The integration of cardiovascular behavioral medicine and psychoneuroimmunology: new developments based on converging research fields

Salivary and plasma levels of matrix metalloproteinase-9 and myeloperoxidase at rest and after acute physical exercise in patients with coronary artery disease

BACKGROUND

Low-grade systemic inflammation is a predictor of recurrent cardiac events in patients with coronary artery disease (CAD). Plasma proteins such as matrix metalloproteinase (MMP)-9 and myeloperoxidase (MPO) have been shown to reflect basal as well as stress-induced inflammation in CAD. Measurements of MMP-9 and MPO in saliva might pose several advantages. Therefore, we investigated whether salivary levels of MMP-9 and MPO corresponded to plasma levels in patients with coronary artery disease (CAD), both at rest and after acute physical exercise.

METHODS

A bicycle ergometer test was used as a model for stress-induced inflammation. Twenty-three CAD patients performed the test on two occasions 3-6 months apart. Whole unstimulated saliva was collected before, directly after and 30 min after exercise while plasma was collected before and after 30 min. MMP-9 and MPO in saliva and plasma were determined by Luminex.

RESULTS

MMP-9 and MPO levels were 2- to 4-fold higher in saliva than in plasma. Amongst the saliva samples, and also to a great extent amongst the plasma samples, the levels of both types of protein showed strong intercorrelations between the levels at rest and after exercise during the two visits. However, there were no (or weak) correlations between salivary and plasma MMP-9 and none between salivary and plasma MPO.

CONCLUSION

We conclude that salivary diagnostics cannot be used to assess systemic levels of MMP-9 and MPO in CAD patients, neither at rest nor after acute physical exercise.

Effect of Stress, Depression and Type D Personality on Immune System in the Incidence of Coronary Artery Disease

BACKGROUND:

Psychoneuroimmunology (PNI) is the study of the interaction between psychological processes and the nervous and immune systems of the human body. The impact of psychological factors on the immune system and the role of this system in Coronary Artery Disease (CAD) are confirmed. Coronary Heart Disease (CHD) is arisen due to the failure of blood and oxygen to the heart tissues.

AIM:

The present study aimed to describe psychoneuroimmunological processes which contribute to CAD and CHD progression.

METHOD:

Such psychological risk factors like stress, depression and type D personality were investigated here. Psychoneuroimmunological pathways of all three mentioned risk factors were described for CAD.

RESULTS:

The studies review indicated that stress could be accompanied with myocardial ischemia and help to rupture. The depression involves in the transfer of stable atherosclerotic plaque to unstable, and type D personality is effective in the initial stages of a CAD.

CONCLUSION:

As more information on cardiovascular immunity becomes available, this will provide a better understanding and thus act as the foundation for the potential development of new treatment strategies for treatment of cardiovascular disorders.

The Integration of Emotional, Physiologic, and Communication Responses to Medical Oncology Surveillance Appointments During Breast Cancer Survivorship

BACKGROUND

Breast cancer survivors regularly interact with providers during routine surveillance medical oncology visits, discussing uncertainty and anxiety about potential cancer recurrence for many years after treatment. Physiologic alteration can also occur as a stress response, triggered by an upcoming surveillance visit. Survivor-provider communication can theoretically allay emotional distress.

OBJECTIVE

The aim of this study was to evaluate associations between emotional (uncertainty, anxiety, concerns about recurrence) and physiologic responses (cytokine levels, lymphocyte counts), and survivor-provider communication (women's plans for their visit, negotiation of decision-making roles).

METHODS

Twenty-seven community-dwelling breast cancer survivors participated. Blood specimens, and self-reported data focusing on the previous month, were collected immediately before and the morning after a regularly scheduled medical oncology visit.

RESULTS

Global concerns about cancer recurrence and acute anxiety and uncertainty were associated with changes in immune status before and after the visit. Postvisit natural killer cells increased in 70% of women, and uncertainty/anxiety decreased. Thirty-three percent of women reported a previous minor illness. Most women had a visit plan; 66% successfully negotiated decision-making roles with providers.

CONCLUSIONS

Triggered by an upcoming medical oncology visit, women experience uncertainty, anxiety, and altered immunity, potentially placing them at risk of disease exacerbations.

IMPLICATIONS FOR PRACTICE

Not all women respond similarly to a routine surveillance visit; thus, providers must determine who may be at increased risk of emotional distress and physiologic alteration. Survivor-provider communication facilitates immediate resolution of concerns. Explanations of symptom meaning reduce anxiety and uncertainty and by extension may help resolve immune alteration. Between visits, this could be done by nurse-operated telephone-based "help lines."

Inflammation: The Common Pathway of Stress-Related Diseases

While modernization has dramatically increased lifespan, it has also witnessed that the nature of stress has changed dramatically. Chronic stress result failures of homeostasis thus lead to various diseases such as atherosclerosis, non-alcoholic fatty liver disease (NAFLD) and depression. However, while 75%-90% of human diseases is related to the activation of stress system, the common pathways between stress exposure and pathophysiological processes underlying disease is still debatable. Chronic inflammation is an essential component of chronic diseases. Additionally, accumulating evidence suggested that excessive inflammation plays critical roles in the pathophysiology of the stress-related diseases, yet the basis for this connection is not fully understood. Here we discuss the role of inflammation in stress-induced diseases and suggest a common pathway for stress-related diseases that is based on chronic mild inflammation. This framework highlights the fundamental impact of inflammation mechanisms and provides a new perspective on the prevention and treatment of stress-related diseases.

Systematic Review of Clinical Practice Guidelines for Failed Antidepressant Treatment Response in Major Depressive Disorder, Dysthymia, and Subthreshold Depression in Adults

OBJECTIVE

This systematic review critically evaluated clinical practice guidelines (CPGs) for treating adults with major depressive disorder, dysthymia, or subthreshold or minor depression for recommendations following inadequate response to first-line treatment with selective serotonin reuptake inhibitors (SSRIs).

METHOD

Searches for CPGs (January 2004 to November 2014) in English included 7 bibliographic databases and grey literature sources using CPG and depression as the keywords. Two raters selected CPGs on depression with a national scope. Data extraction included definitions of adequate response and recommended treatment options. Two raters assessed quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

From 46,908 citations, 3167 were screened at full text. From these 21 CPG were applicable to adults in primary care and outpatient settings. Five CPGs consider patients with dysthymia or subthreshold or minor depression. None provides recommendations for those who do not respond to first-line SSRI treatment. For adults with MDD, most CPGs do not define an "inadequate response" or provide specific suggestions regarding how to choose alternative medications when switching to an alternative antidepressant. There is variability between CPGs in recommending combination strategies. AGREE II ratings for stakeholder involvement in CPG development, editorial independence, and rigor of development are domains in which depression guidelines are often less robust.

CONCLUSIONS

About half of patients with depression require second-line treatment to achieve remission. Consistency and clarity in guidelines for second-line treatment of depression are therefore important for clinicians but lacking in most current guidelines. This may reflect a paucity of primary studies upon which to base conclusions.

Young women post-MI have higher plasma concentrations of interleukin-6 before and after stress testing

OBJECTIVES

Young women have poorer prognosis after myocardial infarction (MI) and a higher rate of mental stress-induced ischemia compared with similarly aged men. A higher inflammatory status may help explain these sex differences.

