Psychological influences on immunity

A pilot study of qigong practice and upper respiratory illness in elite swimmers

Upper respiratory tract infections (URIs) are a common complaint in competitive swimmers and can adversely affect performance. No intervention has yet been shown to reduce URI incidence in intensively trained athletes. The University of Virginia varsity swim team received three weeks of training in qigong for the purpose of reducing stress and improving health. Our primary objective was to assess the relationship between qigong practice and symptoms of URI during a time when swimmers would be at high URI risk. Secondary objectives were to assess degree of compliance with a qigong practice regimen, to evaluate differences between qigong practitioners and non-practitioners, and to determine the response-rate and reliability of a newly developed internet-based, self-report survey. The design was observational, cross-sectional, and prospective. Weekly data on cold and flu symptoms, concurrent health problems and medication use, and qigong practice were gathered for seven weeks. Retrospective information on health and qigong training response was also collected. Participants were 27 of the 55 members of the University of Virginia Swim Team in the Virginia Athletic Department. Main outcomes were measures of aggregated cold/flu symptoms and Qigong practice. Survey completion was 100%, with no missing data, and reliability of the instrument was acceptable. Cold and flu symptoms showed a significant non-linear association with frequency of qigong practice (R(2) = 0.33, p < 0.01), with a strong, inverse relationship between practice frequency and symptom scores in swimmers who practised qigong at least once per week (R(2) = 0.70, p < 0.01). Qigong practitioners did not differ from non-practitioners in demographic or lifestyle characteristics, medical history, supplement or medication use, or belief in qigong. These preliminary findings suggest that qigong practice may be protective against URIs among elite swimmers who practice at least once per week.

Outbreak of Pneumococcal Pneumonia among Military Recruits

BACKGROUND

Between 04 Mar 2002 to 21 Mar 2002, 31 cases of pneumonia were admitted at a military hospital in South India. Most of these cases were young recruits. The out break was investigated to ascertain the cause and suggest preventive measures.

METHODS

Detailed epidemiological history was taken from all 31 cases and 100 controls. Case sheets, laboratory reports and chest radiographs were studied. Laboratory investigations included sputum examination by Gram stain and blood cultures on brain heart infusion broth. Cultures grown on liquid media were subcultured on solid media. The regimental centre was visited to note the living and environmental conditions.

RESULTS

Epidemiological investigations revealed overcrowding in the regimental centre. The space per recruit was below recommended standards. 51.6% of recruits who contacted pneumonia were sleeping on double deckers as compared to 21% of healthy controls. Blood culture was positive for Streptococcus pneumoniae in 25.8% of the cases. Chest radiograph showed consolidation typical of lobar pneumonia in 67% of the cases.

CONCLUSION

The outbreak of pneumococcal pneumonia occurred due to overcrowding. Chilly weather conditions and stress were contributing factors.

Stress and reactivation of latent herpes simplex virus: a fusion of behavioral medicine and molecular biology

Since 1978, the study of health and behavior has become a major focus of scientists in psychology, psychiatry, nursing, neuroscience, and in traditional medical science disciplines. Investigation of psychological or behavioral influences on biological systems has established that biobehavioral processes such as stress play an important role in disease processes. An excellent example of the interactions between stress and health outcomes is the reactivation of latent herpes simplex virus (HSV) leading to recurrent lesions. This article describes what is currently known about HSV latency and reactivation and considers some mechanisms by which stress-induced changes in the host's immune and nervous systems might allow for either the establishment or reactivation of latent viral infections.

Counter-stress effects of relaxation on proinflammatory and anti-inflammatory cytokines

