Daily psychosocial stressors and cyclic response patterns in urine cortisol and neopterin in a patient with systemic lupus erythematosus

Personalized therapy in rheumatoid arthritis (PETRA): a protocol for a randomized controlled trial to test the effect of a psychological intervention in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease that primarily affects cartilage and bone. Psychological stress can both trigger disease exacerbation and result from disease activity. As standard pharmacological interventions alone have limited success in treating RA, a more comprehensive biopsychosocial approach to treatment has been recommended. In this prospective randomized controlled trial (RCT), a psychotherapeutically guided, group-based intervention program will be conducted with RA patients over a period of 9 months. This program combines a dynamic-interactional model with disorder-specific coping-oriented perspectives to improve patients' social, emotional, and problem-solving competencies as well as stress system functional status. The enrolment of 440 patients, randomly allocated to either an intervention (n = 220) or control group (n = 220), is planned. To evaluate the intervention effect, various indicators of RA disease activity, stress system activity, and psychological condition will be assessed through sets of standardized questionnaires and biochemical analyses of blood and saliva samples. Moreover, healthcare-related costs for each patient will be obtained using routine health insurance data. Outcome variables will be measured in all patients at regular intervals prior to intervention (baseline), during the 9-month intervention (five time points), and during a 9-month follow-up phase (three time points), allowing the comprehensive analysis of within- and between-subject effects, i.e. trajectories of the target variables in the intervention and control groups. In addition, to investigate the intervention effects on real-life stress system functioning in RA, 10 integrative single-case studies (n = 5 from the intervention group, n = 5 from the control group) will be conducted. In each study, once before and after the 9-month intervention, urine samples will be collected, and patients will fill out questionnaires for approximately 1 month at 12-h intervals. Moreover, weekly in-depth interviews will be conducted with patients to determine their previous week's emotionally positive and negative incidents. Using time series analysis, it is then possible to investigate whether and how stress system function in these RA patients has improved from the applied intervention. By using both an investigational macro- and microperspective, this project aims to evaluate a psychological intervention in the routine care of individuals with RA.Trial registration German Clinical Trials Register DRKS00028144. Registered on 1 March 2022.

Emotional states predict cellular immune system activity under conditions of life as it is lived: A multivariate time-series analysis approach

The relationship between emotional states and immune system activity is characterized by bidirectional influences; however, limited information is available regarding the temporal dynamics of these effects. The goal of this investigation was to examine how these psychoimmunological interdependencies unfold over time under conditions of "life as it is lived". For this purpose, three healthy women collected their entire urine over a period of approximately two months at 12-h intervals (8 am-8 pm, 8 pm-8 am), resulting in a total of 112 to 126 consecutive measurements per subject. In addition, among other regular psychological assessments, the subjects completed the EWL-60-S, an emotional state questionnaire, each morning and evening. To assess the extent of T-helper type 1 immune activation, the neopterin per creatinine concentration was measured in the urine samples using high-pressure liquid chromatography. The dynamic relationships between the time series of the six emotional states (performance-related activity, general inactivity, extraversion/introversion, general feeling of comfort, emotional irritation, anxiety/depressiveness) and urinary neopterin levels were estimated in vector-autoregressive models and evaluated using Granger-causality tests, impulse-response functions and forecast error variance decompositions. The findings showed that emotional states explained up to 20% of the variance of urinary neopterin per creatinine levels, whereby most of the effects occurred within a period of approximately three days. Across all subjects, increases in anxiety/depressiveness and extraversion led to increases in neopterin levels, while a general feeling of comfort led to decreases in neopterin. These results emphasize the importance of the interdependencies between emotional states and immune system activity and showcase the potential that intensive longitudinal study designs offer for psychoneuroimmunology.

Real-Life Cause-Effect Relations Between Urinary IL-6 Levels and Specific and Nonspecific Symptoms in a Patient With Mild SLE Disease Activity

Background

Little is known about the real-time cause-effect relations between IL-6 concentrations and SLE symptoms.

Methods

A 52-year-old woman with mild SLE activity collected her entire urine for the determination of IL-6/creatinine and protein/creatinine levels (ELISA, HPLC) for a period of 56 days in 12 h intervals (total: 112 measurements). Additionally, she answered questionnaires (VAS) on oral ulceration, facial rash, joint pain, fatigue and tiredness and measured her temperature orally twice a day. Time-series analyses consisted of ARIMA modeling and cross-correlational analyses (one lag = 12 h, significance level = p < 0.05).

Results

Statistical analyses showed that increased urinary IL-6 concentrations preceded increased urinary protein levels by 36-48 h (lag3: r=+.225; p=.017) and that, in the opposite direction of effect, increased urinary protein preceded urinary IL-6 decreases by 12-24 h (lag1: r=-.322; p<.001). Moreover, urinary IL-6 increases co-occurred with increased oral ulceration (lag0: r=+.186; p=.049); after 48-60 h, however, IL-6 increases showed a strong tendency to precede oral ulceration decreases (lag4: r=-.170; p=.072). Increases in facial rash preceded decreases in urinary IL-6 after 84-96 h (lag7: r=-.215; p=.023). As to fatigue, increases in urinary IL-6 co-occurred with decreased fatigue (lag0: r=-.193; p=.042); after 84-96 h, however, IL-6 increases preceded fatigue increases (+lag7: r=+.189; p=.046). Finally, joint pain, tiredness and body temperature did not significantly correlate with urinary IL-6 concentrations in either direction of effect.