METHODS

We examined 98 patients (49 women and 49 men) age 18-59years with recent MI (past 6months). Women and men were matched for age, type of MI, and time since MI. Interleukin 6 (IL-6) concentrations were measured at baseline, after mental stress using a speech task, and after exercise/pharmacologic stress (60 and 90min). Depressive symptoms were measured with the Beck Depression Inventory (BDI-II) and angiographic coronary artery disease (CAD) severity was quantified with the Gensini score. Single-photon emission computed tomography (SPECT) was used to obtain a computerized measurement of stress-induced ischemia (summed difference score, or SDS) and determine whether severity of stress-induced ischemia affects the inflammatory response to stress. Analysis was stratified by the median age of 50. Geometric mean concentrations of IL-6 were obtained from general linear regression models.

RESULTS

In both age groups, women had less angiographic CAD and a similar level of conventional risk factors compared with men. Despite this, baseline IL-6 geometric means before both mental and physical stress were twice as high in women ⩽50years of age compared to age-matched men (3.8 vs. 1.8pg/mL, p=0.001, across both conditions), while they were similar in women and men age >50years (2.3 vs. 2.2pg/mL, p=0.83). After mental stress, IL-6 concentrations increased in both women and men in a similar fashion and remained twice as high in women ⩽50years than men at both 60min (5.4 vs. 2.6pg/mL, p=0.002) and 90min (5.9 vs. 3.4pg/mL, p=0.01). No significant difference was found between women and men >50years of age at any time point after mental stress. Results were similar for physical stress. After accounting for SDS, IL-6 concentrations in young women remained higher after both mental and physical stress. Baseline IL-6 concentrations were not significantly related to inducible ischemia.

CONCLUSIONS

After MI, young women aged 50years or younger, compared with age-matched men, have remarkably higher concentrations of inflammation at baseline and after both mental and physical stress, with a similar inflammatory response to both stressors. Sustained concentrations of inflammation in young women, not their response to stress, may contribute to their adverse outcomes post-MI.

Beta-adrenergic receptor mediated inflammation control by monocytes is associated with blood pressure and risk factors for cardiovascular disease

Overwhelming data indicate that individuals with even mildly elevated blood pressure (BP) are at great risk for developing clinical hypertension and future cardiovascular disease (CVD). There remains a lack of consensus regarding treatment strategies for mildly elevated BP, termed prehypertension, and the knowledge of pathophysiology and mechanisms of its clinical outcomes remains limited. Our primary aim was to investigate βAR-mediated inflammation control (BARIC) responses of blood monocytes to isoproterenol (Iso) in relation to BP and CVD risk factors, including obesity, depressive mood, fasting glucose, triglycerides, and cholesterol levels in the 64 prehypertensive compared to 84 individuals with normal BP. BARIC was determined by measuring the degree of inhibition in lipopolysaccharides-stimulated monocytic intracellular TNF production by ex vivo Iso treatment (10(-8)M). Depressive mood was assessed by Beck Depression Inventory (BDI). Fasting metabolic and lipid panels were assessed, and plasma levels of inflammatory cytokines TNF, IL-1β, IL-6 were measured in a subset to confirm proinflammatory state of prehypertensive participants. Prehypertensive participants were older, heavier, included more men, and presented higher levels of fasting glucose, triglycerides, cholesterol, and plasma TNF compared to normotensive participants (p's<.05). BARIC was significantly attenuated in the prehypertensive compared to normotensive group (p<.05). BARIC was negatively associated with systolic BP, diastolic BP, age, BMI, fasting glucose, triglycerides, total and low density cholesterol levels, and somatic depressive symptoms in all participants (p's<.0001 to .05). However, among the prehypertensive individuals BARIC was positively associated with SBP even after controlling for the covariates (age, gender, race, BMI, glucose and lipid panel, somatic BDI scores) (p<.05). This differing nature of the BARIC-SBP relationship between the two BP groups may be attributed to moderating factors such as cardiorespiratory fitness or depressive symptoms that could not be clearly deciphered in this current study. Nonetheless, our findings indicate the associations between inflammation dysregulation mediated by sympathoadrenal activation and BP that is observable even among individuals with normal to mildly elevated BP. BARIC may be a useful and sensitive indicator of elevated risk for vascular inflammatory disease that can be detected even at lower BP levels, especially given its associations with traditional CVD risk factors and the critical role of monocytes in atherogenic processes.

Randomized controlled trial of heart rate variability biofeedback in cardiac autonomic and hostility among patients with coronary artery disease

Hostility is a psychosocial risk factor that may decrease heart rate variability (HRV) in coronary artery disease (CAD) through cardiac autonomic imbalance. Heart rate variability biofeedback (HRV-BF) increases HRV indices and baroreflex gain. This study examines the effectiveness of HRV-BF in restoring cardiac autonomic balance and decreasing hostility among patients with CAD. One hundred and fifty-four patients with CAD were assigned randomly to receive 6 weeks of HRV-BF, in addition to the standard medical care received by the wait-list control (WLC) group. A 5-min electrocardiogram, blood pressure, and hostility were assessed pre-intervention, post-intervention, and at 1-month follow-up. The standard deviation of normal-to-normal intervals (SDNN), low frequency (LF), and log LF at post-intervention was significantly higher than that at pre-intervention in the HRV-BF group. Baseline log LF was significantly higher post-intervention and at follow-up after HRV-BF training than at pre-intervention. The treatment curve of log LF pre-session increased significantly after session 2, which was maintained to post-intervention. Expressive hostility, suppressive hostility, and hostility total score at post-intervention and one-month follow-up after HRV-BF were significantly lower than at pre-intervention. This study showed increased HRV and decreased expressive and suppressive hostility behavior in patients with CAD following HRV-BF.

Pharmacological approaches to manage persistent symptoms of major depressive disorder: rationale and therapeutic strategies

Major depressive disorder (MDD) is a highly prevalent chronic psychiatric illness associated with significant morbidity, mortality, loss of productivity, and diminished quality of life. Typically, only a minority of patients responds to treatment and meet criteria for remission as residual symptoms may persist, the result of an inadequate course of treatment and/or the presence of persistent side effects. The foremost goal of treatment should be to restore patients to full functioning and eliminate or relieve all MDD symptoms, while being virtually free of troublesome side effects. The current available pharmacological options to manage persistent depressive symptoms include augmentation or adjunctive combination strategies, both of which target selected psychobiological systems and specific mood and somatic symptoms experienced by the patient. As well, non-pharmacological interventions including psychotherapies may be used in either first-line or adjunctive approaches. However, the evidence to date with respect to available adjunct therapies is limited by few studies and those published have utilized only a small number of subjects and lack enough data to allow for a consensus of expert opinion. This underlines the need for further longer term, large population-based studies and those that include comorbid populations, all of which are seen in real world community psychiatry.

Comparison of the effects of exercise participation on psychosocial risk factors and cardiovascular disease in women

[Purpose] The aim of this study was to research the association of Type D personality with CVD risk factors and psychology through comparison of the association of exercise participation with CVD risk factors and psychological risk factors in women with Type D. [Subjects] This study included 416 middle-aged women. All participants completed the 14-item Type D Scale (DS14) to assess Type D personality. The DS14 consists of two subscales, NA and SI, both of which comprise 7 items. The research subjects were randomly assigned to four groups: Type D+Exercise (n=12), Type D+non-Exercise (n=12), non-Type D+Exercise (n=12), non-Type D+non-Exercise (n=10). The study consisted of 46 participants. [Methods] An aerobic exercise program and meditation were conducted in parallel for 10 months. Stretching was performed for 10 min as a warm-up, and then walking and running were performed on a treadmill at the HRmax 60–70% level for 40 min; this was done three times a week. Blood samples were processed according to standard laboratory procedures. The concentrations of TG and HDL-cholesterol were determined enzymatically on a clinical chemistry analyzer. Blood glucose was measured by the hexokinase method. [Results] Weight, percent fat, social support, and waist circumference showed a significant difference between times in the Exercise groups, and the values were significantly lower than those of the non-Exercise groups. Anxiety and depression showed a significant interaction effect between groups. The average number of CVD risk factors in subjects showed a significant difference between groups. [Conclusion] In conclusion, there were significant differences between groups in terms of CVD risk factors and psychological risk factors in women with Type D personality.