The counter-stress effects of relaxation on proinflammatory and anti-inflammatory cytokines were examined. From 36 medical students, 18 were randomly assigned to the relaxation group, and 18 were randomly assigned to the non-relaxation group. Relaxation lasted for four weeks. The levels of stimulated production of IL-6, TNF-alpha, and IL-10, and blood pressure were measured during the non-examination period (baseline period) and the pre-examination period (stress period). The levels of perceived stress were assessed by the Global Assessment of Recent Stress (GARS) scale, the Stress Response Inventory (SRI) and the Symptom Checklist-90-Revised (SCL-90-R) anxiety subscale. Repeat measure ANOVA revealed that the SRI total score, scores of the SCL-90-R anxiety subscale and diastolic blood pressure were significantly higher during the stress period than during the baseline period regardless of groups. The level of IL-6 production was significantly lower but the level of IL-10 production was significantly higher during the stress period than during the baseline period. Significant reduction in the delta (stress period value minus baseline period value) in the total GARS score, systolic and diastolic blood pressure, the levels of IL-6 and TNF-alpha production but significant enhancement in the delta in the level of the IL-10 production were found in the relaxation group compared with the non-relaxation group. These results suggest that relaxation is associated with reduction in stress-induced psychological or physiological responses and proinflammatory cytokine alterations but with enhancement in stress-induced anti-inflammatory cytokine alteration. Therefore, relaxation is more likely to have counter-stress effect on proinflammatory cytokines than on anti-inflammatory cytokine.

Appraisal and Consequences of Cadaver Dissection

First exposure to human cadaver dissection has the potential to be an actual stressor which can cause psychological trauma. This study examines the relationship between anatomy students' experience of this potential stressor and various psychological and personal factors. Questionnaires measuring emotional reactions to cadaver dissection, coping strategies, personality and attitudes to death were administered to anatomy students at two medical schools immediately after their first exposure to human cadaver dissection. Emotional reactions to recalling this experience were assessed 4 months later. Data on these variables were obtained from 141 students. Students found the experience mostly challenging and, on average, did not report serious emotional difficulties. However, a minority of students (10/141) experienced serious adverse consequences. It is possible that the typical student who undertakes an anatomy course is already psychologically prepared for such transactions. However, low cost desensitization programs could be made available for the minority of individuals who may experience adverse reactions in this situation.

Post-traumatic stress disorder: advances in psychoneuroimmunology

Exposure to trauma can result in immune dysregulation, and increasing evidence suggests that there are immune alterations associated with post-traumatic stress disorder (PTSD). However, the exact nature of these immune findings in PTSD has not been defined. The study of psychoneuroimmunology in PTSD is relevant not only for understanding the biological underpinnings of this disorder, but also for establishing the nature of the associations between PTSD and other medical and psychiatric illnesses.

Risk factors for postoperative anxiety in adults

We identified risk factors for postoperative anxiety and quantified their effect on 712 adults between 18 and 60 years of age (ASA I-III physical status) undergoing elective surgery under general anaesthesia, neural blockade or both. The measuring instruments were a structured questionnaire, a pain visual analogue scale, the McGill Pain Questionnaire, the State-Trait Anxiety Inventory, the Montgomery-Asberg Depression Rating Scale, a Self-Reporting Questionnaire-20, and a Self-Perception of Future Questionnaire. Multivariate conditional regression modelling taking into account the hierarchical relationship between risk factors revealed that postoperative anxiety was associated with ASA status III (OR = 1.48), history of smoking (1.62), moderate to intense postoperative pain (OR = 2.62) and high pain rating index (OR = 2.35), minor psychiatric disorders (OR = 1.87), pre-operative state-anxiety (OR = 2.65), and negative future perception (OR = 2.20). Neural block anaesthesia (OR = 0.72), systemic multimodal analgesia (OR = 0.62) and neuroaxial opioids with or without local anaesthesia (OR = 0.63) were found to be protective factors against postoperative anxiety.

Associations between coping and survival time of adult leukemia patients receiving allogeneic bone marrow transplantation: results of a prospective study

BACKGROUND

To investigate associations between coping strategies and length of survival in a sample of 52 adult leukemia patients receiving allogeneic bone marrow transplantation (BMT).

METHODS

52 adult patients, diagnosed with acute (AML) and chronic myeloid leukemia (CML) admitted for allogeneic BMT to a university hospital BMT unit in preparation for a transplantation of genotypically matched HLA donor marrow, were interviewed immediately after informed consent and prior to preparatory treatment for transplantation. Semistructured interviews were conducted and recorded for analysis to assess coping styles and were evaluated by a new content analytic coping measure [Ulm Coping Manual (UCM)]. Patients were a random sample of all eligible patients on the BMT unit between May 1990 and May 1994.