Conclusions

The results of this evaluation point to real-life feedback mechanisms between immune activity and SLE symptoms. Comparison with a previous evaluation of this patient suggests a counterregulatory mechanism between Th1 activity and IL-6. These findings are preliminary and require replication to draw firm conclusions about the real-time relation between IL-6 and SLE disease activity.

About-Weekly Pattern in the Dynamic Complexity of a Healthy Subject's Cellular Immune Activity: A Biopsychosocial Analysis

In a previous integrative single-case study, we collected biological, psychological and social time-series data on a 25-year-old healthy woman over the course of 126 12-h intervals (63 days) and used urinary neopterin as an indicator of cellular immune activity [Schubert et al. 2012 (1)]. The present re-evaluation introduced Dynamic Complexity (DC) as an additional non-linear and non-stationary measure to further investigate the subject's biopsychosocial dynamics during the study. The new time series dealing with urinary neopterin complexity revealed a cyclic, circaseptan (about-weekly) repeating pattern (6.59 days). The only weekly reoccurring events over the course of the study that were associated with this immunological pattern were the in-depth interviews with the subject (mean distance between interviews: 6.5 days). Superposed epoch analysis (SEA) revealed a U-shaped relation between neopterin complexity and interviews, with a decrease in neopterin complexity before and during interviews and an increase after interviews. Furthermore, the complexity scores for irritation, anxiousness/depressiveness and mental activity were positively correlated with neopterin complexity. The results suggest that the interviews, which had been found to be related to the subject's need for educational and/or social accomplishment, were marked by stress (decrease in psycho-immunological flexibility and adaptability), which was then relieved after the interviews (increase in psycho-immunological flexibility and adaptability). It appears that the subject's cellular immune activity, as indicated by neopterin complexity, functionally mirrored the emotional meaning she ascribed to the in-depth interviews. This re-evaluation is in line with the view that biopsychosocial research requires multimodal analysis of single cases based on qualitative (e.g., in-depth interviews) and quantitative (e.g., time series analysis) data under conditions of "life as it is lived".

Adverse Life Trajectories Are a Risk Factor for SARS-CoV-2 IgA Seropositivity

Asymptomatic individuals, called “silent spreaders” spread SARS-CoV-2 efficiently and have complicated control of the ongoing COVID-19 pandemic. As seen in previous influenza pandemics, socioeconomic and life-trajectory factors are important in disease progression and outcome. The demographics of the asymptomatic SARS-CoV-2 carriers are unknown. We used the CON-VINCE cohort of healthy, asymptomatic, and oligosymptomatic individuals that is statistically representative of the overall population of Luxembourg for age, gender, and residency to characterise this population. Gender (male), not smoking, and exposure to early-life or adult traumatic experiences increased the risk of IgA seropositivity, and the risk associated with early-life exposure was a dose-dependent metric, while some other known comorbidities of active COVID-19 do not impact it. As prior exposure to adversity is associated with negative psychobiological reactions to external stressors, we recorded psychological wellbeing during the study period. Exposure to traumatic events or concurrent autoimmune or rheumatic disease were associated with a worse evolution of anxiety and depressive symptoms throughout the lockdown period. The unique demographic profile of the “silent spreaders” highlights the role that the early-life period plays in determining our lifelong health trajectory and provides evidence that the developmental origins of health and disease is applicable to infectious diseases.

Dynamic Effects of CAM Techniques on Inflammation and Emotional States: An Integrative Single-Case Study on a Breast Cancer Survivor

BACKGROUND

This study on a breast cancer survivor investigated how episodic practice of various complementary and alternative medicine (CAM) techniques affected the dynamics of emotional states and urinary neopterin-an inflammation marker.

METHODS

The 49-year-old female patient (diagnosis: ductal breast carcinoma 5 years before study start, suffering from chronic fatigue and depression) collected her entire urine in 12-hour intervals (from about 8 a.m. to 8 p.m. and from about 8 p.m. to 8 a.m.) for 28 days. The resulting 55 consecutive urine samples were analyzed for neopterin and creatinine levels using HPLC. Also in 12-hour intervals, the patient filled out questionnaires on emotional states and everyday routine, including CAM practice. Weekly, she was interviewed to identify emotionally meaningful everyday incidents, including use of CAM techniques. Time series analysis consisted of ARIMA modeling and cross-correlational analyses.