Personality, socio-economic status and inflammation: cross-sectional, population-based study

Background

Associations between socio-economic status (SES), personality and inflammation were examined to determine whether low SES subjects scoring high on neuroticism or hostility might suffer relatively higher levels of inflammation than affluent subjects.

Methods

In a cross-sectional design, 666 subjects were recruited from areas of high (most deprived – “MD”) and low (least deprived – “LD”) deprivation. IL-6, ICAM-1, CRP and fibrinogen were measured along with demographic and health-behaviour variables, and personality traits of neuroticism, extraversion and psychoticism (hostility). Regression models assessed the prediction of inflammation as a function of personality, deprivation and their interaction.

Results

Levels of CRP and IL-6 were an increasing function of neuroticism and extraversion only in LD subjects opposite trends were seen in MD subjects. The result was ascribed parsimoniously to an inflammatory ceiling effect or, more speculatively, to SES-related health-behaviour differences. Psychoticism was strongly associated with ICAM-1 in both MD and LD subjects.

Conclusions

The association between neuroticism, CRP and IL-6 may be reduced in MD subjects confirming speculation that the association differs across population sub-groups. The association between psychoticism and ICAM-1 supports evidence that hostility has adverse effects upon the endothelium, with consequences for cardiovascular health. Health interventions may be more effective by accounting for personality-related effects upon biological processes.

Personality as a risk factor for the metabolic syndrome: a systematic review

OBJECTIVE

The metabolic syndrome is a cluster of risk factors for the development of cardiovascular disease and/or type 2 diabetes. Personality can be defined as a stable set of behavioral characteristics of a person. In this review we systematically reviewed whether different personality characteristics are associated with the risk of having or developing the metabolic syndrome.

METHODS

Systematic review.

RESULTS

In total 18 studies were included. Thirteen cross-sectional analyses, and ten longitudinal analyses were grouped according to personality constructs: hostility, anger, and Type A behavior, temperament, neuroticism, and Type D personality. Conflicting evidence was reported on persons with high hostility, neuroticism, or Type D personality scores to be associated with an increased metabolic syndrome prevalence and development. All significant findings do point in the same direction: a more negative, or hostile personality type is associated with an increased prevalence of metabolic syndrome and its development over time.

CONCLUSION

There was no clear association between personality measures and the occurrence and development of the metabolic syndrome. There is, however, a cluster of risk factors that include the presence of the metabolic syndrome, as well as a more negative prone personality style, that both predispose to the development of coronary heart disease and diabetes. Future studies should investigate the role of personality measures in the development of these conditions, while taking into account metabolic syndrome, lifestyle and socio-demographic factors.

Tend and befriend in the intensive care unit

Stress is a common phenomenon in the intensive care unit for both patients and nurses. Critical care nurses may experience many forms of stress, including physical, psychological, and moral stress or distress. The physiological stress response traditionally associated with the hypothalamic-pituitary-adrenal axis has been expanded to include a new model, called tend and befriend, that has been linked to females of different species, including humans. Studies have shown that stress also affects immune function. Although commonly associated with adverse outcomes, stress can lead to personal growth. The tend and befriend strategy is an intervention that was developed to help nurses increase their ability to grow from stressful situations, especially those related to moral distress.

Dipping status and hostility in newly diagnosed essential hypertension

AIM

Personality traits, including hostility, play an important role in the development of cardiovascular disease. Moreover, abnormalities in blood pressure circadian pattern, such as a lack of nocturnal BP fall, are related with target organ damage and increased cardiovascular risk. The aim of this study was to investigate the impact of hostility and its dimensions on dipping status, in newly diagnosed hypertensive patients.

METHODS

The study population consisted of 114 newly diagnosed untreated essential hypertensives. All participants underwent 24-hour ambulatory blood pressure monitoring (ABPM) in order to assess dipping status. Hostility was assessed by Hostility and Direction of Hostility Questionnaire (HDHQ). The study population was divided in terms of dipping status in two groups, "dippers" and "non-dippers."

RESULTS

The statistical analysis revealed that dippers presented significantly higher score of extrapunitiveness (13.2 +/- 4.9 vs 11.4 +/- 3.9, p = 0.032), as well as significantly higher score of the dimension "urge to act out hostility (AH)" (4 +/- 3 vs 3 +/- 2, p = 0.025) compared to non-dippers. Multivariate regression analysis revealed extrapunitiveness as the only independent predictor of dipping status. The odds ratio (OR) for dipping status associated with each point increase in extrapunitiveness was 0.912 (95% CI: 0.832-0.992; p = 0.048).

CONCLUSION

The present findings may suggest that hostility and its features affect the circadian variation of blood pressure in hypertensive patients, providing a promising objective for future investigations linking psychological factors and dipping status in essential hypertension.

Cognitive/affective and somatic/affective symptom dimensions of depression are associated with current and future inflammation in heart failure patients

BACKGROUND

Little is known about whether cognitive/affective depressive symptoms or somatic/affective depressive symptoms are associated with inflammation in heart failure (HF), or that the relation is confounded with disease severity.

AIM

To examine the association between depressive symptom dimensions in HF patients with inflammatory markers cross-sectionally and prospectively, while adjusting for appropriate confounders.

RESULTS

Consecutive HF patients completed the Beck Depression Inventory at inclusion and at 12 month follow-up. Cytokines were assessed at both occasions. Cross-sectional--multivariate linear regression analysis (n=110) demonstrated that cognitive/affective depressive symptoms were independently associated with increased levels of sTNFR2 (β=0.20, p<0.05) and IL-1ra (β=0.28, p<0.01). Somatic/affective depressive symptoms were independently related to sTNFR2 (β=0.21, p<0.05). Prospective--(n=125) the level of cognitive/affective depressive symptoms at inclusion was prospectively associated with increased levels of sTNFR1 and sTNFR2 (β=0.21 and 0.25 resp. p<0.05), independent of covariates. Change in somatic/affective depressive symptoms over the 12 month period was associated with sTNFR2 (β=0.30, p=0.008). At symptom level, core depressive cognitions such as hopelessness and guilt drove the relation between the sTNF receptors and the cognitive/affective component, while having sleep problems was the most important associate of the somatic/affective dimension.

CONCLUSIONS

Baseline cognitive/affective depressive symptoms were prospectively associated with sTNFR1 and sTNFR2 in HF patients, while change in somatic/affective depressive symptoms was associated with sTNFR2, independent from clinical and demographic covariates. Further studies are warranted to replicate these findings and to examine the association between depression dimensions, inflammation and prognosis in HF.

Depression in heart failure: biobehavioral mechanisms

The etiology, predictive value, and biobehavioral aspects of depression in heart failure (HF) are described in this article. Clinically elevated levels of depressive symptoms are present in approximately 1 out of 5 patients with HF. Depression is associated with poor quality of life and a greater than 2-fold risk of clinical HF progression and mortality. The biobehavioral mechanisms accounting for these adverse outcomes include biological processes (elevated neurohormones, autonomic nervous system dysregulation, and inflammation) and adverse health behaviors (physical inactivity, medication nonadherence, poor dietary control, and smoking). Depression often remains undetected because of its partial overlap with HF-related symptoms and lack of systematic screening. Behavioral and pharmacologic antidepressive interventions commonly result in statistically significant but clinically modest improvements in depression and quality of life in HF, but not consistently better clinical HF or cardiovascular disease outcomes. Documentation of the biobehavioral pathways by which depression affects HF progression will be important to identify potential targets for novel integrative behavioral and pharmacologic interventions.