RESULTS

Complete audiotaped interviews were rated by blind raters, employing a newly developed content analysis for the identification of patients' coping strategies. Multivariate analysis using a Cox model revealed three pretransplant variables that demonstrated a statistically significant influence on 5-year survival: Stage of Disease at transplant (P < .012), Distraction (P < .007), and Fighting Spirit as coping modalities (P < .013).

CONCLUSIONS

The results of this prospective study document the impact of certain psychological variables, notably coping style on survival with BMT. This suggests the necessity of utilizing psychosocial interventions to address stress and anxiety in patients awaiting transplantation in order to reduce anxieties and to employ more effective coping techniques to deal more appropriately with their situation and to enhance Fighting Spirit. The effects on survival of such psychosocial interventions need to be tested in a randomized controlled study.

Can psycotherapy increase the survival time of cancer patients?

OBJECTIVE

The aim of this paper was to review the evidence regarding the possibility of a relationship between psychological intervention and survival time of cancer patients.

METHOD

A literature search was conducted using CD ROM databases to identify studies which have evaluated the effects of psychological interventions on the survival time of cancer patients. The identified studies were critically reviewed.

RESULTS

Eight studies which used scientifically acceptable methodology to examine this question were identified. Three of these studies found evidence for a relationship between psychological intervention and patients' survival time, while five did not. Methodological issues and potentially confounding factors are discussed.

CONCLUSION

To date, a direct relationship between psychological intervention and patient survival time has not been conclusively demonstrated. Large-scale replication studies which are currently under way will provide more conclusive evidence on this question within the next few years.

Contemporary psychosocial issues in cystic fibrosis: treatment adherence and quality of life

This review focuses on the two major psychosocial areas currently topical in cystic fibrosis research: treatment adherence and quality of life. First, the paper discusses the importance of evaluating adherence to treatments and medical advice, its measurement, predictors of adherence and non-adherence and whether the data should be used to inform clinical practice and policy decisions. Second, the purpose of evaluating quality of life in cystic fibrosis and an overview of the data are discussed. Both areas have suffered from problems with terminology and definition, inappropriate methodologies and hence difficulties with data interpretation. Future directions for research are advocated.

Integrated Primary Health Care: Opportunities for Psychiatric-Mental Health Nurses in a Reforming Health Care System

As changes in our health care system evolve, making the transition to greater parity of mental and physical health is paramount to move health care in the direction of prevention and health promotion. Although parity is the goal, the most feasible path to reaching it may lie in relinking mental health to physical health in managed care models of primary health care. This article identifies emerging directions in the mental health field and points to new opportunities for advancing the practice of psychiatric-mental health nurses.

Psychological distress and bereavement

Some 115 bereaved subjects (43 spouses, 39 adult children, and 33 parents) were followed-up prospectively over 12 months following the acute bereavement period. They completed the Zung Depression Scale, Spielberger's State and Trait Anxiety Measure, the GHQ-28, and Eysenck's Personality Inventory at four time points. With the exception of EPI-Extroversion, there was a significant decrease in all scores over the period encompassing the study. There were no differences between the three groups on any of the psychological variables measured. Scores on the Zung Depression Scale, state and trait anxiety, and neuroticism correlated significantly with a measure of core bereavement phenomenology, the Core Bereavement Items, at each time point for each group.

Immunity and Somatic Health in Bereavement. A Prospective Study of 39 Norwegian Widows

Immunity and health have been reported to be negatively affected after bereavement. It seems probable that these findings are interrelated. However, few studies have studied both health and immunity simultaneously. The present investigation addressed the question of whether immunity was related to health in forty-five widows studied shortly after the death of their husband, and one year later. General health, health subscales (UHI) and immunoglobulins (IgA, IgM, IgG) with components (C3, C4) were measured. Statistics employed were frequencies, paired t-tests, and correlations. Major findings show that general health improved and IgM increased significantly after one year of bereavement. Few and weak relationships were found between health scores and immune parameters. The results were primarily discussed in relation to the connection between depression and immunity, and the unclear connection between changes in immune parameters within normal ranges and health consequences.

