables can alter their construct validity. In three studies, the interpersonal circumplex (IPC) and a related analytic approach (i.e., Structural Summary Method) were used to evaluate changes in interpersonal correlates of negative affective characteristics resulting from partialing. METHODS Samples of undergraduates (Sample 1 n = 3283; Sample 2 = 688) and married couples (n = 300 couples) completed self-report (three samples) and partner rating (sample 3) measures of anxiety, depression and anger, and IPC measures of interpersonal style. RESULTS Anxiety, depression, and anger had expected interpersonal correlates across samples. Partialing depression eliminated interpersonal correlates of anxiety. When anxiety was controlled, depression measures were more strongly associated with submissiveness and less closely associated with low warmth. Adjustments involving anger magnified differences in dominance versus submissiveness associated with the negative affects. DISCUSSION Removal of overlap among negative affective measures via partialing alters their interpersonal correlates, potentially complicating interpretation of adjusted associations.
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Vassou C, D'Cunha NM, Naumovski N, Panagiotakos DB. Hostile personality as a risk factor for hyperglycemia and obesity in adult populations: a systematic review. J Diabetes Metab Disord 2021; 19:1659-1669. [PMID: 33520858 DOI: 10.1007/s40200-020-00551-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/14/2020] [Accepted: 05/21/2020] [Indexed: 12/12/2022]
Abstract
Purpose Several studies have already provided valuable insights into the physiological and genetic causes of hyperglycemia and obesity. Concurrently, personality traits, such as hostility, have been suggested to have an impact on health and illness (i.e., self-reported general health, coronary artery disease, and overall mortality). The present systematic review investigated possible effects of hostility upon metabolic markers, such as high plasma glucose level and obesity among adults. We also attempted to reveal current gaps in knowledge and provide insights for future directions. Methods This systematic review was performed following the PRISMA 2009 guidelines to examine current evidence arising from observational studies regarding the potential impact of hostile behavior on hyperglycemia and obesity among adults. Of the initial 139 articles, 13 studies were included. Results The evidence supports an association between pre-diabetes and obesity with a hostile temperament in certain populations. The relationship between hostility and hyperglycemia was most common in African American women, in women with a family history of diabetes, in unmarried individuals, in White men, as well as in middle-aged and older people. Regarding obesity, high body mass index (BMI) was associated with a hostile personality, particularly among men. However, the paths by which hostile temperament affects glucose levels and BMI, as well as potential mediating and moderating mechanisms, are not entirely understood. Conclusions There is a need for research to enhance the understanding of biological, psychological and social factors related to hostility with a view to prevention and effective intervention.
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Affiliation(s)
- Christina Vassou
- Department of Nutrition and Dietetics, School of Health Science and Education, Harokopio University, 70 El. Venizelou Ave, Athens, 176 71 Greece
| | - Nathan M D'Cunha
- Faculty of Health, University of Canberra, Canberra, 2601 Australia
| | - Nenad Naumovski
- Faculty of Health, University of Canberra, Canberra, 2601 Australia
| | - Demosthenes B Panagiotakos
- Department of Nutrition and Dietetics, School of Health Science and Education, Harokopio University, 70 El. Venizelou Ave, Athens, 176 71 Greece.,Faculty of Health, University of Canberra, Canberra, 2601 Australia
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Yang HJ, Koh E, Sung MK, Kang H. Changes Induced by Mind-Body Intervention Including Epigenetic Marks and Its Effects on Diabetes. Int J Mol Sci 2021; 22:ijms22031317. [PMID: 33525677 PMCID: PMC7865217 DOI: 10.3390/ijms22031317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 12/20/2022] Open
Abstract
Studies have evidenced that epigenetic marks associated with type 2 diabetes (T2D) can be inherited from parents or acquired through fetal and early-life events, as well as through lifelong environments or lifestyles, which can increase the risk of diabetes in adulthood. However, epigenetic modifications are reversible, and can be altered through proper intervention, thus mitigating the risk factors of T2D. Mind-body intervention (MBI) refers to interventions like meditation, yoga, and qigong, which deal with both physical and mental well-being. MBI not only induces psychological changes, such as alleviation of depression, anxiety, and stress, but also physiological changes like parasympathetic activation, lower cortisol secretion, reduced inflammation, and aging rate delay, which are all risk factors for T2D. Notably, MBI has been reported to reduce blood glucose in patients with T2D. Herein, based on recent findings, we review the effects of MBI on diabetes and the mechanisms involved, including epigenetic modifications.