Psychosocial working conditions and exhaustion in a working population sample of Swedish middle-aged men and women

BACKGROUND

Exhaustion is a concept of interest for both occupational health research and stress-disease theory research. The aim of the present study was to explore associations between chronic stressors, in terms of psychosocial working conditions, and exhaustion in a Swedish middle-aged population sample.

METHODS

A vocationally active population sample of the Malmö Shoulder and Neck Study cohort, comprising 2555 men and 2466 women between 45 and 64 years of age, was used. Psychosocial working conditions, assessed by means of the demand-control-support model, were measured longitudinally with a 1-year interval. Exhaustion was assessed by the SF-36 vitality scale and measured at follow-up, yielding a cross-sectional study design.

RESULTS

Exhaustion was twice as common in women as in men. High psychological job demands, low job control and low job support were independently associated with exhaustion in both men and women. These associations remained after controlling for a variety of potential confounders and mediators, including socio-demographic factors, lifestyle factors, musculoskeletal pain, disease, other work-related factors (including physical workload) and non-work-related factors. High demands in combination with low control (job strain), and job strain combined with low job support (iso-strain), increased the risk for exhaustion.

CONCLUSION

Psychosocial working conditions seem to contribute to exhaustion in middle-aged men and women. Future research should include exploration of exhaustion as a possible mediator between work stress and disease, as well as exploration of other chronic stressors, including non-work-related stressors, regarding their effects on exhaustion in men and women.

Psychosocial factors of coronary heart disease and quality of life among Roma coronary patients: a study matched by socioeconomic position

OBJECTIVES

The aim of this study was to assess whether psychosocial factors and health-related quality of life (HRQL) differ between Roma and non-Roma coronary patients and to what degree socioeconomic status (SES) explains these differences.

METHODS

We included 138 patients out of 437 interviewed: 46 Roma, all with low SES, 46 non-Roma with low SES, and 46 non-Roma with high SES. Groups were matched for age, gender and education. The GHQ-28 was used for measuring psychological well-being, the Maastricht interview for vital exhaustion, the type D questionnaire and the Cook-Medley scale for personality and the SF-36 for HRQL. SES was indicated by income and education, and disease severity by ejection fraction. ANOVA and linear regression were used.

RESULTS

Roma scored poorly compared to non-Roma in psychological well-being, vital exhaustion and HRQL (p ≤ 0.001); however, these differences could be to a substantial extent explained by SES. With regard to personality traits, ethnicity and SES played a less significant role.

CONCLUSIONS

The adverse quality of life among Roma coronary patients may warrant additional care, which should target their low SES but also other factors related to their ethnic background, such as culture and living conditions.

Low vagal tone is associated with impaired post stress recovery of cardiovascular, endocrine, and immune markers

Reduced heart rate variability (HRV) and delayed blood pressure recovery are associated with increased cardiovascular risk. Besides this evident link, the vagus is thought to play an inhibitory role in the regulation of other allostatic systems, including inflammation and the hypothalamic-pituitary-adrenal (HPA) axis. However, human evidence is scarce. To further explore these associations and with special regard to the postulated mediating role of the vagus, we hypothesised that subjects with low vagal tone as indexed by reduced resting HRV would show impaired post-stress recovery of cardiovascular, endocrine and immune system markers involved in cardiovascular pathology. 44 healthy men underwent a standardised mental stress test. Besides continuous measurement of systolic and diastolic blood pressure (SBP, DBP), heart rate (HR), and HRV serum cortisol, tumour necrosis factor-alpha (TNF-alpha), and interleukin-6 (IL-6) were measured before, after, 20, and 60 min after stress. Low versus high HRV groups was defined by median split on resting HRV (RMSSD). The task elicited significant time effects for SBP, DBP, HR, HRV, cortisol, and TNF-alpha. Subjects with low baseline HRV showed almost no modulation of HRV coupled with overall reduced HRV levels, and impaired recovery of DBP, cortisol, and TNF-alpha. Confirming our hypothesis, low vagal tone was associated with impaired recovery of cardiovascular, endocrine, and immune markers in healthy males. The data support an inhibitory role of the vagus in the regulation of allostatic systems as described in the neurovisceral integration model. We posit reduced resting HRV as a risk marker for future cardiovascular and other stress-related disease.

Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management

BACKGROUND

Major depressive disorder (MDD) is one of the most burdensome illnesses in Canada. The purpose of this introductory section of the 2009 revised CANMAT guidelines is to provide definitions of the depressive disorders (with an emphasis on MDD), summarize Canadian data concerning their epidemiology and describe overarching principles of managing these conditions. This section on "Classification, Burden and Principles of Management" is one of 5 guideline articles in the 2009 CANMAT guidelines.

METHODS

The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to the Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included evidence and expert clinical support.

RESULTS

Epidemiologic data indicate that MDD afflicts 11% of Canadians at some time in their lives, and approximately 4% during any given year. MDD has a detrimental impact on overall health, role functioning and quality of life. Detection of MDD, accurate diagnosis and provision of evidence-based treatment are challenging tasks for both clinicians and for the health systems in which they work.

LIMITATIONS

Epidemiologic and clinical data cannot be seamlessly linked due to heterogeneity of syndromes within the population.

CONCLUSIONS

In the eight years since the last CANMAT Guidelines for Treatment of Depressive Disorders were published, progress has been made in understanding the epidemiology and treatment of these disorders. Evidence supporting specific therapeutic interventions is summarized and evaluated in subsequent sections.

A review of neuroimaging studies of stressor-evoked blood pressure reactivity: emerging evidence for a brain-body pathway to coronary heart disease risk

An individual's tendency to show exaggerated or otherwise dysregulated cardiovascular reactions to acute stressors has long been associated with increased risk for clinical and preclinical endpoints of coronary heart disease (CHD). However, the 'brain-body' pathways that link stressor-evoked cardiovascular reactions to CHD risk remain uncertain. This review summarizes emerging neuroimaging research indicating that individual differences in stressor-evoked blood pressure reactivity (a particular form of cardiovascular reactivity) are associated with activation patterns in corticolimbic brain areas that are jointly involved in processing stressors and regulating the cardiovascular system. As supported empirically by activation likelihood estimates derived from a meta-analysis, these corticolimbic areas include divisions of the cingulate cortex, insula, and amygdala--as well as networked cortical and subcortical areas involved in mobilizing hemodynamic and metabolic support for stress-related behavioral responding. Contextually, the research reviewed here illustrates how behavioral medicine and health neuroscience methods can be integrated to help characterize the 'brain-body' pathways that mechanistically link stressful experiences with CHD risk.

Mental-stress-induced platelet activation among patients with coronary artery disease

OBJECTIVE

To study patients with coronary artery disease (CAD) scheduled for coronary angioplasty and to examine platelet activation in response to mental stress as a potential mechanism involved in the association between psychosocial factors and cardiac outcomes. Psychosocial factors have been identified as risk factors for CAD and adverse cardiac outcomes, although the underlying mechanisms are poorly understood.

METHODS

Markers of platelet activation and platelet reactivity in response to experimentally induced mental stress (mental arithmetic and anger recall) were examined, using flow cytometry analysis and beta-thromboglobulin (BTG) assays among 249 CAD patients (age = 60.3 +/- 9.0 years, 15% women) who were scheduled to undergo elective percutaneous coronary intervention.