RESULTS

Qualitative evaluation revealed that, with the exception of Tai Chi, all CAM techniques, that is, Jin Shin Jyutsu, music, physiotherapy and energy healing, were experienced as positive. Cross-correlational analyses showed that practice of such CAM techniques was followed first by significant (P < .05) increases in positive mood and mental activity on the same day (lag 0) and then by decreases in positive mood after a total of 72 to 84 hours (+lag 6) and in mental activity after a total of 84 to 96 hours (+lag 7). Negative mood, by contrast, first decreased on the day of CAM practice (lag 0) and then increased after a total of 84 to 96 hours (+lag 7) following CAM. Moreover, urinary neopterin levels first increased on the day of CAM practice (lag 0) and then decreased after a total of 36 to 48 hours (+lag 3). Similar biphasic effects were also detected for irritation in response to CAM, although only partly significant.

CONCLUSION

Cyclic psychophysiological response patterns following CAM practice were attributable to biopsychosocial feedback mechanisms involving personally meaningful experiences. As lower neopterin levels following CAM point to a health-promoting effect, the patient of this study may have actively contributed to her healing process through episodic CAM practice.

Case Report: Dynamic Interdependencies Between Complementary and Alternative Medicine (CAM) Practice, Urinary Interleukin-6 Levels, and Fatigue in a Breast Cancer Survivor

Background: This study investigated the influence of complementary and alternative medicine (CAM) techniques (i.e., Jin Shin Jyutsu, music, physiotherapy, Tai Chi, and energy healing) on urinary interleukin-6 (IL-6) levels and fatigue in a 49-year-old breast cancer survivor suffering from cancer-related fatigue and depression. Data were sampled under conditions of "life as it is lived." Methods: For 28 days, a female breast cancer survivor collected her full urine output in 12-h intervals from about 8 a.m. to 8 p.m. and from about 8 p.m. to 8 a.m. These urine samples were used to determine urinary IL-6 levels through ELISA and creatinine concentrations via HPLC. In 12-h intervals (every morning and evening), the patient completed the DIARI, which included fatigue measurement and notes on incidents and activities such as CAM practice. In addition, the patient was interviewed weekly to identify meaningful everyday incidents. In this context, CAM practice was also discussed. Time series analysis consisted of ARIMA modeling and cross-correlational analyses (p < 0.05). Results: When each CAM technique was considered separately in time series analysis, CAM was consistently associated with increases in urinary IL-6 release and decreases in fatigue. Furthermore, when all CAM techniques experienced as positive were included in one time series, a biphasic urinary IL-6 response pattern was found in which CAM practice was first preceded by decreases in IL-6 by 12-0 h and then followed by increases in IL-6 after 108-120 h. Finally, cross-correlations between IL-6 and fatigue showed that increases in IL-6 were followed by decreases in fatigue intensity after 48-60 h and, conversely, that decreases in fatigue intensity were followed by decreases in IL-6 after 24-36 h and 48-60 h. Conclusion: IL-6 increases and fatigue decreases highlight potential health-promoting effects of CAM practice. Moreover, a cyclic IL-6 pattern in response to all CAM activities experienced as positive underscores that CAM was meaningful to the patient. Additionally, a negative feedback circuit between IL-6 and fatigue intensity was detected. Taken together, this study confirms the necessity of integrating subjective meaning and dynamic complexity into biopsychosocial research in order to understand human functioning under real-life conditions.

Bidirectional Cause-Effect Relationship Between Urinary Interleukin-6 and Mood, Irritation, and Mental Activity in a Breast Cancer Survivor

This "integrative single-case study" investigated the bidirectional cause and effect relations between various emotional states (i.e., mood, irritation, mental activity) and urinary IL-6 levels in a 49-year-old female breast cancer survivor (woman) under conditions of "life as it is lived." During a period of 28 days, the patient collected her entire urine in 12-h intervals for IL-6 measurement and completed each morning and evening a list of adjectives regarding mood, irritation, and mental activity (55 measurements in total). Autoregressive integrated moving average modeling revealed a 4-day (circasemiseptan) cycle in the IL-6 time series. Furthermore, cross-correlational analyses after controlling for serial dependencies (significance level: p < 0.05) showed that worsening in mood and increases in irritation were followed by increases in urinary IL-6 levels with temporal delays between 12 and 36 h. In the opposite direction of effect, increases in urinary IL-6 levels were followed by elevations in mood and mental activity as well as decreases in irritation with temporal delays between 48 and 72 h. These results from cross-correlational analyses suggest that IL-6 may have a regulatory function in psychoneuroimmunological interplay and that, under certain conditions, IL-6 may be involved in health rather than sickness behavior. Moreover, the findings of this study are indicators of real-life negative feedback loops and are in line with psychoneuroimmunological research postulating complex brain-to-body-to-brain network-like structures.