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Affiliation(s)
- Hyun-Jeong Yang
- Korea Institute of Brain Science, Seoul 06022, Korea; (M.-K.S.); (H.K.)
- Department of Integrative Health Care, University of Brain Education, Cheonan 31228, Korea
- Correspondence:
| | - Eugene Koh
- Temasek Life Sciences Laboratories, Singapore 117604, Singapore;
| | - Min-Kyu Sung
- Korea Institute of Brain Science, Seoul 06022, Korea; (M.-K.S.); (H.K.)
| | - Hojung Kang
- Korea Institute of Brain Science, Seoul 06022, Korea; (M.-K.S.); (H.K.)
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Chan VWY, Kong APS, Lau JTF, Mak WWS, Cameron LD, Mo PKH. An Intervention to Change Illness Representations and Self-Care of Individuals With Type 2 Diabetes: A Randomized Controlled Trial. Psychosom Med 2021; 83:71-84. [PMID: 33141790 DOI: 10.1097/psy.0000000000000883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Suboptimal self-care by individuals with diabetes mellitus (DM) is a significant public health concern. The common-sense model (CSM) proposes that illness representations are associated with coping and health outcomes across various conditions. The present study examined the efficacy of a CSM-based intervention in improving illness representations, self-care, self-care self-efficacy, use of adaptive coping strategies, and glycated hemoglobin among individuals with type 2 DM (T2DM). METHODS A two-arm randomized controlled trial was used. A total of 455 T2DM patients were recruited from an outpatient DM clinic and randomized to an intervention group that consisted of five weekly group-based education sessions or a control group that received five weekly educational booklets. Evaluation was conducted at baseline and at 1- and 6-month follow-up. RESULTS The 2 × 3 linear mixed-model analysis using a modified intention to treat revealed a significant time by condition interaction effect on level of self-care (F(2,840) = 7.78, p < .001), self-care self-efficacy (F(1.89,794.57) = 14.40, p < .001), and use of adaptive coping strategies (F(1.94,812.93) = 4.75, p = .010) in which participants in the intervention group reported greater improvement in such aspects compared with those in the control group. A significant time effect was observed in some dimensions of illness representations. No significant effect was found in glycated hemoglobin. Participants reported positive feedback to the intervention and perceived improvement in various domains. CONCLUSIONS The CSM-based intervention was effective in improving self-care and coping among DM patients. The intervention also demonstrated high feasibility and acceptability. Findings provided important insights in improving health-related outcomes for patients with T2DM using the CSM framework.
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Affiliation(s)
- Virginia W Y Chan
- From the Centre for Health Behaviours Research, School of Public Health and Primary Care (Chan, Lau, Mo), and Departments of Medicine and Therapeutics (Kong) and Psychology (Mak), the Chinese University of Hong Kong, Shatin, Hong Kong; and Department of Psychological Sciences (Cameron), University of California Merced, Merced, California
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Neuvonen E, Hall A, Tolppanen AM, Ngandu T, Rusanen M, Laatikainen T, Soininen H, Kivipelto M, Solomon A. Late-life personality traits, cognitive impairment, and mortality in a population-based cohort. Int J Geriatr Psychiatry 2020; 35:989-999. [PMID: 32363652 DOI: 10.1002/gps.5321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/21/2020] [Accepted: 04/25/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES We examined longitudinal associations between late-life personality traits and cognitive impairment, dementia, and mortality in the population-based Cardiovascular Risk Factors, Aging and Dementia (CAIDE) Study. METHODS Anger expression and trait anger (State-Trait Anger Expression Inventory), anxiety (State-Trait Anxiety Inventory), and sense of coherence (Sense of Coherence Scale) were assessed at the 1998 CAIDE visit (1266 cognitively normal individuals, mean age 71.0 years). Totally, 582 participants had complete re-examination in 2005-2008 (105 mild cognitive impairment, MCI; and 29 dementia). National registers data until 2008 were also used for both participants and nonparticipants to ascertain incident dementia (96 cases) and mortality (227 died). Analyses were adjusted for age, sex, education, follow-up time, cardiovascular and lifestyle factors, and depressive symptoms. RESULTS Higher anxiety was associated with higher risk of MCI/dementia (OR 1.68, 95% CI 1.07-2.63) and death (HR 1.46, 95% CI 1.08-1.98). High sense of coherence was associated with lower mortality (HR 0.65, 95% CI 0.45-0.93). These associations were attenuated after accounting for depressive symptoms (OR 1.57, 95% CI 0.96-2.58 for anxiety-MCI/dementia; HR 1.35, 95% CI 0.97-1.86 for anxiety-mortality; and HR 0.68, 95% CI 0.45-1.04 for sense of coherence-mortality). Trait anger was associated with higher dementia risk even after adjustments (HR 1.90, 95% CI 1.14-3.18). CONCLUSIONS Anxiety was linked to worse cognitive outcome and mortality and sense of coherence to lower mortality. Depressive symptoms attenuated the associations. As a novel finding, trait anger was connected to dementia risk. These findings emphasize the importance of personality-related risk factors for dementia and mortality. J Am Geriatr Soc 68:-, 2020.