RESULTS

Mental stress-induced increases in platelet activation (CD41 (GP IIb/IIIa), p = .002; percent of mononuclear cells positive for CD41, p = .01; CD62P (P-selectin) expression, p = .005; and percent platelets positive for CD62P, p < .001). The degree of platelet reactivity was not related to demographic, clinical, or psychological variables, or cardiovascular hemodynamic changes.

CONCLUSIONS

Experimentally induced mental stress induced platelet activation in patients with CAD. This mechanism may partially explain the link between psychosocial variables and the development of adverse cardiac outcomes in patients with CAD.

Depressive symptoms and levels of C-reactive protein: a population-based study

BACKGROUND

Depression and depressive symptoms have been repeatedly linked to elevated levels of C-reactive protein (CRP) but questions remain as to the statistical robustness of the association and particularly whether the association between depression and CRP reflects the presence of a chronic disease.

METHODS

A random sample of 6,126 men and women aged 45-69 years was examined in a cross-sectional study in seven towns in the Czech Republic. Depressive symptoms were assessed by the Center for Epidemiologic Studies Depression (CESD) scale.

RESULTS

Center for Epidemiologic Studies Depression score was significantly related to increased levels of CRP in a linear fashion. After controlling for a range of potential confounders, subjects with depressive symptoms (CESD score >or= 16) had CRP concentrations 0.43 mg/l (95% CI 0.16-0.72) higher than those without symptoms. The association remained significant when study sample was restricted to healthy subjects; among individuals who did not report any chronic disease, the difference between those with and without depressive symptoms was 0.44 mg/l (95% CI 0.14-0.74), and among persons who did not visit a doctor in the last 12 months the difference was 1.20 mg/l (95% CI 0.52-1.87).

CONCLUSIONS

These results confirm that there is a statistically robust association between depressive symptoms and increased levels of CRP. We did not find evidence that the association is due presence of a chronic condition.

The rebirth of neuroscience in psychosomatic medicine, Part I: historical context, methods, and relevant basic science

Neuroscience was an integral part of psychosomatic medicine at its inception in the early 20th century. Since the mid-20th century, however, psychosomatic research has largely ignored the brain. The field of neuroscience has burgeoned in recent years largely because a variety of powerful new methods have become available. Many of these methods allow for the noninvasive study of the living human brain and thus are potentially available for integration into psychosomatic medicine research at this time. In this first paper we examine various methods available for human neuroscientific investigation and discuss their relative strengths and weaknesses. We next review some basic functional neuroanatomy involving structures that are increasingly being identified as relevant for psychosomatic processes. We then discuss, and provide examples of, how the brain influences end organs through "information transfer systems," including the autonomic, neuroendocrine, and immune systems. The evidence currently available suggests that neuroscience holds great promise for advancing the goal of understanding the mechanisms by which psychosocial variables influence physical disease outcomes. An increased focus on such mechanistic research in psychosomatic medicine is needed to further its acceptance into the field of medicine.

Chronic work stress and exhaustion is associated with higher allostastic load in female school teachers

Epidemiological studies have shown that chronic work stress or unfavourable psychosocial work conditions are prospectively associated with different adverse health outcomes. The aim of the present cross-sectional study was to investigate the relationship between work-related chronic stress as well as exhaustion and a cumulative measure of physiological wear-and-tear called allostastic load (AL). AL could be a possible biological pathway for how chronic work stress and exhaustion lead to health impairments in the long run. As the teaching profession has been proposed to be a potentially high stressful occupation, chronic work stress (effort-reward-imbalance) and exhaustion were assessed in 104 female school teachers. AL was first analyzed according to McEwen's classical model comprised of ten parameters including cortisol, epinephrine and norepinephrine, dehydroepiandrosterone-sulphate (DHEA-S), waist/hip-ratio (WHR), glycosylated haemoglobin (HbA1c), high-density lipoprotein (HDL), total cholesterol/HDL-ratio, and systolic and diastolic blood pressure. Additionally it was extended to include tumor-necrosis-factor-alpha (TNF-alpha), C-reactive protein (CRP), fibrinogen, D-dimer, percent-body-fat, triglycerides, and glucose levels. A substantial proportion of our sample was highly exhausted whereas relatively few teachers showed high effort-reward-imbalance. AL scores were significantly higher in women high on effort-reward-imbalance or suffering from exhaustion. Although all teachers had been in a good health status, chronic work stress as well as exhaustion appears to be associated with changes in a multi-system summary indicator of physiological risk.

Menopause, the metabolic syndrome, and mind-body therapies

Cardiovascular disease risk rises sharply with menopause, likely due to the coincident increase in insulin resistance and related atherogenic changes that together comprise the metabolic or insulin resistance syndrome, a cluster of metabolic and hemodynamic abnormalities strongly implicated in the pathogenesis and progression of cardiovascular disease. A growing body of research suggests that traditional mind-body practices such as yoga, tai chi, and qigong may offer safe and cost-effective strategies for reducing insulin resistance syndrome-related risk factors for cardiovascular disease in older populations, including postmenopausal women. Current evidence suggests that these practices may reduce insulin resistance and related physiological risk factors for cardiovascular disease; improve mood, well-being, and sleep; decrease sympathetic activation; and enhance cardiovagal function. However, additional rigorous studies are needed to confirm existing findings and to examine long-term effects on cardiovascular health.

Hostility is related to clusters of T-cell cytokines and chemokines in healthy men

Hostility is a risk factor for adverse health outcomes as diverse as cardiovascular disease and post-traumatic stress disorder (PTSD). Cytokines have been suggested to mediate this relationship. We investigated whether in healthy men a relation existed between hostility and T-cell mitogen-induced cytokines and chemokines. Male Dutch military personnel (n=304) were included before deployment. Eleven cytokines and chemokines were measured in supernatants of T-cell mitogen-stimulated whole blood cultures by multiplex immunoassay. Factor analysis was used to identify clusters of cytokines and chemokines. In a regression analysis hostility was related to the cytokine/chemokine clusters, and the potential risk factors age, BMI, smoking, drinking, previous deployment, early life trauma and depression. Explorative factor analysis showed four functional clusters; a pro-inflammatory factor (IL-2, TNFalpha, IFNgamma), an anti-inflammatory factor (IL-4, IL-5, IL-10), IL-6/chemokine factor (IL-6, MCP-1, RANTES, IP-10), and MIF. Hostility was significantly related to decreased IL-6/chemokine secretion and increased pro- and anti-inflammatory cytokines. There was an inverse relation between age and hostility scores. Early life trauma and depression were positively and independently related to hostility as well. This study represents a novel way of investigating the relation between cytokines and psychological characteristics. Cytokines/chemokines clustered into functional factors, which were related to hostility in healthy males. Moreover this relation appeared to be independent of reported depression and early trauma.