Subjective Positive and Negative Sleep Variables Differentially Affect Cellular Immune Activity in a Breast Cancer Survivor: A Time-series Analysis Approach

This study on a breast cancer survivor suffering from cancer-related fatigue (CaRF) and depression investigated the bidirectional relationship between cellular immune activity and subjective sleep. The 49-year-old patient (breast cancer diagnosis 5 years before the study, currently in remission) collected her full urine output for 28 days in 12-h intervals (8:00 p.m. to 8:00 a.m. and 8:00 a.m. to 8:00 p.m.). These urine samples were used to determine urinary neopterin (cellular immune activation marker) and creatinine concentrations via high-pressure liquid chromatography (HPLC). Each morning, the patient answered questions on five sleep variables: sleep quality (SQ), sleep recreational value (SRV), total sleep time (TST), total wake time (TWT), and awakenings during sleep period (ADS). For the purpose of this study, the time series of the nighttime urinary neopterin levels and the five sleep variables were determined. Using centered moving average (CMA) smoothing and cross-correlational analysis, this study showed that increases in the positive sleep variables SQ and SRV were followed by urinary neopterin concentration decreases after 96–120 h (SQ, lag 4: r = −0.411; p = 0.044; SRV: lag 4: r = −0.472; p = 0.021) and 120–144 h (SRV, lag 5: r = −0.464; p = 0.026). Increases in the negative sleep variable TWT, by contrast, were followed by increases in urinary neopterin concentrations 72–96 h later (lag 3: r = 0.522; p = 0.009). No systematic effects in the other direction, i.e., from urinary neopterin levels to sleep, were observed in this study. Although preliminary, the findings of this study highlight the benefit of carefully investigating temporal delays and directions of effects when studying the dynamic relationship between sleep and immune variables in the natural context of everyday life.

The relationship between 63days of 24-h urinary free cortisol and hair cortisol levels in 10 healthy individuals

BACKGROUND

Interest in measuring cortisol in scalp hair is increasing because of its assumed ability to provide a historical timeline of previous systemic levels of cortisol. Yet, it remains uncertain how well hair cortisol represents the total systemic secretion of cortisol over time.

METHODS

Ten healthy individuals collected 24-h urine samples for 63 consecutive days and provided a hair sample at the end of the study period. 24-h urinary creatinine levels in every urine sample were determined to assess completeness of the samples. Cortisol levels in 24-h urine samples and in hair were measured with liquid chromatography tandem mass spectrometry. The correlations between urinary cortisol and hair cortisol were calculated using Kendall's tau.

RESULTS

We found a nonsignificant moderate correlation between average urinary cortisol secretion and average hair cortisol concentration r_т=0.422, p=0.089.

CONCLUSIONS

Hair cortisol concentration correlates low to moderately with 24-h urinary cortisol concentration over a period of 63days.

Stress as a predictor of cognitive functioning in lupus

The objective of this study was to investigate the possible effects of the daily stress experienced during a six-month period on the cognitive functioning of patients with systemic lupus erythematosus (SLE). For this purpose, we evaluated the daily stress of 21 patients with lupus every day for six months. Later, we carried out a neuropsychological exam that included an evaluation of attention and memory. At the same time, scores on depression and anxiety were recorded with the objective of controlling other emotional variables that might be influencing these cognitive processes. The results show that daily stress was able to predict the scores on the neuropsychological variables studied. Specifically, the daily stress experienced in the previous six months is the variable with the greatest explanatory-predictive power on the scores for delayed recall visual memory, visual fluency and attention speed. This relationship proved to be negative in all three cases ( R2 corr = 0.290; t = −2.712, P < 0.014); ( R2 corr = 0.318; t = −2.818, P < 0.012); ( R2 corr = 0.319; t −2.906, P < 0.009), which means that the greater the daily stress, the lower the score on visual memory, fluency and total attention speed. We can state that daily stress is related to impairments in visual memory, fluency and attention in patients with SLE. This effect was not found with other emotional variables, such as depression and anxiety.

The temporal dynamics of cortisol and affective states in depressed and non-depressed individuals

OBJECTIVES

Cortisol levels have been related to mood disorders at the group level, but not much is known about how cortisol relates to affective states within individuals over time. We examined the temporal dynamics of cortisol and affective states in depressed and non-depressed individuals in daily life. Specifically, we addressed the direction and timing of the effects, as well as individual differences.

METHODS

Thirty depressed and non-depressed participants (aged 20-50 years) filled out questionnaires regarding their affect and sampled saliva three times a day for 30 days in their natural environment. They were pair-matched on age, gender, smoking behavior and body mass index. The multivariate time series (T=90) of every participant were analyzed using vector autoregressive (VAR) modeling to assess lagged effects of cortisol on affect, and vice versa. Contemporaneous effects were assessed using the residuals of the VAR models. Impulse response function analysis was used to examine the timing of effects.

RESULTS

For 29 out of 30 participants, a VAR model could be constructed. A significant relationship between cortisol and positive or negative affect was found for the majority of the participants, but the direction, sign, and timing of the relationship varied among individuals.

CONCLUSION

This approach proves to be a valuable addition to traditional group designs, because our results showed that daily life fluctuations in cortisol can influence affective states, and vice versa, but not in all individuals and in varying ways. Future studies may examine whether these individual differences relate to susceptibility for or progression of mood disorders.