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Affiliation(s)
- Elisa Neuvonen
- Institute of Clinical Medicine/Neurology, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Anette Hall
- Institute of Clinical Medicine/Neurology, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Anna-Maija Tolppanen
- Research Centre for Comparative Effectiveness and Patient Safety, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Tiia Ngandu
- Public Health Promotion Unit, Department of Public Health Solutions, National Institute for Health and Welfare, Helsinki, Finland.,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden
| | - Minna Rusanen
- Institute of Clinical Medicine/Neurology, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Public Health Promotion Unit, Department of Public Health Solutions, National Institute for Health and Welfare, Helsinki, Finland.,Neurocenter, Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - Tiina Laatikainen
- Public Health Promotion Unit, Department of Public Health Solutions, National Institute for Health and Welfare, Helsinki, Finland.,Institute of Public Health and Clinical Nutrition, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Joint Municipal Authority for North Karelia Social and Health Services (Siun sote), Joensuu, Finland
| | - Hilkka Soininen
- Institute of Clinical Medicine/Neurology, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Neurocenter, Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - Miia Kivipelto
- Institute of Clinical Medicine/Neurology, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden.,Institute of Public Health and Clinical Nutrition, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Ageing Epidemiology (AGE) Research Unit, School of Public Health, Imperial College London, London, UK
| | - Alina Solomon
- Institute of Clinical Medicine/Neurology, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden
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Luo J, Chen X, Tindle H, Shadyab AH, Saquib N, Hale L, Garcia L, Springfield S, Liu B, Nassir R, Snetselaar L, Hendryx M. Do health behaviors mediate associations between personality traits and diabetes incidence? Ann Epidemiol 2020; 53:7-13.e2. [PMID: 32805399 DOI: 10.1016/j.annepidem.2020.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/17/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Personality traits have been reported to be associated with type 2 diabetes (T2DM) risk. The objective of this study was to examine whether and to what extent the associations between personality traits (dispositional optimism, hostility, and negative emotional expressiveness) and risk of T2DM were mediated by health behaviors and obesity. METHODS Postmenopausal women (n = 110,992) aged 50-79 years without diabetes at enrollment in the Women's Health Initiative study (1993-1998) were followed up to 25 years. Incident diabetes was assessed via a validated self-report of physician-diagnosed diabetes treated with insulin or other hypoglycemic medications. Mediation analyses were performed using approaches under a counterfactual framework. RESULTS An inverse association of optimism with diabetes was significantly mediated by a factor primarily extracted from physical activity, diet quality, and sleep quality with a mediated proportion of 28%. Positive associations for hostility and negative emotional expressiveness were substantially mediated by a factor primarily composed of body mass index and waist circumference with mediated proportions of 32% and 44%, respectively. CONCLUSIONS Our data revealed that less than half of the associations between personality traits and risk of T2DM were explained by indirect health behavior pathways. Women's personality traits should be considered in prevention of diabetes in addition to promoting health behaviors.