Absorption and imagery locate immune responses in the body

Imagery instructions specifying mucosal immunity should alter mucosal immunoglobulin A (m-IgA) levels in high absorbers, whose intent concentration evokes intense physiological responses. After screening for health status, 121 high or low absorbers were randomly assigned to either Relaxation Alone (R), Relaxation with Mucosal Immune Imagery (RI), or Vigilance Task control (VT). Before and after one 60-min intervention, subjects reported theory-relevant psychological variables and provided 5 ml whole saliva, which was immediately frozen and assayed later en masse with enzyme-linked immunoabsorbence (ELISA). MANOVA analysis of psychological variables replicated past research. ANOVA on residualized m-IgA found Time x Absorption interaction and Condition main effects. High more than low absorbers responded to relaxation with mucosal immune imagery by producing higher m-IgA. High absorbers appear able to locate where their immune systems will respond. Individual differences like absorption level need to be emphasized in diagnosis and treatment responsiveness.

Immune function in cigarette smokers who quit smoking for 31 days

A group of 28 healthy, white, male, light-to-moderate smokers, 21 to 35 years of age, were offered a financial inducement to abstain from smoking for 31 days. A matched control group of 11 smokers were paid to continue smoking during the same period. Nonspecific parameters of immune system function were monitored before and at various times after smoking abstinence. Abstinence increased natural killer cell cytotoxic activity but did not alter mitogen-induced T-lymphocyte proliferation as measured by responses to concanavalin A or phytohemagglutinin. Serum cortisol concentrations also decreased after smoking cessation; however, changes in immune function were not correlated with serum cortisol change, nor with indices of smoking such as plasma nicotine and cotinine levels. Responses to concanavalin A and phytohemagglutinin were positively correlated with change in self-reported alcohol ingestion during smoking abstinence. Results indicate that elevation in natural kill cell cytotoxic activity is detectable within 1 month of smoking cessation, even in light-to-moderate smokers. However, elevation in natural killer cell cytotoxic activity appears not to be directly related to cessation-induced reductions in plasma nicotine, cotinine, or circulating cortisol levels.

Stress influence on development of hepatocellular tumors in transgenic mice overexpressing TGF alpha

We investigated whether stress increases tumorigenesis in male transgenic mice that overexpress the gene encoding human transforming growth factor alpha (TGF alpha). At the age of 10-15 months, these mice begin to develop spontaneous hepatocellular carcinomas at high incidence. The male TGF alpha mice were housed with their siblings (non-stressful environment), housed in social isolation, or housed with aggressive non-siblings (stressful environment). Some animals in each group were exposed once a week to a second stressor (swim stress), beginning at the age of 7 months. Housing with aggressive non-siblings increased neoplastic growth in the male TGF alpha mice: the incidence and multiplicity of liver tumors, and tumor burden were higher in these animals than in the sibling-housed mice. Among the isolated TGF alpha mice, only the tumor burden was increased, when compared with the sibling-housed TGF alpha mice. Swim stress significantly increased the incidence of liver tumors and tumor burden in the sibling-housed TGF alpha mice. Plasma levels of 17 beta-estradiol (E2) that are elevated in the TGF alpha mice, were modestly but significantly higher in the non-sibling housed transgenic mice than in the sibling-housed. Natural killer (NK) cell activity, reduced in these mice, was not affected by housing environment. These data suggest that stress promotes the growth of hepatocellular tumors in the male TGF alpha mice. Whether estrogens are involved in mediating this association remains to be determined.

Effects of background stress and anxiety on postoperative recovery

The effects of background stress and anxiety on both short- and long-term recovery were measured in 30 healthy patients undergoing general anaesthesia for day-case dental extractions. Standardised questionnaires presented pre-operatively, assessed psychological status in terms of trait and state anxiety and stress levels. State anxiety was again measured postoperatively; recovery was assessed with pre- and postoperative batteries of cognitive tasks. Correlation coefficients revealed that the level of background stress in the preceding 6 months correlated with physical parameters of recovery such as time taken for patients to open their eyes, perceived pain and increased postoperative morbidity. The study also demonstrated that high levels of state anxiety after surgery correlated with postoperative pain. Trait and state anxiety before surgery did not correlate with any parameters of recovery or postoperative morbidity.