How to assess stress biomarkers for idiographic research?

Associations between stress-related biomarkers, like cortisol or catecholamines, and somatic or psychological symptoms have often been examined at the group level. Studies using this nomothetic approach reported equivocal findings, which may be due to high levels of intra-individual variance of stress biomarkers. More importantly, analyses at the group level provide information about the average patient, but do not necessarily have meaning for individual patients. An alternative approach is to examine data at the level of individual patients in so-called idiographic research. This method allows identifying individuals in whom symptoms are explained by preceding alterations in specific stress biomarkers, based on time series of symptoms and stress biomarkers. To create time series of sufficient length for statistical analysis, many subsequent stress biomarker measurements are needed for each participant. In the current paper, different matrices (i.e. saliva, urine, nail and hair) are discussed in light of their applicability for idiographic research. This innovative approach might lead to promising new insights in the association between stress biomarkers and psychological or somatic symptoms. New collection tools for stress biomarkers, like the use of sweat pads, automated microdialysis systems, dried blood spots, or smartphone applications, might contribute to the feasibility and implementation of idiographic research in the future.

Cause-effect relations between 55 kD soluble TNF receptor concentrations and specific and unspecific symptoms in a patient with mild SLE disease activity: an exploratory time series analysis study

BACKGROUND

This integrative single-case study investigated the 12 h-to-12 h cause-effect relations between 55 kD soluble tumor necrosis factor receptor type 1 (sTNF-R55) and specific and unspecific symptoms in a 52-year-old Caucasian woman with mild systemic lupus erythematosus (SLE) disease activity.

METHODS

The patient collected her entire urine for 56 days in 12 h-intervals to determine sTNF-R55/creatinine and protein/creatinine levels (ELISA, HPLC). Additionally, twice a day, she took notes on oral ulceration and facial rash; answered questionnaires (VAS) on fatigue, weakness, and joint pain; and measured body temperature orally. Time series analysis consisted of ARIMA modeling and cross-correlational analyses (significance level = p < 0.05).

RESULTS

Time series analysis revealed both a circadian and a circasemiseptan rhythm in the urinary sTNF-R55 data. Moreover, several significant lagged correlations between urinary sTNF-R55 concentrations and SLE symptoms in both directions of effect were identified. Specifically, increased urinary sTNF-R55 concentrations preceded decreased urinary protein levels by 36-48 h (r = -0.213) and, in the opposite direction of effect, increased protein levels preceded increased sTNF-R55 concentrations by 24-36 h (r = +0.202). In addition, increased urinary sTNF-R55 levels preceded increased oral ulcers by 36-48 h (r = +0.277) and, conversely, increased oral ulceration preceded decreased sTNF-R55 levels by 36-48 h (r = -0.313). Moreover, increased urinary sTNF-R55 levels preceded decreased facial rash by 36-48 h (r = -0.223) and followed increased body temperature after 36-48 h (r = +0.209). Weakness, fatigue and joint pain were not significantly correlated with urinary sTNF-R55 levels.

CONCLUSIONS

This study gathered first evidence of real-life, long-term feedback loops between cytokines and SLE symptoms in mild SLE disease activity. Such insights into the potential role of sTNF-R55 in SLE would not have been possible had we applied a pre-post design group study. These findings require replication before firm conclusions can be drawn.

Elevated Salivary Alpha-Amylase Level, Association Between Depression and Disease Activity, and Stress as a Predictor of Disease Flare in Systemic Lupus Erythematosus: A Prospective Case-Control Study

Psychological stress has been shown to trigger systemic lupus erythematosus (SLE). However, objective evidence of symptom aggravation due to mental stress is difficult to identify. We aimed to investigate the relationship between SLE disease activity and mental stress, and the usefulness of saliva as an assessment index for stress in patients with SLE.We prospectively assessed the salivary stress hormone and disease-related biomarkers, and questionnaire data regarding stress and depression in 100 patients with SLE and 49 sex- and age-matched normal controls (NCs).Patients with SLE had higher mean salivary α-amylase levels (5.7 ± 4.6 U/mL vs 2.7 ± 2.5 U/mL, P < 0.001), anti-chromatin antibody levels (25.3 ± 22.9 U/mL vs 15.9 ± 10.9 U/mL, P < 0.001), and Beck Depression Index (BDI) scores (11.1 ± 9.2 vs 5.3 ± 5.1, P < 0.001) than NCs. However, salivary cortisol levels and Perceived Stress Scale (PSS) scores did not differ between the groups. The BDI scores correlated with the SLE disease activity index (SLEDAI) scores (r = 0.253, P = 0.011) and erythrocyte sedimentation rates (r = 0.234, P = 0.019). SLE patients with the highest-quartile PSS scores had significantly increased SLEDAI scores compared to those with the lowest-quartile PSS scores after 4 to 5 months' follow-up. Moreover, SLE patients with elevated SLEDAI scores had higher baseline PSS scores.Patients with SLE showed uncoupling of the sympathetic nervous system and hypothalamic-pituitary-adrenal axis; higher salivary α-amylase and no different cortisol levels compared with NCs. Also, patients with SLE were more depressed, which correlated with disease activity. Furthermore, perceived stress was not correlated with disease activity; however, disease activity worsened several months later with elevated perceived stress levels.