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Affiliation(s)
- Juhua Luo
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University Bloomington, Bloomington, IN.
| | - Xiwei Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University Bloomington, Bloomington, IN
| | - Hilary Tindle
- Department of Medicine, Vanderbilt Univeristy, Nashville, TN
| | - Aladdin H Shadyab
- Department of Family Medicine and Public Health, University of California, San Diego School of Medicine, La Jolla
| | - Nazmus Saquib
- Research Unit, College of Medicine, Sulaiman AlRajhi University, Saudi Arabia
| | - Lauren Hale
- Department of Family, Population and Preventive Medicine, School of Medicine, Stony Brook University, NY
| | - Lorena Garcia
- Department of Public Health Sciences, School of Medicine University of California, Davis
| | - Sparkle Springfield
- Department of Public Health, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL
| | - Buyun Liu
- Department of Epidemiology, College of Public Health, University of Iowa, IA
| | - Rami Nassir
- Department of Pathology, School of Medicine, Umm Al-Qura University, Saudi Arabia
| | - Linda Snetselaar
- Department of Epidemiology, College of Public Health, Univeristy of Iowa, IA
| | - Michael Hendryx
- Department of Environmental and Occupational Health, School of Public Health, Indiana University Bloomington, Bloomington, IN
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10
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Sims M, Glover LSM, Gebreab SY, Spruill TM. Cumulative psychosocial factors are associated with cardiovascular disease risk factors and management among African Americans in the Jackson Heart Study. BMC Public Health 2020; 20:566. [PMID: 32345300 PMCID: PMC7189712 DOI: 10.1186/s12889-020-08573-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 03/24/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Racial disparities in cardiovascular disease (CVD) have been attributed in part to negative psychosocial factors. Prior studies have demonstrated associations between individual psychosocial factors and CVD risk factors, but little is known about their cumulative effects. METHODS Using the Jackson Heart Study, we examined the cross-sectional associations of cumulative psychosocial factors with CVD risk factors among 5306 African Americans. We utilized multivariable Poisson regression to estimate sex-stratified prevalence ratios (PR 95% confidence interval-CI) of obesity, hypertension and diabetes prevalence and hypertension and diabetes control with negative affect (cynicism, anger-in, anger-out, depressive symptoms and cumulative negative affect) and stress (global stress, weekly stress, major life events-MLEs and cumulative stress), adjusting for demographics, socioeconomic status, and behaviors. RESULTS After full adjustment, high (vs. low) cumulative negative affect was associated with prevalent obesity among men (PR 1.36 95% CI 1.16-1.60), while high (vs. low) cumulative stress was similarly associated with obesity among men and women (PR 1.24 95% CI 1.01-1.52 and PR 1.13 95% CI 1.03-1.23, respectively). Psychosocial factors were more strongly associated with prevalent hypertension and diabetes among men than women. For example, men who reported high cynicism had a 12% increased prevalence of hypertension (PR 1.12, 95% CI 1.03-1.23). Psychosocial factors were more strongly associated with lower hypertension and diabetes control for women than men. Women who reported high (vs. low) cynicism had a 38% lower prevalence of hypertension control (PR 0.62, 95% CI 0.46-0.84). CONCLUSIONS Cumulative psychosocial factors were associated with CVD risk factors and disease management among African Americans. The joint accumulation of psychosocial factors was more associated with risk factors for men than women.
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Affiliation(s)
- Mario Sims
- Department of Medicine, University of Mississippi Medical Center, 350 W. Woodrow Wilson Avenue, Jackson, MS 39213, USA
| | - Lá Shauntá M. Glover
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | | | - Tanya M. Spruill
- Department of Population Health, NYU School of Medicine, New York, USA
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Abstract
OBJECTIVE We examined whether personality traits, including optimism, ambivalence over emotional expressiveness, negative emotional expressiveness, and hostility, were associated with risk of developing type 2 diabetes (hereafter diabetes) among postmenopausal women. METHODS A total of 139,924 postmenopausal women without diabetes at baseline (between 1993 and 1998) aged 50 to 79 years from the Women's Health Initiative were prospectively followed for a mean of 14 (range 0.1-23) years. Multivariable Cox proportional hazards regression models were used to assess associations between personality traits and diabetes incidence adjusting for common demographic factors, health behaviors, and depressive symptoms. Personality traits were gathered at baseline using questionnaires. Diabetes during follow-up was assessed via self-report of physician-diagnosed treated diabetes. RESULTS There were 19,240 cases of diabetes during follow-up. Compared with women in the lowest quartile of optimism (least optimistic), women in the highest quartile (most optimistic) had 12% (hazard ratio [HR], 0.88; 95% confidence interval [CI]: 0.84-0.92) lower risk of incident diabetes. Compared with women in the lowest quartile for negative emotional expressiveness or hostility, women in the highest quartile had 9% (HR, 1.09; 95% CI: 1.05-1.14) and 17% (HR, 1.17; 95% CI: 1.12-1.23) higher risk of diabetes, respectively. The association of hostility with risk of diabetes was stronger among nonobese than obese women. CONCLUSIONS Low optimism and high NEE and hostility were associated with increased risk of incident diabetes among postmenopausal women independent of major health behaviors and depressive symptoms. In addition to efforts to promote healthy behaviors, women's personality traits should be considered to guide clinical or programmatic intervention strategies in diabetes prevention.