Psychosocial factors in the development and progression of breast cancer

The factors responsible for the genesis of breast cancer remain unclear. Emerging, although controversial, evidence suggests that factors related to life-style, such as dietary fat or alcohol intake, or exposure to various forms of stressors, are associated with mammary tumorigenesis. The possible role of life-style factors in breast cancer is important in light of the fact that mortality to this disease is increasing in most countries and that development of curative therapies for breast cancer has not been forthcoming. Thus, determining the role of life-style factors in the onset and progression of breast cancer, particularly among individuals genetically vulnerable to breast cancer or women with breast cancer in remission, is critical to prevent this disease. We will review the three main hypotheses which have been suggested to link psychosocial factors to the etiology of cancer, emphasizing data obtained through animal models. Interpretation of the existing data suggests that the number of stressful life-events does not predict vulnerability to develop breast cancer or survival from it; a certain level of stress appears to protect from malignancies. The crucial factor affecting tumor growth is the interaction among stress, an individual's personality, and available psychosocial support, and the effect of this interaction on an individual's ability to cope with stress. In addition, other risk factors for breast cancer known to be closely associated with psychosocial factors, namely dietary fat and alcohol consumption, may interact with the effects of psychosocial factors on breast cancer.

Brain self-stimulation and immunity: effect on humoral and cell-mediated immune responses

This study was designed to evaluate the effect of intracranial self-stimulation (ICSS) on specific immunological reactivity in the rat. Male Wistar rats were implanted with stimulating electrodes in the lateral hypothalamus (LH) and ventral tegmental area (VTA). After recovery from surgery and screening procedure, animals were allowed to self-stimulate 30 minutes daily during different periods of time before or after immunization with sheep red blood cells (SRBC) and bovine serum albumin (BSA). We report here on the in vivo immunoregulating effects of ICSS on plaque-forming cell (PFC) response, hemagglutinin production to SRBC, and antibody titer and hypersensitivity skin reactions to BSA. The effects produced were dependent on the brain area which was stimulated, time relationship of ICSS and immunization, type of immune reaction, and antigen used for immunization. Therefore, ICSS appears to be a significant tool in the regulation of the immune system function, and thus provides further evidence of the interconnections between the immune system and behavior.

Alterations in behavior, steroid hormones and natural killer cell activity in male transgenic TGF alpha mice

The expression of transforming growth factor alpha (TGF alpha) is widely distributed throughout many normal and neoplastic tissues, but its physiological significance remains unclear. We have utilized male transgenic mice overexpressing the gene encoding human TGF alpha in multiple tissues to further identify those functions which are influenced by this protein. Male TGF alpha mice develop hepatocellular carcinoma at the age of 10-15 months. At the age of 2-3 months these mice, compared to age matched CD-1 controls, spent significantly longer times immobile in Porsolt's swim test, a model of stress and depressive behavior, and exhibiting aggressive behavior in the resident-intruder test. In contrast, the transgenic TGF alpha mice did not differ from the controls in either the plusmaze test of anxiety, or in their voluntary alcohol intake. Significantly, the TGF alpha mice exhibited a 25% lower Natural Killer (NK) cell activity and a four-fold increase in the plasma levels of 17-beta-estradiol (E2) than the controls. No significant changes in plasma testosterone or corticosterone levels were noted. The results indicate that transgenic male mice overexpressing TGF alpha exhibit behaviors characteristic of both an impaired ability to cope with stress and an increased aggressivity. The TGF alpha mice also show reduced NK cell activity and increased plasma estradiol concentrations. The present data suggest that TGF alpha may be important in influencing behavioral, immunological and hormonal systems prior to the onset of tumors. It remains to be determined whether hepatocarcinoma is associated with the direct proliferative and transforming effects of TGF alpha and/or indirect effects mediated through immune, hormonal and behavioral mechanisms.

The effects of noise stress on leukocyte function in rats

It has been reported that exposure to increased noise levels impairs wound healing in surgical patients and in rats. The purpose of the present study was to determine if exposure to noise stress would alter the biological function of neutrophils, macrophages, and lymphocytes, leukocytes that are involved in wound healing. Rats were exposed to 80 db of "rock" music for 24 hr, during which time the control animals were maintained in their usual environment. Leukocyte subpopulations were obtained and stimulated in vitro. Neutrophils and macrophages from noise-exposed animals secreted significantly less superoxide anion and interleukin-1 than cells from control animals. Lymphocyte function was not altered following noise stress. We conclude that short-term exposure of rats to noise stress alters some of the biological functions of leukocytes.