Emotion regulation and mental representation of attachment in patients with systemic lupus erythematosus: a study using the Adult Attachment Interview

Mental representations of attachment and emotion regulation influence individual patterns of stress response and vulnerability to illness. The present study investigates the adult attachment states of mind of 40 women with systemic lupus erythematosus (SLE) using the Adult Attachment Interview. We also assessed alexithymia using the Toronto Alexithymia Scale and dissociation using the Dissociative Experiences Scale. The results showed a high prevalence of the unresolved state of mind (13 patients, 32.5%) and the entangled state of mind (10 patients, 25%). The alexithymia score also varied significantly as a function of the mental representation of attachment and was modulated by amnestic dissociation. These findings suggest that adult attachment in patients with SLE influences the presence of alexithymic features. Moreover, these also indicate that dissociative states mediate the perception of painful memories and feelings, thus contributing to the partial avoidance of emotions and the failure to fully experience and recognize them. The clinical implications of these findings are also discussed.

Symbolic diseases and "mindbody" co-emergence. A challenge for psychoneuroimmunology

Physical diseases that appear to be symbolic somatic representations of patients' personal meanings or individual 'stories' continue to be reported in the medical literature. The identification of a symbolic disease requires a clinical focus upon a patient's highly individual and nuanced meanings largely rendered invisible by the usual methodologies of clinical and research medicine, which has no coherent model for understanding symbolic disease. Therefore, a model is proposed of co-emergence of physicality and subjectivity, body and mind, disease and meaning, disease and symbol, which does provide a coherent basis for understanding symbolic disease. The 'mindbody' co-emergence model avoids mind and body dualism, assumes unbroken continuity between internal body processes and external interpersonal meanings and influences, and asserts that disease-related 'internal' bodily changes and collateral external interpersonal and environmental fluxes are mutually contingent and crucial to the development of the disease. The co-emergence model is discussed specifically in relation to psychoneuroimmunology, but it has exciting clinical and research implications for the whole of medicine.

Stress system dynamics during "life as it is lived": an integrative single-case study on a healthy woman

Little is known about the dynamic characteristics of stress system activity during "life as it is lived". Using as representative a study design as possible, this investigation sought to gain insights into this area. A healthy 25-year-old woman collected her entire urine over a period of 63 days in 12-h intervals (126 measurements) to determine cortisol and neopterin (immune activation marker) levels. In addition, she filled out questionnaires on emotional state and daily routine in 12-h intervals, and was interviewed weekly to identify emotionally negative and positive everyday incidents. Adjusted cross-correlational analyses revealed that stressful incidents were associated with cyclic response patterns in both urinary cortisol and urinary neopterin concentrations. Urinary cortisol levels first decreased 12-24 h after stressful incidents occurred (lag 1: -.178; p = 0.048) and then increased a total of 72-84 h later (lag 6: +.224; p = 0.013). Urinary neopterin levels first increased 0-12 h before the occurrence of stressful incidents (-lag 1: +.185; p = 0.040) and then decreased a total of 48-60 h following such stressors (lag 4: -.181; p = 0.044). Decreases in urinary neopterin levels were also found 24-36 and 48-60 h after increases in pensiveness (lag 2: -.215; p = 0.017) and depressiveness (lag 4: -.221; p = 0.014), respectively. Findings on emotionally positive incidents sharply contrasted with those dealing with negative experiences. Positive incidents were followed first by urinary cortisol concentration increases within 12 h (lag 0: +.290; p = 0.001) and then by decreases after a total of 60-72 h (lag 5: -.186; p = 0.039). Urinary neopterin levels first decreased 12-24 h before positive incidents occurred (-lag 2: -.233; p = 0.010) and then increased a total of 12-24 h following these incidents (lag 1: +.222; p = 0.014). As with previous investigations on patients with systemic lupus erythematosus (SLE), this study showed that stress system response can be considerably longer and more complex and differentiated than findings from conventional group studies have suggested. Further integrative single-case studies will need to be conducted in order to draw firm conclusions about stress system dynamics under real-life conditions.

[Psychoneuroimmunology: an update]

Psychoneuroimmunology (PNI) is closely associated with the bidirectional pathways between mind/brain and the immune system. PNI research represents a rapidly growing area within psychosomatic research. Recent studies in PNI are based mainly on the immunological concepts of Th1/Th2 dichotomy and inflammation. This review covers human PNI studies dealing with stress-associated changes in cytokine (Th1, Th2) levels in immune-related processes such as wound healing, atopic diseases as well as autoimmune and other inflammatory diseases. It is shown that PNI studies measuring immune activity near the site of the disease (e. g. woundhealing) and dealing with objective stressors show more consistent findings (stress-associated Th1/Th2 shift, stress-associated proinflammatory activation) than those dealing with chronic and complex diseases (e. g., autoimmune disease). This warrants the expansion of the methodological repertoire in future PNI research toward designs allowing for the investigation of complex psychosomatic phenomena.