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12
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de Bles NJ, Rius Ottenheim N, van Hemert AM, Pütz LEH, van der Does AJW, Penninx BWJH, Giltay EJ. Trait anger and anger attacks in relation to depressive and anxiety disorders. J Affect Disord 2019; 259:259-265. [PMID: 31450135 DOI: 10.1016/j.jad.2019.08.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/31/2019] [Accepted: 08/14/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with various psychiatric disorders may suffer from feelings of anger, sometimes leading to maladaptive (e.g., aggressive) behaviors. We examined to what extent depressive and anxiety disorders, relevant clinical correlates, and sociodemographics determined the level of trait anger and the prevalence of recent anger attacks. METHODS In the Netherlands Study of Depression and Anxiety (NESDA), the Spielberger Trait Anger Subscale and the Anger Attacks Questionnaire were analyzed in patients with depressive (n = 204), anxiety (n = 288), comorbid (n = 222), and remitted disorders (n = 1,107), as well as in healthy controls (n = 470) based on DSM-IV criteria. RESULTS On average, participants were 46.2 years old (SD = 13.1) and 66.3% were female. Trait anger and anger attacks were most prevalent in the comorbid group (M = 18.5, SD = 5.9, and prevalence 22.1%), followed by anxiety disorder, depressive disorder, remitted disorder, and controls (M = 12.7; SD = 2.9, and prevalence 1.3%). Major depressive disorder, social phobia, panic disorder, and generalized anxiety disorder were most strongly associated to trait anger and anger attacks. LIMITATIONS Due to a cross-sectional design, it was not possible to provide evidence for temporal or causal relationships between anger and depressive and anxiety disorders. CONCLUSIONS Trait anger and anger attacks are linked to depressive and anxiety disorders, although the strength of the relationship differed among both anger constructs.
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Affiliation(s)
- Nienke J de Bles
- Department of Psychiatry, Leiden University Medical Center, PO Box 9600, 2300 Leiden, the Netherlands.
| | - Nathaly Rius Ottenheim
- Department of Psychiatry, Leiden University Medical Center, PO Box 9600, 2300 Leiden, the Netherlands
| | - Albert M van Hemert
- Department of Psychiatry, Leiden University Medical Center, PO Box 9600, 2300 Leiden, the Netherlands
| | - Laura E H Pütz
- Department of Psychiatry, Leiden University Medical Center, PO Box 9600, 2300 Leiden, the Netherlands
| | | | - Brenda W J H Penninx
- Department of Psychiatry, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Erik J Giltay
- Department of Psychiatry, Leiden University Medical Center, PO Box 9600, 2300 Leiden, the Netherlands
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Wang M, Gong W, Hu R, Pan J, Lv J, Guo Y, Bian Z, Chen Z, Li L, Zhong J. Associations between stressful life events and diabetes: Findings from the China Kadoorie Biobank study of 500,000 adults. J Diabetes Investig 2019; 10:1215-1222. [PMID: 30784202 PMCID: PMC6717902 DOI: 10.1111/jdi.13028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 01/29/2019] [Accepted: 02/19/2019] [Indexed: 01/14/2023] Open
Abstract
AIMS/INTRODUCTION Evidence has shown that stressful life events are associated with the development of diabetes, yet studies in mainland China are scarce. In the present study, we explored the associations between cumulative and specific stressful life events and the prevalence of diabetes in Chinese adults. MATERIALS AND METHODS The cross-sectional data were from the China Kadoorie Biobank study, which enrolled approximately 500,000 adults aged 30-79 years from 10 diverse regions of China. Logistic regression models were used to calculate the adjusted odds ratio (OR) and the 95% confidence interval (CI). RESULTS Of the 473,607 participants, 25,301 (5.34%) had type 2 diabetes (2.68% clinically-identified and 2.66% screen-detected). Participants who experienced one and two or more stressful life events were 1.10-fold (OR 1.10, 95% CI 1.05-1.16) and 1.33-fold (OR 1.33, 95% CI 1.13-1.57) more likely to have type 2 diabetes. Three categories of work-related events (OR 1.15, 95% CI 1.01-1.31), as well as family-related events (OR 1.11, 95% CI 1.06-1.18) and personal-related events (OR 1.18, 95% CI 1.03-1.36), were associated with an increased likelihood of type 2 diabetes. Regarding the specific life events, the ORs of loss of job or retirement, as well as major conflict within family, death or major illness of other close family member and major injury or traffic accident, were 1.24 (95% CI 1.02-1.52), 1.24 (95% CI 1.08-1.43), 1.13 (95% CI 1.06-1.20) and 1.20 (95% CI 1.01-1.43), respectively. CONCLUSIONS The present study showed that cumulative and specific stressful life events were significantly associated with an increased prevalence of diabetes.