Comparing Type D personality and older age as correlates of tumor necrosis factor-alpha dysregulation in chronic heart failure

Tumor necrosis factor-alpha (TNF-alpha) and its soluble receptors 1 (sTNFR1) and 2 (sTNFR2) have been shown to be implicated in the pathogenesis of chronic heart failure (CHF). Ageing is accompanied by increased plasma levels of pro-inflammatory cytokines. We hypothesized that Type D personality (joint tendency to experience negative emotions and to inhibit self-expression) and age may have similar pro-inflammatory effects in the context of CHF. Participants in this study were 130 consecutive outpatients with CHF (76% men); there were 70 relatively younger (<or=59 years) and 60 relatively older (>or=60 years) patients. They all completed the 14-item Type D Scale (DS14); 43 patients (33%) had a Type D personality. A multivariate model of cytokine levels indicated an independent overall effect of both older age [F(1,128)=9.11, p=.003] and Type D personality [F(1,128)=8.28, p=.005]. Stratifying patients in age/personality subgroups showed that younger non-Type D patients had the lowest and older Type D patients the highest sTNFR1 and sTNFR2 levels (986+/-318 vs 1661+/-1128 pg/ml and 1838+/-777 vs 2823+/-1439 pg/ml, p<.0001). Importantly, the mean sTNFR1 level in younger Type D patients (1359+/-660 pg/ml) was equivalent to that in older non-Type D patients (1360+/-440 pg/ml, p=.99) who were on average 18 years older. Younger Type D and older non-Type D patients also had similar sTNFR2 levels (2406+/-1329 vs 2448+/-812 pg/ml, p=.88). Only older Type D patients had a higher mean TNF-alpha level as compared to patients who were younger or who were not Type D (5.4+/-2.9 vs 3.9+/-2.4 pg/ml, p=.008). A logistic regression model including sex, severity of CHF, systolic heart failure and ischemic etiology indicated that the combined risk category of older age or Type D was independently associated with substantially increased sTNFR1 and sTNFR2 levels. Hence, Type D personality was associated with increased TNF-alpha activity. This disease-promoting effect of Type D matched the pro-inflammatory effect of ageing.

Socioeconomic differences in psychosocial factors contributing to coronary heart disease: a review

Psychosocial factors have been shown to play an important role in the aetiology of coronary heart disease (CHD). A strong association between CHD and socioeconomic status (lower-level education, poor financial situation) has also been well established. Socioeconomic differences may thus also have an effect on psychosocial risk factors associated with CHD, and socioeconomic disadvantage may negatively affect the later prognosis and quality of life of cardiac patients. The aim of this study was to review the available evidence on socioeconomic differences in psychosocial factors which specifically contribute to CHD. A computer-aided search of the Medline and PsycINFO databases resulted in 301 articles in English published between 1994 and 2007. A comprehensive screening process identified 12 empirical studies which described the socioeconomic differences in CHD risk factors. A review of these studies showed that socioeconomic status (educational grade, occupation or income) was adversely associated with psychosocial factors linked to CHD. This association was evident in the case of hostility and depression. Available studies also showed a similar trend with respect to social support, perception of health and lack of optimism. Less consistent were the results related to anger and perceived stress levels. Socioeconomic disadvantage seems to be an important element influencing the psychosocial factors related to CHD, thus, a more comprehensive clarification of associations between these factors might be useful. More studies are needed, focused not only on well-known risk factors such as depression and hostility, but also on some lesser known psychosocial factors such as Type D and vital exhaustion and their role in CHD.

Effects of acute mental stress and exercise on inflammatory markers in patients with coronary artery disease and healthy controls

Physical and mental stressors result in increased inflammation markers in populations free of coronary artery disease (CAD). However, inflammatory responses to mental and exercise challenges have not been established in patients with CAD. This study investigated the responses of inflammatory markers, including C-reactive protein (CRP), interleukin-6 (IL-6), and soluble intercellular adhesion molecule-1, in patients with CAD after successful elective percutaneous coronary intervention (n = 36, 59 +/- 8 years of age, 33% women) and healthy controls without a history of CAD (n = 28, 54 +/- 10 years of age, 36% women). Increases in inflammatory markers were examined in response to mental challenge tasks (anger recall and mental arithmetic) and treadmill exercise. Stress echocardiography was used to rule out stress-induced ischemia as a possible confounding factor. Results showed that CRP increased significantly to mental challenge and exercise (p values <0.01), and CRP responses were higher in patients with CAD than in controls (change in mental arithmetic 0.19 +/- 0.11 vs 0.01 +/- 0.03 mg/L, p = 0.003; change in exercise 0.57 +/- 0.11 vs 0.08 +/- 0.0.03 mg/L, p = 0.001). Increased norepinephrine responses were related to larger CRP and IL-6 increases to mental challenge tasks (p values <0.05). Exercise elicited increased CRP, IL-6, and soluble intercellular adhesion molecule-1 levels (p values <0.01), and these responses were larger than with mental challenge tasks (p values <0.05). In conclusion, mental stress and exercise induce increased levels of inflammatory markers in patients with CAD. These stress-induced increases are larger than in healthy subjects, occur in the absence of myocardial ischemia, and are related to the neurohormonal stress response.

Diseases of poverty and lifestyle, well-being and human development

The problems of the haves differ substantially from those of the have-nots. Individuals in developing societies have to fight mainly against infectious and communicable diseases, while in the developed world the battles are mainly against lifestyle diseases. Yet, at a very fundamental level, the problems are the same-the fight is against distress, disability, and premature death; against human exploitation and for human development and self-actualisation; against the callousness to critical concerns in regimes and scientific power centres.While there has been great progress in the treatment of individual diseases, human pathology continues to increase. Sicknesses are not decreasing in number, they are only changing in type.The primary diseases of poverty like TB, malaria, and HIV/AIDS-and the often co-morbid and ubiquitous malnutrition-take their toll on helpless populations in developing countries. Poverty is not just income deprivation but capability deprivation and optimism deprivation as well.While life expectancy may have increased in the haves, and infant and maternal mortality reduced, these gains have not necessarily ensured that well-being results. There are ever-multiplying numbers of individuals whose well-being is compromised due to lifestyle diseases. These diseases are the result of faulty lifestyles and the consequent crippling stress. But it serves no one's purpose to understand them as such. So, the prescription pad continues to prevail over lifestyle-change counselling or research.The struggle to achieve well-being and positive health, to ensure longevity, to combat lifestyle stress and professional burnout, and to reduce psychosomatic ailments continues unabated, with hardly an end in sight.WE THUS REALISE THAT MORBIDITY, DISABILITY, AND DEATH ASSAIL ALL THREE SOCIETIES: the ones with infectious diseases, the ones with diseases of poverty, and the ones with lifestyle diseases. If it is bacteria in their various forms that are the culprit in infectious diseases, it is poverty/deprivation in its various manifestations that is the culprit in poverty-related diseases, and it is lifestyle stress in its various avatars that is the culprit in lifestyle diseases. It is as though poverty and lifestyle stress have become the modern "bacteria" of developing and developed societies, respectively.For those societies afflicted with diseases of poverty, of course, the prime concern is to escape from the deadly grip of poverty-disease-deprivation-helplessness; but, while so doing, they must be careful not to land in the lap of lifestyle diseases. For the haves, the need is to seek well-being, positive health, and inner rootedness; to ask science not only to give them new pills for new ills, but to define and study how negative emotions hamper health and how positive ones promote it; to find out what is inner peace, what is the connection between spirituality and health, what is well-being, what is self-actualisation, what prevents disease, what leads to longevity, how simplicity impacts health, what attitudes help cope with chronic sicknesses, how sicknesses can be reversed (not just treated), etc. Studies on well-being, longevity, and simplicity need the concerted attention of researchers.THE TASK AHEAD IS CUT OUT FOR EACH ONE OF US: physician, patient, caregiver, biomedical researcher, writer/journalist, science administrator, policy maker, ethicist, man of religion, practitioner of alternate/complementary medicine, citizen of a world community, etc. Each one must do his or her bit to ensure freedom from disease and achieve well-being.Those in the developed world have the means to make life meaningful but, often, have lost the meaning of life itself; those in the developing world are fighting for survival but, often, have recipes to make life meaningful. This is especially true of a society like India, which is rapidly emerging from its underdeveloped status. It is an ancient civilization, with a philosophical outlook based on a robust mix of the temporal and the spiritual, with vibrant indigenous biomedical and related disciplines, for example, Ayurveda, Yoga, etc. It also has a burgeoning corpus of modern biomedical knowledge in active conversation with the rest of the world. It should be especially careful that, while it does not negate the fruits of economic development and scientific/biomedical advance that seem to beckon it in this century, it does not also forget the values that have added meaning and purpose to life; values that the ancients bequeathed it, drawn from their experiential knowledge down the centuries.The means that the developed have could combine with the recipes to make them meaningful that the developing have. That is the challenge ahead for mankind as it gropes its way out of poverty, disease, despair, alienation, anomie, and the ubiquitous all-devouring lifestyle stresses, and takes halting steps towards well-being and the glory of human development.

