Examining the mediational role of psychological flexibility, pain catastrophizing, and visceral sensitivity in the relationship between psychological distress, irritable bowel symptom frequency, and quality of life

Health correlates of experiential and behavioral avoidance among trauma-exposed veterans

INTRODUCTION

Avoidance is a well-documented risk factor for poor mental and physical health outcomes. However, limited research has explored this relationship specifically among trauma-exposed veterans, a population known to be particularly prone to avoidance behavior. Conceptually, avoidance is often divided into two distinct but overlapping constructs - experiential avoidance (resisting distressing internal states) and behavioral avoidance (avoiding or changing experiences that elicit distress). In this exploratory survey study, we examined associations between behavioral and experiential avoidance and mental, physical, and cognitive functioning, as well as quality of life.

METHODS

Veterans with a trauma history (N = 89) completed a 121-item survey containing validated assessments to examine several mental and physical health and wellness-related variables. Correlations between experiential avoidance and outcome measures, and behavioral avoidance and outcome measures, were explored. Multivariable linear regression analyses were conducted to explore the association between experiential and behavioral avoidance on mental health outcomes. In addition, we conducted exploratory analyses in which we investigated these correlations in those who screened positive for PTSD versus those who did not, and between different types of behavioral avoidance and major outcomes.

RESULTS

Experiential avoidance was moderately correlated with distress from depressive symptoms, distress related to past trauma, and health-related and cognitive dysfunction. Experiential Avoidance was weakly correlated with distress from anxiety symptoms and poorer quality of life. Behavioral avoidance was moderately correlated with distress from depressive and anxiety symptoms, distress related to past trauma, and cognitive dysfunction, and was weakly correlated with health-related dysfunction and poorer quality of life. Results from multivariable analyses revealed that experiential avoidance was associated with greater distress related to depressive symptoms and past trauma, and behavioral avoidance was associated with greater distress related to anxiety symptoms, depressive symptoms, and past trauma.

CONCLUSIONS

Results suggest that avoidance negatively influences major domains of mental and physical health as well as functioning and health-related quality of life in trauma-exposed veterans. They further indicate that behavioral and experiential avoidance may be differentially linked to mental health outcomes. The results support the idea that avoidance may be an important marker for psychosocial functioning and may serve as a treatment target in trauma-exposed veterans.

Sleep Characteristics in Dance Students Related to Psychological Inflexibility

Introduction: Dance, as a performance activity, is associated with various problems. Among these challenges, sleep disturbances are notably prevalent. Aims: This study aimed to explore the potential relationship between sleep characteristics-specifically chronotype and subjective sleep quality- and psychological inflexibility in dance students. Methods: This research adopted a cross-sectional design using non-probabilistic sampling. The data were collected in paper format by visiting public conservatories and private academies, and online. One hundred fourteen dance students, with a mean age of 23.87 years, participated in the study. Assessment tools included the Acceptance and Action Questionnaire-II, Pittsburgh Sleep Quality Index, and the Composite Scale of Morningness. Results: The results revealed that 80.7% of all students reported poor sleep quality, compared to 19.3% who reported good sleep quality. Differences emerged in both subjective sleep quality (F(2, 113) = 4.825, P = .010) and chronotype (F(2, 113) = 6.172, P = .003) when students were grouped according to low, medium, or high levels of psychological inflexibility. Those with low inflexibility, as opposed to those with high inflexibility, report better sleep quality, with no differences observed between medium and high inflexibility groups. Students with high-medium levels of psychological inflexibility showed a higher risk (OR = 6.373 times higher) of experiencing poor sleep quality compared to those with low psychological inflexibility. In terms of chronotype, the low inflexibility group is inclined to be more of a morning type than the medium and high inflexibility groups, with no differences between the latter 2 groups. Students categorized as having low inflexibility tend to have a longer history of dancing under the guidance of a teacher and dedicate more hours and days per week to rehearsal. Conclusion: Conservatories can become "healthy spaces." In this regard, sleep hygiene programs and Acceptance and Commitment Therapy interventions can provide guidance to professionals working with dancers in professional companies and conservatories.

Psychological flexibility and global health in young adults with and without a self-reported functional somatic syndrome: a preliminary investigation

Functional somatic syndromes (FSS) are associated with functional impairments and distress. FSSs are common among young adults, and psychological flexibility may be a transdiagnostic process appropriate for treatment of FSS in this population. The objective of the current study was to compare physical and mental health in young adults with and without a self-reported FSS and examine which psychological flexibility processes are associated with better physical and mental health in the FSS subset. A total of 447 young adults participated in the current study. Individuals who reported an FSS diagnosis were coded as having a self-reported FSS. Physical and mental health and psychological flexibility were measured via self-report. FSS and non-FSS groups were compared regarding demographic characteristics and on the primary outcomes. Hierarchical regression analyses were conducted to examine the role of the psychological flexibility processes in physical and mental health in the FSS subset. Findings revealed that the FSS group scored significantly lower on measures of physical health and demonstrated less behavioral awareness than the non-FSS group. No differences regarding mental health were found. All three psychological flexibility processes were associated with physical and mental health, accounting for 26-49% of the variance in these outcomes. In conclusion, young adults with FSS experience more physical health difficulties than those without FSS. Psychological flexibility processes were related to better physical and mental health in those with FSS. These findings add to the literature and provide preliminary support for psychological flexibility as a future target for intervention development and implementation aimed at young adults with FSS.