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Affiliation(s)
- Meng Wang
- Department of NCDs Control and PreventionZhejiang Provincial Center for Disease Control and PreventionHangzhouChina
| | - Wei‐Wei Gong
- Department of NCDs Control and PreventionZhejiang Provincial Center for Disease Control and PreventionHangzhouChina
| | - Ru‐Ying Hu
- Department of NCDs Control and PreventionZhejiang Provincial Center for Disease Control and PreventionHangzhouChina
| | - Jin Pan
- Department of NCDs Control and PreventionZhejiang Provincial Center for Disease Control and PreventionHangzhouChina
| | - Jun Lv
- Department of EpidemiologySchool of Public HealthPeking University Health Science CenterBeijingChina
| | - Yu Guo
- Chinese Academy of Medical SciencesBeijingChina
| | - Zheng Bian
- Chinese Academy of Medical SciencesBeijingChina
| | - Zheng‐Ming Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NuffieldDepartment of Population HealthUniversity of OxfordOxfordUK
| | - Li‐Ming Li
- Department of EpidemiologySchool of Public HealthPeking University Health Science CenterBeijingChina
| | - Jie‐Ming Zhong
- Department of NCDs Control and PreventionZhejiang Provincial Center for Disease Control and PreventionHangzhouChina
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Healey LV, Holmes V, Curry S, Seto MC, Ahmed AG. Self-Reported Dysfunctional Anger in Men and Women at a Psychiatric Outpatient Clinic. JOURNAL OF RATIONAL-EMOTIVE AND COGNITIVE-BEHAVIOR THERAPY 2019. [DOI: 10.1007/s10942-019-00318-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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15
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Deschênes SS, Burns RJ, Schmitz N. Comorbid depressive and anxiety symptoms and the risk of type 2 diabetes: Findings from the Lifelines Cohort Study. J Affect Disord 2018; 238:24-31. [PMID: 29852343 DOI: 10.1016/j.jad.2018.05.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/16/2018] [Accepted: 05/21/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Prior studies indicate that depression is a risk factor for type 2 diabetes (T2D), though there is considerable heterogeneity in reported estimates. Identifying homogeneous subgroups of depression strongly associated with T2D may be beneficial. This study examined associations between depression and anxiety comorbidity with the risk of T2D. METHODS 78,025 participants from the Lifelines Cohort Study (age range = 30-75 years) without diabetes at baseline were included in this study. The Mini-International Neuropsychiatric Interview assessed depressive and anxiety symptoms at baseline. Incident T2D was assessed by self-report or hemoglobin A1c levels during an approximately 3.8-year follow-up period. Risk of T2D was compared across four groups (no depressive or anxiety symptoms, depressive symptoms alone, anxiety symptoms alone, comorbid depressive/anxiety symptoms) using mixed effects logistic regression analyses adjusted for sociodemographic, lifestyle, and cardiometabolic characteristics. RESULTS 1,096 participants developed diabetes. Compared to those without depressive or anxiety symptoms (n = 74,467), those with comorbid depressive and anxiety symptoms (n = 743) were more likely to develop T2D (n = 28, OR = 2.12, 95% CI = 1.22-3.68). Depressive symptoms alone (n = 650) and anxiety symptoms alone (n = 2,165) were not significantly associated with T2D (n = 23 and n = 24, respectively, developed diabetes). Those with comorbid symptoms were also more likely to develop T2D compared to those with depressive symptoms alone (OR = 2.86, 95% CI = 1.25-6.54). LIMITATIONS Depressive and anxiety symptom assessments were based on a screening tool. Hemoglobin A1c data were only available for a subset of participants. CONCLUSIONS Depression with comorbid anxiety may be a subgroup of depression that is strongly associated with the risk of T2D.