The influence of yoga-based programs on risk profiles in adults with type 2 diabetes mellitus: a systematic review

There is growing evidence that yoga may offer a safe and cost-effective intervention for Type 2 Diabetes mellitus (DM 2). However, systematic reviews are lacking. This article critically reviews the published literature regarding the effects of yoga-based programs on physiologic and anthropometric risk profiles and related clinical outcomes in adults with DM 2. We performed a comprehensive literature search using four computerized English and Indian scientific databases. The search was restricted to original studies (1970-2006) that evaluated the metabolic and clinical effects of yoga in adults with DM 2. Studies targeting clinical populations with cardiovascular disorders that included adults with comorbid DM were also evaluated. Data were extracted regarding study design, setting, target population, intervention, comparison group or condition, outcome assessment, data analysis and presentation, follow-up, and key results, and the quality of each study was evaluated according to specific predetermined criteria. We identified 25 eligible studies, including 15 uncontrolled trials, 6 non-randomized controlled trials and 4 randomized controlled trials (RCTs). Overall, these studies suggest beneficial changes in several risk indices, including glucose tolerance and insulin sensitivity, lipid profiles, anthropometric characteristics, blood pressure, oxidative stress, coagulation profiles, sympathetic activation and pulmonary function, as well as improvement in specific clinical outcomes. Yoga may improve risk profiles in adults with DM 2, and may have promise for the prevention and management of cardiovascular complications in this population. However, the limitations characterizing most studies preclude drawing firm conclusions. Additional high-quality RCTs are needed to confirm and further elucidate the effects of standardized yoga programs in populations with DM 2.

Combination of caregiving stress and hormone replacement therapy is associated with prolonged platelet activation to acute stress among postmenopausal women

OBJECTIVE

To investigate the combined effects of caregiving and hormone replacement therapy (HRT) on platelet hyperactivity to acute psychological stress. Both HRT and the chronic stress of caregiving have been associated with increased cardiovascular risk, potentially through a mechanism of platelet hyperactivity.

METHODS

A total of 78 elderly postmenopausal women (51 caregivers (CG) and 27 noncaregivers (NC)) were assessed for platelet activation in response to a laboratory speech test. Half the sample was taking HRT. Blood was sampled at baseline, post speech, and after 14 minutes of recovery. Platelet activation was assessed through whole blood flow cytometry assays of % aggregates (Agg), and expression of % fibrinogen receptors (FbR) and % P-selectin (P-sel) on platelet surface.

RESULTS

Multivariate repeated-measures analysis of variance revealed that CG taking HRT exhibited significantly prolonged platelet activation in response to acute stress. There was an interaction between HRT and CG on recovery from stress for Agg (F (1,71) = 5.260, p = .025), P-Sel (F(1,71 = 6.426, p = .013), and FbR (F(1,71 = 6.653, p = .012), controlling for age, cardiovascular disease, and aspirin. Among HRT users, regression analysis revealed that CG had delayed recovery of Agg (beta = 0.354, t(34) = 2.154, p = .038) and P-sel (beta = 0.498, t(34)=3.126, p = .004) from stress relative to NC. No caregiving effects on recovery were present among non-HRT users. In addition, these effects were maintained after controlling for health behaviors, medications, and medical conditions.

CONCLUSION

Chronic dementia caregiving stress in combination with HRT may impair recovery of platelet activation after acute mental stress (i.e., activation levels do not quickly return to resting levels), thereby potentially increasing cardiovascular risk among CG who take HRT.

Imagery in the Clinical Setting: A Tool for Healing

This article addresses the why and how of imagery and its relation with holistic theories. The description of clinical applications, program development, and research demonstrates successful interventions in virtually every area of nursing. Case examples show the profound healing that is experienced by the patient and the nurse simultaneously through this work. Imagery is harmless, is time- and cost-effective, and creates a healing partnership between the nurse and patient.

Association between plasma inflammatory markers and irrational beliefs; the ATTICA epidemiological study

OBJECTIVE

Recent research data suggest that inflammation and/or depression are associated with the development and progression of cardiovascular disease (CVD). Considering that depression may arise as a response to irrational beliefs according to the Ellis model of psychological disturbances and therapy, we sought to evaluate whether irrational beliefs are associated with plasma inflammatory factors in cardiovascular disease-free people.

METHOD

From May 2001 to December 2002 we randomly enrolled 453 men (23-69 years old) and 400 women (24-71 years old) stratified by age and gender. C-reactive protein, interleukin-6, serum amyloid-A, tumor necrosis factor-alpha and white blood cells were measured in all participants. Detailed dietary characteristics of these people were assessed through a validated food frequency questionnaire. Subjects completed also the irrational beliefs inventory (IBI), which is a brief self-report measure consistent with the Ellis model of psychological disturbance and therapy and the Zung's Depression questionnaire.

RESULTS

The IBI scores were similar in men and women (53+/-11 vs. 53+/-10, p = 0.83). IBI score was positively correlated with C-reactive protein (rho = 0.14, p = 0. 02), interleukin-6 (rho = 0.11, p = 0.02), tumor necrosis factor-alpha (rho = 0.21, p = 0.014) and white blood cell counts (rho = 0.14, p = 0.02). These associations were confirmed even after adjusting for age, sex, years of school, body mass index, physical activity status, depression level and food items consumed by the participants.

CONCLUSION

These findings indicate that irrational beliefs are associated with increased inflammation process, among apparently healthy individuals.

[Psychological stress, immune function and disease development. The psychoneuroimmunologic perspective]

Interdisciplinary psychoneuroimmunological (PNI) research increasingly demonstrates clinically relevant interrelations between psychological stressors and the onset or progression of chronic diseases. Disturbances of the bi-directional interaction between the nervous system, the immune system and the endocrine system have been hypothesized to be implicated in several diseases. Here, we review evidence from psychoneuroimmunology within the theoretical framework of allostatic load to conceptualize some of these associations. Interdisciplinary PNI research investigating the importance of psychological stress for the higher incidence of infections, decreased responses to vaccinations and delayed wound healing is reviewed. Furthermore, the literature supporting similar associations with regard to progression of oncological diseases and autoimmune disorders is reviewed with a focus on breast cancer and multiple sclerosis. The accumulating evidence regarding the importance of neuroendocrine-immune interaction in these diseases may thus lead to novel insights into pathogenetic mechanisms and could contribute to the development of novel preventive and therapeutic strategies.