Exploring the Impact of Covid-19-Related Perceptions on Psychological Distress and Quality of Life in an International Gastrointestinal Cohort Over Time Guided by the Common Sense Model

The aim of this longitudinal study was to examine changes in COVID-19 and illness-related perceptions, gastrointestinal symptoms, coping, catastrophising, psychological distress, and QoL during the COVID-19 pandemic. A total of 831 adults with a gastrointestinal condition completed an online questionnaire at baseline (May-October 2020). Of those, 270 (32.5%) participants (85.2% female, mean age = 47.3 years) provided follow-up data (March-May 2021). Repeated-measures multiple analysis of variance and a cross-lagged panel model were used to test the study hypotheses. Gastrointestinal symptoms and COVID-19 perceptions at follow-up were strongly predicted by their baseline values, while illness perceptions were predicted by baseline gastrointestinal symptoms. Cross-lagged relationships indicated a reciprocal relationship between gastrointestinal symptoms and psychological distress. Moreover, gastrointestinal symptoms had substantial predictive utility, strongly predicting future gastrointestinal symptoms, and to a lesser extent, more negative illness perceptions, greater psychological distress, and greater use of adaptive coping strategies across time.

Comparing the effect of internet-delivered short-term progressive muscle relaxation and psychoeducation on mindful ability, visceral hypersensitivity and symptoms of patients with irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a functional bowel disorder that psychological interventions are effective on it. The present study aimed to compare the effect of internet-delivered short-term PMR (iPMR) and psychoeducation on mindful ability (MA), visceral hypersensitivity (VH), and symptoms of patients with IBS.

MATERIALS AND METHODS

This randomized clinical trial was performed on individuals with IBS in 2020, recruiting a total of 60 patients fulfilling the inclusion criteria. Prior to the intervention, the Freiburg Questionnaire- Short Form (FMI-SF), the Visceral Sensitivity Questionnaire (VSI), and the Gastrointestinal Symptoms Rating Scale (GSRS) were filled out for the patients. Patients were divided into iPMR and psychoeducation groups randomly. All training in both groups was accomplished via WhatsApp social network. FMI-SF, VSI, and GSRS questionnaires for patients were completed 1 month (post-test) and 2 months later (follow-up). The data was analyzed by SPSS-23 software and one-way analysis of variance (ANOVA).

RESULTS

Compared to the psychoeducation group, the MA of the iPMR group increased significantly in post-test and follow-up (43.06 ± 7.12 and 42.88 ± 6.28 vs 51.23 ± 11.7 and 56.74 ± 12.36 and P < 0.001) and their VH decreased significantly (37.85 ± 11.6 and 38.03 ± 11.8 vs 26.9 ± 6.45 and 22.46 ± 5.32 and P < 0.001). Also, their GSRS had significant decreases (43.27 ± 10.73 and 41.18 ± 9.31 vs 32.33 ± 8.21 and 25.79 ± 6.30 and P < 0.001).

CONCLUSION

The findings showed iPMR in patients with IBS, in spite of a few sessions and internet-delivered approach, increased MA and decreased VH and gastrointestinal symptoms of them.

The epidemioflogy and psychological comorbidity of disorders of gut-brain interaction in Australia: Results from the Rome Foundation Global Epidemiology Study

BACKGROUND

The Rome Foundation Global Epidemiology Study on the disorders of gut-brain interaction (DGBI) was used to assess the national prevalence of all 22 DGBI, the percentage of respondents meeting diagnostic criteria for at least one DGBI, and the rates of comorbid anxiety, depression, and somatization in Australia and 25 other countries.

METHODS

The survey was conducted in Australia and 25 other countries through the Internet and included the Rome IV Diagnostic Questionnaire and an in-depth supplemental questionnaire.

KEY RESULTS

Two thousand thirty-six Australian adults completed the survey nationwide: mean age 47.34 ± 17.00 years, 50.15% males. Overall, 38.67% of Australians met criteria for at least one DGBI, with unspecified functional bowel disorder (8.01%) and then functional constipation (7.71%) being the most prevalent. For those Australians with at least one DGBI, rates of anxiety, depression, and somatization where high (26.58%, 28.96%, and 63.10%, respectively), with functional chest pain having the highest rates of anxiety (55.00%) and depression (57.50%), and irritable bowel syndrome (mixed) having the highest somatization rate (75.86%). The odds of having a DGBI increased with greater anxiety (OR: 1.09, CI 95%: 0.97, 1.23), depression (OR: 1.17, CI 95%: 1.04, 1.32), and somatization (OR: 1.17, CI 95%: 1.14, 1.20) symptom severity.