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Affiliation(s)
- Sonya S Deschênes
- Department of Psychiatry, McGill University, Montreal, Canada; Douglas Mental Health University Institute, Montreal, Quebec, Canada.
| | - Rachel J Burns
- Department of Psychology, Carleton University, Ottawa, Ontario, Canada
| | - Norbert Schmitz
- Department of Psychiatry, McGill University, Montreal, Canada; Douglas Mental Health University Institute, Montreal, Quebec, Canada; Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
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16
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Smith KJ, Deschênes SS, Schmitz N. Investigating the longitudinal association between diabetes and anxiety: a systematic review and meta-analysis. Diabet Med 2018; 35:677-693. [PMID: 29460506 PMCID: PMC5969311 DOI: 10.1111/dme.13606] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2018] [Indexed: 12/17/2022]
Abstract
AIM Previous research has indicated an association between diabetes and anxiety. However, no synthesis has determined the direction of this association. The aim of this study was to determine the longitudinal relationship between anxiety and diabetes. METHODS We searched seven databases for studies examining the longitudinal relationship between anxiety and diabetes. Two independent reviewers screened studies from a population aged 16 or older that examined either anxiety as a risk factor for incident diabetes or diabetes as a risk factor for incident anxiety. Studies that met eligibility criteria were put forward for data extraction and meta-analysis. RESULTS In total 14 studies (n = 1 760 800) that examined anxiety as a risk factor for incident diabetes and two (n = 88 109) that examined diabetes as a risk factor for incident anxiety were eligible for inclusion in the review. Only studies examining anxiety as a risk factor for incident diabetes were put forward for the meta-analysis. The least adjusted (unadjusted or adjusted for age only) estimate indicated a significant association between baseline anxiety with incident diabetes (odds ratio 1.47, 1.23-1.75). Furthermore, most-adjusted analyses indicated a significant association between baseline anxiety and incident diabetes. Included studies that examined diabetes to incident anxiety found no association. CONCLUSIONS There was an association between baseline anxiety and incident diabetes. The results also indicate the need for more research to examine the direction of association from diabetes to incident anxiety. This work adds to the growing body of evidence that poor mental health increases the risk of developing diabetes.
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Affiliation(s)
- K. J. Smith
- Department of Psychological SciencesUniversity of SurreyGuildfordUK
| | - S. S. Deschênes
- Douglas Mental Health University InstituteMontrealCanada
- Department of PsychiatryMcGill UniversityMontrealCanada
| | - N. Schmitz
- Douglas Mental Health University InstituteMontrealCanada
- Department of PsychiatryMcGill UniversityMontrealCanada
- Department of Epidemiology and BiostatisticsMcGill UniversityMontrealCanada
- Montreal Diabetes Research CenterMontrealCanada
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Abstract
Psychological stress is common in many physical illnesses and is increasingly recognized as a risk factor for disease onset and progression. An emerging body of literature suggests that stress has a role in the aetiology of type 2 diabetes mellitus (T2DM) both as a predictor of new onset T2DM and as a prognostic factor in people with existing T2DM. Here, we review the evidence linking T2DM and psychological stress. We highlight the physiological responses to stress that are probably related to T2DM, drawing on evidence from animal work, large epidemiological studies and human laboratory trials. We discuss population and clinical studies linking psychological and social stress factors with T2DM, and give an overview of intervention studies that have attempted to modify psychological or social factors to improve outcomes in people with T2DM.