Effects of stress on heart rate complexity--a comparison between short-term and chronic stress

This study examined chronic and short-term stress effects on heart rate variability (HRV), comparing time, frequency and phase domain (complexity) measures in 50 healthy adults. The hassles frequency subscale of the combined hassles and uplifts scale (CHUS) was used to measure chronic stress. Short-term stressor reactivity was assessed with a speech task. HRV measures were determined via surface electrocardiogram (ECG). Because respiration rate decreased during the speech task (p<.001), this study assessed the influence of respiration rate changes on the effects of interest. A series of repeated-measures analyses of covariance (ANCOVA) with Bonferroni adjustment revealed that short-term stress decreased HR D2 (calculated via the pointwise correlation dimension PD2) (p<.001), but increased HR mean (p<.001), standard deviation of R-R (SDRR) intervals (p<.001), low (LF) (p<.001) and high frequency band power (HF) (p=.009). Respiratory sinus arrhythmia (RSA) and LF/HF ratio did not change under short-term stress. Partial correlation adjusting for respiration rate showed that HR D2 was associated with chronic stress (r=-.35, p=.019). Differential effects of chronic and short-term stress were observed on several HRV measures. HR D2 decreased under both stress conditions reflecting lowered functionality of the cardiac pacemaker. The results confirm the importance of complexity metrics in modern stress research on HRV.

A new look at the neural diathesis--stress model of schizophrenia: the primacy of social-evaluative and uncontrollable situations

The neural diathesis-stress model of schizophrenia proposes that stress, through its effects on cortisol production, acts upon a preexisting vulnerability to trigger and/or worsen the symptoms of schizophrenia. In line with its focus on the neurobiology of stress response in schizophrenia, this model treats stressors as a homogeneous category. Recent research has shown that, in healthy individuals, cortisol is most strongly produced in response to stressors that result from perceived uncontrollable threats to important goals and/or social-evaluative threats. We hypothesize that it is specifically these stressors that trigger and/or worsen the symptoms of schizophrenia in those with a preexisting vulnerability. This hypothesis may provide a way of making sense of contradictory findings on the relations between stress and schizophrenia. We propose some empirical tests of this hypothesis and explore implications for the treatment and management of the disorder.

The association between fatigue and inflammatory marker levels in cancer patients: a quantitative review

Increased cytokine and neopterin levels may be responsible for cancer-related fatigue, the most common complaint among cancer patients. We quantitatively reviewed empirical findings on this topic, focusing on studies not using immunotherapy. PubMed, PsychINFO and BIOSIS were searched for articles published until July 2006. Studies remained unweighted or were weighted according to study quality and sample size. The correlation coefficient r was used for statistical analyses. Heterogeneity among the studies was examined using the I(2) index. Eighteen studies (1037 participants) of moderately high methodological quality were located and statistically analyzed. Most studies measured more than one inflammatory marker, resulting in a total of 58 correlation estimates. In 31 of these, we had to input a null correlation because results had been simply reported as nonsignificant and no further statistical information was available. General analyses based on weighting according to sample size showed a significantly positive correlation between fatigue and circulating levels of inflammatory markers (r=0.11, p<0.0001). Analyses of individual inflammatory markers revealed significantly positive correlations between fatigue and IL-6 (r=0.12, p=0.004), fatigue and IL-1 ra (r=0.24, p=0.0005), and fatigue and neopterin (r=0.22, p=0.0001). Fatigue did not correlate significantly with IL-1 beta (r=0.05, p=0.42) or TNF-alpha (r=0.04, p=0.34). Given its preliminary nature due to the limited available data, this quantitative review showed a positive association between cancer-related fatigue and circulating levels of IL-6, IL-1 ra and neopterin. Future studies examining the relationship between cancer related fatigue and inflammation would benefit from multiple rather than single blood sampling and from repeated daily ratings of the multidimensional nature of fatigue.

Fluctuation in self-perceived stress and increased risk of flare in patients with lupus nephritis carrying the serotonin receptor 1A -1019 G allele

OBJECTIVE

Stress is believed to be a risk factor for systemic lupus erythematosus (SLE) flare. Two serotonin-related gene polymorphisms, the serotonin receptor 1A (5-HT1A) polymorphism at -1019C>G and the serotonin transporter LS polymorphism, have been reported to affect stress-related behaviors. The purpose of this study was to assess the relationship between self-perceived stress (SPS), variability in SPS, and the 2 serotonin-related gene polymorphisms as risk factors for SLE flare.