Findings of interest from immunology and psychoneuroimmunology

The biopsychosocial paradigm is now the main model when dealing with most human health disorders. One of the strengths of this model is that it encourages broader thinking when assessing and managing patients. It also encourages broader reading into areas not traditionally associated with manual therapy. Immunology and neuroscience are amongst the fastest growing medical sciences. These fields come together in the relatively new area of psychoneuroimmunolgy. This article examines some findings from these fields that are not widely discussed in the physical therapy professions. These findings are of relevance to many of the disciplines within the physical therapies. It is the authors aim to stimulate further interest in the relevant, yet often under explored areas of immunology and psychoneuroimmunology.

Dementia severity of the care receiver predicts procoagulant response in Alzheimer caregivers

BACKGROUND

The procoagulant factor D-dimer has been shown to be associated with thrombus formation and degradation as seen with conditions such as myocardial infarction and unstable angina. Research has demonstrated that spousal dementia caregivers have elevated levels of D-dimer relative to their non-caregiving peers.

OBJECTIVE

The objective of this study was to determine the relationship of basal level and laboratory stressor-induced concentration of D-dimer to severity of dementia in spousal care recipients.

METHODS

Seventy-one elderly caregivers were compared with a comparison group of 37 non-caregivers (average age: 71 years). Clinical Dementia Rating (CDR), a global measure of dementia, was used to assess severity of spousal dementia. Plasma D-dimer was measured at baseline and in response to an acute speech stressor.

RESULTS

Regression analysis revealed a significant positive association between severity of spousal dementia and caregiver D-dimer, both at baseline and in response to acute stress, while controlling for age. The model examined an exponential relationship, with D-dimer increasing progressively across the span of dementia stages.

DISCUSSION

Dementia severity of the care recipient was associated with increasing hypercoagulability among elderly caregivers. Effect size estimates suggest that such D-dimer increases may have clinical implications, particularly among late-stage caregivers.

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

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

Coping processes and hemostatic reactivity to acute stress in dementia caregivers

BACKGROUND

A hypercoagulable stress response might contribute to the increased cardiovascular risk in Alzheimer's caregivers.

OBJECTIVES

(1) To evaluate whether coping processes affect hemostatic reactivity to acute psychological stress and (2) whether these effects differ substantially between caregivers and noncaregivers.

METHODS

Sixty elderly community-dwelling spousal caregivers of patients with Alzheimer's disease and 33 noncaregiving controls completed the revised Ways of Coping Questionnaire to assess approach/problem-solving versus avoidant coping processes. Participants were administered an acute stress test that required them to deliver a 3-minute speech challenge to the interviewer on an assigned topic. The hypercoagulability marker D-dimer was measured at three time points: baseline, immediately postspeech, and during recovery (15 minutes postspeech).

RESULTS

Multivariate analysis of covariance revealed that subjects who endorsed greater levels of approach coping had decreased levels of D-dimer at all time points (p = .048). A significant three-way interaction between planful problem solving, caregiver status, and the temporal pattern of D-dimer was found (p = .004), indicating that caregivers with low levels of planful problem solving exhibited greater increases in D-dimer from baseline to speech and recovery time points relative to controls. No relationship between avoidant coping and D-dimer was found.

CONCLUSIONS

These findings suggest the possibility that approach and problem-solving coping processes buffer the impact of acute psychological stressors on procoagulant activity. It remains to be seen whether interventions that increase approach/problem-solving processes might produce salutary effects among caregiving populations.

Increased C reactive protein in response to acute stress in patients with rheumatoid arthritis

OBJECTIVE

To assess the effects of acute stress on inflammatory, haemostatic, rheological, and haemodynamic activity in patients with rheumatoid arthritis (RA) in comparison with patients with osteoarthritis (OA).

METHODS

21 patients with RA and 10 with OA underwent a brief mental stress task while standing. Inflammatory, haemostatic, rheological, and haemodynamic variables were measured at baseline, during the task, and at recovery.

RESULTS

At baseline, erythrocyte sedimentation rate and fibrinogen were higher in RA than OA. White blood cell count, fibrinogen, blood pressure, and pulse rate increased, whereas prothrombin time and plasma volume decreased during the task in both patient groups. The stress task increased C reactive protein (CRP) only in patients with RA, and more specifically in those patients with RA with high disease activity.

CONCLUSIONS

The increase in the inflammatory marker CRP, which was specific to patients with RA, combined with the haemostatic, rheological, and haemodynamic reactions to the stress task, over and above the already high baseline levels, could underlie the increased risk for myocardial infarction in this vulnerable patient group.

Anger, Anxiety, and Depression as Risk Factors for Cardiovascular Disease: The Problems and Implications of Overlapping Affective Dispositions

Several recent reviews have identified 3 affective dispositions--depression, anxiety, and anger-hostility--as putative risk factors for coronary heart disease. There are, however, mixed and negative results. Following a critical summary of epidemiological findings, the present article discusses the construct and measurement overlap among the 3 negative affects. Recognition of the overlap necessitates the development of more complex affect-disease models and has implications for the interpretation of prior studies, statistical analyses, prevention, and intervention in health psychology and behavioral medicine. The overlap among the 3 negative dispositions also leaves open the possibility that a general disposition toward negative affectivity may be more important for disease risk than any specific negative affect.

Alexithymia predicts attenuated autonomic reactivity, but prolonged recovery to anger recall in young women

Alexithymia has been prospectively associated with all-cause mortality and with cardiovascular morbidity. Here, stress-induced autonomic reactivity and recovery were examined as potential pathways linking alexithymia to cardiovascular disease. The relation of alexithymia to blood pressure, heart rate, and other cardiovascular parameters derived from impedance cardiography (N = 80) and heart rate variability (N = 40) was evaluated during rest, an anger recall task and recovery in women (ages 18-30). During anger recall, alexithymia was associated with significantly attenuated heart rate and stroke index reactivity, greater low frequency power, and with marginally dampened blood pressure and high frequency power reactivity. Overall, this response pattern suggests blunted sympathetic activation and diminished vagal withdrawal. Alexithymia was also related to slower diastolic blood pressure and quicker preejection period recovery implying abbreviated sympathetic arousal and possibly greater vagal modulation. These results impart some evidence for the hypoarousal model of alexithymia during reactivity, but the hyperarousal model during recovery. Autonomic dysregulation during and following acute emotional stress is suggested as a possible physiological pathway connecting alexithymia to cardiovascular disease.

Association of fear of terror with low-grade inflammation among apparently healthy employed adults

OBJECTIVE

Based on evidence that psychological stress may induce a chronic inflammatory process, we hypothesized that the stress caused by chronic fear of terror may be associated with low-grade inflammation. This hypothesis was examined in employed men and women with the presence of low-grade inflammation measured by high sensitivity C-reactive protein (CRP).

METHODS

Apparently healthy employed adults (N = 1153) undergoing periodic health check-ups in a tertiary hospital in Israel completed a questionnaire. Fear of terror (scored 1-5) was assessed by three items measuring the extent to which respondents have deep concern for personal safety, elevated tension in crowded places, and fear of terror strikes causing harm to one's self or one's family members. The main outcome measure was the presence or absence of an elevated CRP level (>3.0 mg/L).

RESULTS

Women scored significantly higher on fear of terror compared with men (M = 2.16 vs. M = 1.68, respectively; p <.0001). Most of the study participants who scored high (4 or 5) on fear of terror, reported having experienced this feeling for 1 year or more. In women only, there was a positive association between fear of terror and risk of elevated CRP level (adjusted OR = 1.7, 95% CI 1.2-2.4) in a multivariate model adjusting for generalized anxiety, depressive symptoms, and potentially confounding demographic and biomedical variables.

CONCLUSIONS

Chronic fear of terror in women, but not in men, is associated with elevated CRP levels, which suggests the presence of low-grade inflammation and a potential risk of cardiovascular disease.