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Affiliation(s)
- Ruth A Hackett
- Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
| | - Andrew Steptoe
- Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
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18
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Abstract
Type 2 diabetes is a chronic disease that is increasing in prevalence globally. Cardiovascular disease is a major cause of mortality and morbidity in diabetes, and lifestyle and clinical risk factors do not fully account for the link between the conditions. This article provides an overview of the evidence concerning the role of psychosocial stress factors in diabetes risk, as well as in cardiovascular complications in people with existing diabetes. Several types of psychosocial factors are discussed including depression, other types of emotional distress, exposure to stressful conditions, and personality traits. The potential behavioral and biological pathways linking psychosocial factors to diabetes are presented and implications for patient care are highlighted.
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Affiliation(s)
- Ruth A. Hackett
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
| | - Andrew Steptoe
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
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Lau CG, Tang WK, Liu XX, Liang HJ, Liang Y, Wong A, Mok V, Ungvari GS, Wong KS, Kim JS, Paradiso S. Poststroke agitation and aggression and social quality of life: a case control study. Top Stroke Rehabil 2016; 24:126-133. [PMID: 27603431 DOI: 10.1080/10749357.2016.1212564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Aggression and agitation are common after a stroke. The association between agitation/aggression following stroke and Health-Related Quality of Life (HRQoL) in stroke survivors is unknown. This study aimed to examine the association between agitation/aggression and HRQoL in Chinese stroke survivors. METHODS Three hundred and twenty-four stroke patients entered this cross-sectional study. Agitation/aggression was assessed using the Chinese version of Neuropsychiatric Inventory (CNPI). HRQoL was measured with the Stroke Specific Quality of Life (SSQoL). RESULTS Three months after the index stroke, agitation/aggression was found in 60 (18.5%) patients. In the agitation/aggression group, 44 patients (73.3%) showed passive agitation/aggression, whereas 16 (26.7%) displayed passive and active agitation/aggression. No patients showed only active agitation/aggression. Patients with agitation/aggression were more likely to have history of diabetes and greater severity of depression, as well as lower SSQoL total score and Personality Changes and Social Role scores. Controlling for diabetes and depression severity did not alter the above results. The Energy and Thinking scores of the SSQoL were significantly lower in the passive/active agitation/aggression group relative to the passive agitation/aggression group (adjusted for CNPI aggression/agitation score). CONCLUSION In this study sample, agitation/aggression was preponderantly of the passive type and was associated with poorer HRQoL independently from depression or medical conditions. Patients with both passive and active agitation/aggression had lower Quality of Life (QoL) than patients with only passive agitation/aggression. The causality of the association between low QoL and agitation/aggression needs to be explored in future studies.
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Affiliation(s)
- Chieh Grace Lau
- a Department of Psychiatry , Chinese University of Hong Kong , Hong Kong SAR , China
| | - Wai Kwong Tang
- a Department of Psychiatry , Chinese University of Hong Kong , Hong Kong SAR , China
| | - Xiang Xin Liu
- a Department of Psychiatry , Chinese University of Hong Kong , Hong Kong SAR , China
| | - Hua Jun Liang
- a Department of Psychiatry , Chinese University of Hong Kong , Hong Kong SAR , China
| | - Yan Liang
- a Department of Psychiatry , Chinese University of Hong Kong , Hong Kong SAR , China
| | - Adrian Wong
- b Department of Medicine and Therapeutics , Chinese University of Hong Kong , Hong Kong SAR , China
| | - Vincent Mok
- b Department of Medicine and Therapeutics , Chinese University of Hong Kong , Hong Kong SAR , China
| | - Gabor S Ungvari
- c School of Psychiatry & Clinical Neurosciences , University of Western Australia , Perth , Australia.,d Department of Psychiatry , University of Notre Dame Australia/Marian Centre , Perth , Australia
| | - Ka Sing Wong
- b Department of Medicine and Therapeutics , Chinese University of Hong Kong , Hong Kong SAR , China
| | - Jong S Kim
- e Department of Neurology , Asan Medical Center, University of Ulsan , Seoul , Korea
| | - Sergio Paradiso
- f Una Mano per la Vita - Association of Families and their Doctors , Catania , Italy.,g Facultad de Psicología , Universidad Diego Portales , Santiago , Chile
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