Innervation of lymphoid organs and implications in development, aging, and autoimmunity

We now have substantial evidence demonstrating noradrenergic sympathetic and peptidergic innervation of both primary and secondary lymphoid organs. We have established criteria for norepinephrine, and some of the neuropeptides, as neurotransmitters, and have found changes in immune responsiveness following pharmacological manipulation of noradrenergic sympathetic or peptidergic nerves. Classic receptor binding studies have demonstrated a wide variety of target cells that possess beta-adrenoceptors and receptors for neuropeptides on cells of the immune system, including lymphocyte subsets, macrophages, accessory cells, or stromal elements. In this chapter we describe noradrenergic and peptidergic innervation of primary and secondary lymphoid organs in development, at maturation and during the normal aging process, and discuss possible functional implications of direct neural signals onto cells of the immune system at critical time points in the lifespan of an animal. Further, we examine for involvement of noradrenergic sympathetic and peptidergic innervation in the development and progression of several autoimmune disorders, including adjuvant-induced arthritis, New Zealand mice strains as a model for hemolytic anemia and lupus-like syndrome, and the experimental allergic encephalomyelitis model for multiple sclerosis.

Sudden unexplained death syndrome--a new manifestation in melioidosis?

The indirect haemagglutination (IHA) test using sensitized turkey erythrocytes and the indirect immunofluorescence assay (IgM-IFA) was confirmed to be sensitive in the detection of a recent or current Pseudomonas pseudomallei infection in 19 culture-confirmed Singapore melioidosis patients. All were found to have antibody titres from 4 to 32768 in the IHA test and 10 to 320 in the IgM-IFA test. When these tests were employed on sera from 16 immigrant Thai construction workers who died of sudden unexplained death syndrome (SUDS) and 73 healthy Thai fellow workers, 93.8% and 68.8% of SUDS cases had IHA titre of greater than or equal to 4 and IgM-IFA titre of greater than or equal to 10 respectively, in contrast to 39.7% and 12.3% found among healthy Thai workers. These data indicate that at the time of death, most of the SUDS patients had an active infection with P. pseudomallei, possibly resulting from reactivation of a latent infection. The aetiological role of P. pseudomallei as the major cause of SUDS is discussed.

The lived experience of survival and bereavement following the death of a lover from AIDS

This phenomenologic study explored the lived experience of survival and bereavement following the death of a lover from AIDS. The sample (N = 8) included individuals who had lost a lover/partner to AIDS within the 18 month period prior to interview. Respondents were asked to reply to the following question: "Please describe your experience of losing a lover to AIDS. Describe events and feelings which you experienced both prior to and after the death of your lover." Themes were identified, analyzed, sorted into theme clusters and then categorized. Categories of Isolation/Disconnectedness, Emotional Confusion, and Acceptance/Denial were identified. A statement of the essential nature of the experience of surviving the death of a lover/partner from AIDS is presented.

Social psychology of the immune system: a conceptual framework and review of the literature

The literature on psychosocial factors affecting the immune system is reviewed. The literature is summarized in terms of a provisional model accounting for immunosuppression in terms of four mutually influential explanatory constructs (dysphoric responses; immunosuppressive behaviors; adverse life experiences; and vulnerability) and the relationships among the diverse manifestations of the constructs. The literature and the summary provisional model point to directions for future research that should establish the intervening role of immunosuppression in the relationships between psychosocial factors and the disease process.

Human psychoneuroimmunology today

Studies in human psychoneuroimmunology began around 1919, but a systematic approach wasn't used until the work of Solomon in the 1960s. Recently, the new specialty has achieved relative independence due to considerable data acquisition. Stress research has revealed relationships between neuroendocrine and immune changes. In parallel, increasing evidence of immunological alterations in psychiatric diseases has expanded the field; presently, immunological correlates of psychosomatic diseases and personality are sought. On the other hand, while immunological disease has been psychologically assessed for many years, a clear-cut link between psyche and immunological changes has yet to be shown. This fact, along with the therapeutic implications of advancing knowledge, will influence strongly the future trends of psychoneuroimmunology. Concepts emerging from the study of this field will be of heuristic value to both psychiatry and immunology and will help define new and expanded limits for both disciplines.