METHODS

Seventy-seven SLE patients (50 with lupus nephritis) were evaluated every 2 months (mean +/- SD total followup 18.5 +/- 8.5 months), and patients recorded their daily SPS levels (0-10 scale). Values for mean SPS and coefficient of variation (CV) for SPS were calculated from the 60-day block of daily measurements between study visits. Serotonin-related gene polymorphism genotypes were determined by polymerase chain reaction-based methods.

RESULTS

Of the 77 patients, 53 experienced 80 flares of SLE (32 renal flares) based on prespecified criteria. Multivariate analysis revealed that whereas neither the serotonin-related gene polymorphisms nor the mean SPS was predictive of an SLE flare, an increased CV for SPS was predictive (P = 0.0031). Interaction between the CV for SPS and the 5-HT1A -1019C>G polymorphism was also found to be a predictor of SLE flare (P = 0.0039). Subset analysis revealed that only in lupus nephritis patients were increasing CVs for SPS (P = 0.0002) and the interaction between CVs for SPS and 5-HT1A (P < 0.0001) predictive of a flare. Odds ratio curves demonstrated that the predictive effect of increasing CVs for SPS required the presence of the 5-HT1A -1019 G allele, but appeared to be independent of the G allele number.

CONCLUSION

Fluctuation in the level of SPS is a risk factor for the onset of flare in SLE patients with major renal manifestations when it occurs on the background of a stress-related susceptibility gene (the 5-HT1A -1019 G allele).

Stress and coping strategies in systemic lupus erythematosus: a review

Systemic lupus erythematosus (SLE), a chronic and unpredictable disease accompanied by functional disability and a possible involvement of the central nervous system, leads to considerable psychological distress. A review of studies on stress and/or coping strategies in SLE since 1990 is presented. Many studies have investigated the place of major and minor stress and coping strategies in SLE morbidity (disease activity, organ damage, and physical and mental components of quality of life). Stress as a causal factor is not proved, but it seems to act as an exacerbating factor in disease activity and to have an impact on the quality of life. Coping strategies are more consistently associated with quality of life than with disease activity. Organ damage appears to be less associated with psychosocial factors than disease activity or quality of life. Despite the limitations of these studies, therapeutic interventions should be proposed to reduce psychological distress, to improve the quality of life and possibly to moderate the evolution of the disease.

Using interaction graphs for analysing the therapy process

BACKGROUND

Therapy processes are complex dynamical systems where several variables are constantly interacting with each other. In general, the underlying mechanisms are difficult to assess. Our approach is to identify the dependency structure of relevant variables within the therapy process using interaction graphs. These are instruments for multivariate time series which are based on the analysis of partial spectral coherences. We used interaction graphs in order to investigate the therapy process of a multimodal therapy concept for fibromyalgia patients. Our main hypothesis was that self-efficacy plays a central role in the therapy process.

METHODS

Patients kept an electronic diary for 13 weeks. Pain intensity, depression, sleep quality, anxiety and self-efficacy were assessed via visual analogue scales. The resulting multivariate time series were aggregated over individuals, and partial spectral coherences between each pair of the variables were calculated. From the partial coherences, interaction graphs were plotted.

RESULTS

Within the resulting graphical model, self-efficacy was strongly related to pain intensity, depression and sleep quality. All other relations were substantially weaker. There was no direct relationship between pain intensity and sleep quality.

CONCLUSIONS

The relations between two variables within the therapy process are mainly induced by self-efficacy. Interaction graphs can be used to pool time series data of several patients and thus to assess the common underlying dependency structure of a group of patients. The graphical representation is easily comprehensible and allows to distinguish between direct and indirect relationships.

The effects of daily stress and stressful life events on the clinical symptomatology of patients with lupus erythematosus

OBJECTIVE

The purpose of this study was to verify whether stress worsens the clinical symptomatology perceived by patients with lupus erythematosus. Toward this end, we considered two types of stressors-daily stress and high-intensity stressful life events.

METHODS

In 46 patients with systemic lupus erythematosus and 12 patients with chronic lupus discoid, we studied the stress they experienced daily for 6 months and their disease symptoms. During this period, we also analyzed the levels of C3 and C4 complements and anti-DNAn antibodies. The systemic lupus erythematosus activity (assessed by the Systemic Lupus Activity Measures) and cumulative organ damage (assessed by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index) were also analyzed.

RESULTS

We did not find that high-intensity stressful life events produced a worsening of the symptomatology of the disease. However, using a time-series analysis (Box-Jenkins), we found that a high percentage of lupus patients (74.1%) perceived a worsening in their clinical symptomatology due to the effects of daily stress. Of this 74.1%, 53.4% worsened the same day they suffered the perceived daily stress, and the remaining 20.7% experienced an increase in symptoms both the same day and the following day. Subsequent Mann-Whitney analyses showed that the patients who worsened for 2 days because of the effects of stress had greater lupus activity, as evaluated by their levels of C3, C4, and anti-DNAn.

CONCLUSION

Daily stress, and not stressful life events, worsened the clinical symptomatology perceived by lupus erythematosus patients. This increase extended at times to 2 days, and was associated with greater lupic activity.