Emotional expression in cancer onset and progression

Despite the intensive biomedical research in oncology since World War II, recent studies show a steady increase in age-adjusted mortality for all kinds of cancer. This findings gives impetus to the efforts of researchers who have adopted the biopsychosocial model. Systematic research using such a model has shown several psychosocial factors to be associated with cancer onset and progression, and Temoshok has recently suggested a theoretical model which unifies these findings. In this paper, I consider the evidence that one of these psychosocial factors, emotional expression, may be directly involved in cancer onset and progression. I review 18 relevant studies, discuss how one might operationalize the term 'emotional expression', and make 12 suggestions for future research.

AIDS-related illness and AIDS risk in male homo/bisexual substance abusers: case reports and clinical issues

Little has been written about the treatment of substance use disorders among seropositive HIV patients or high-risk seronegative substance abusers. Demographic and clinical characteristics, along with treatment issues, were examined based on experience with 18 patients in a substance abuse program in a university medical center (3 AID, 3 ARC, 9 seropositive only, and 3 seronegative high risk). Scores on a substance abuse rating scale were extremely high. Most of them abused three or more different substances, had used drugs parenterally, had more than 50 sex partners, and/or had received previous substance abuse treatment. Affective disorder, suicide attempt, and antisocial personality were frequent in this group. About half of the patients complied with treatment and showed improvement in their substance disorder. Several common themes in the management of these patients are described.

Current perspectives on immunology and psychiatry

We selectively review recent research findings in the field of psychoimmunology which test the hypotheses that immunological dysfunction may be aetiologically related to mental illnesses such as schizophrenia, and that certain morbid affective states such as depression and other forms of psychosocial distress may be the cause of immunosuppression and through this mechanism affect the outcome of illnesses such as cancer. Our examination of research implicating immunological or infective mechanisms in the aetiology of schizophrenia indicates that most studies have been unable to control for major methodological difficulties but the compatibility of these theories with the dopamine hypothesis suggests that further research attention is warranted. More clearly, there is growing evidence demonstrating a link between depression, other states of psychological distress and immunosuppression, but the clinical significance of these findings remains uncertain. The complex relationship between stress and the outcome of illnesses such as cancer is discussed and the possible implications of these findings for clinical psychiatry are suggested.

A biopsychosocial model of medical student distress

Medical student distress was examined in two consecutive first-year classes (N = 312) in September, before they interacted with the school regimen, and again in May before exams. Anxiety means were one SD above the normative mean for nonpatients at both times. The number of students reporting a significant level of depression doubled from September (N = 36) to May (N = 78). The correlation of distress in September and May was .40, indicating that for many students distress was enduring. A biopsychosocial model of initial distress explained more variance (36%) in the cross-validation sample than did any one variable alone. Distressed students had higher Type A scores. Also, anger held in was a risk factor for distress in students with a family history of cardiovascular disease (CVD). Students who hold anger in may experience prolonged stress which, coupled with a family history of CVD, could make them psychobiologically vulnerable to distress.

Neuroendocrine modulation of the immune system. Possible implications for inflammatory bowel disease

Evidence for neuroendocrine regulation of the immune system is reviewed. This includes human clinical studies of the influence of psychological stress on immune function, direct experimentation in animals, including classical Pavlovian conditioning of the immune response, modulation of immune function in vitro by chemical messengers such as neuropeptides, the finding of receptors for neuropeptides on immunocytes, and the demonstration that lymphoid tissue is directly innervated. Secretory products of the immune system, which include interleukins and neuropeptides, may also influence the neuroendocrine system. Communication between the two systems is therefore bidirectional. The potential importance of the neuropeptide-immunocyte interaction within the intestinal mucosal immune system is emphasized, and its possible relevance in inflammatory disorders is discussed. This aspect of the "gut-brain" interaction deserves further study.