CONCLUSIONS AND INFERENCES

The current study represents the most comprehensive epidemiological exploration of DGBI and mental health in Australia to date, including their prevalence and distributions across sex and age, associations between DGBI and anxiety, depression, and somatization. The findings warrants future comparisons between population characteristics and health care systems differences in order to reduce the burden of DGBI and mental illness worldwide.

Negative Impact of Disorders of Gut-Brain Interaction on Health-Related Quality of Life: Results From the Rome Foundation Global Epidemiology Survey

BACKGROUND & AIMS

This study used the database from the Rome Foundation Global Epidemiology Survey to assess the differences in quality of life overall, and by age and sex, across individual disorders of gut-brain interaction (DGBI), gastrointestinal anatomical region(s), and number of overlapping DGBI.

METHODS

Data were collected via the Internet in 26 countries, using the Rome IV diagnostic questionnaire and a supplemental questionnaire including the Patient-Reported Outcomes Measurement Information Systems Global-10 quality of life measure. Factorial analyses of variance were used to explore physical and mental quality of life, adjusting for multiple comparisons.

RESULTS

Among the 54,127 respondents, quality of life deteriorated significantly with increasing number of overlapping DGBI, with respondents reporting ≥2 DGBI having significantly poorer quality of life than those with only 1 DGBI or those without any DGBI. Men with DGBI reported better quality of life than women, and those aged ≥65 years reported better quality of life than those <65 years. Age, sex, number of overlapping DGBI, somatization, anxiety, depression, and functional experiences (concern, embarrassment, or stress associated with bowel functioning) relating to DGBI, were significant predictors of poorer physical and mental quality of life.

CONCLUSIONS

This study is the most comprehensive assessment of quality of life to date in adults living with a DGBI. It provides a representative picture of DGBI impact on adults in the global adult population and highlights the significant detrimental impact of living with a DGBI on quality of life.

The Interplay of Biopsychosocial Factors and Quality of Life in Inflammatory Bowel Diseases: A Network Analysis

GOAL

The aim of this study was to investigate the network of biopsychosocial factors and quality of life (QoL) in persons with inflammatory bowel diseases (IBDs) and explore the influence of psychological factors on the course of the disease.

BACKGROUND

QoL of persons with IBD depends on disease activity but also on numerous interacting psychosocial factors. The influence of psychosocial factors on the disease course in controversially discussed.

MATERIALS AND METHODS

In 2 independent IBD samples (sample 1: n=209, anonymous internet survey; sample 2: n=84, outpatients with active disease), we measured QoL, anxiety, depression, illness identity, self-esteem, loneliness, childhood trauma, and visceral sensitivity with questionnaires. In addition, fatigue, hemoglobin levels, and response to therapy were assessed in sample 2. We estimated multiple regularized partial correlation networks and conducted accuracy and stability tests of the networks.

RESULTS

In both samples, QoL had the strongest relationships with visceral sensitivity and the illness identity engulfment. Depression was the most central factor in the networks. Baseline depression scores, visceral sensitivity, and engulfment were associated with response to therapy in sample 2.

CONCLUSIONS

This first network study to assess the interplay between biopsychosocial factors and QoL in IBD reveals a comparable network structure in 2 samples. Results partly replicate findings from previous studies with regard to the importance of depression and yield information on the central role of the newly introduced concepts of illness identity and visceral sensitivity. Preliminary findings point to an influence of these parameters on the disease course, which indicates their role as a possible target in individualized therapy.

Quality of life in irritable bowel syndrome: Exploring mediating factors through structural equation modelling

BACKGROUND

Irritable Bowel Syndrome (IBS) negatively influences mental and physical quality of life (QoL), but factors that explain this impact are still unclear. Increasing evidence has associated IBS severity, psychological distress, somatic symptoms, and gastrointestinal (GI)-specific anxiety with QoL in IBS. The aim of this study is to further explore these associations and to analyze potential mediating factors.

METHOD

A total of 1017 IBS patients (69.3% female, mean age 40.6 years) who completed a QoL measure (SF-36) were included in this study. A proportion of these participants (N = 183; 72.7% female, mean age 41.7), who additionally completed psychological distress, somatic symptoms, and GI-specific anxiety measures, was included in the mediation analysis. This analysis was conducted via structural equation modelling to identify factors of importance for generic QoL, using a cross-sectional design.

RESULTS

IBS patients reported lower QoL than what is observed in the general population, in particular regarding role limitations caused by health and emotional functioning, vitality, and social functioning. Female patients scored lower than male patients on most QoL dimensions. The effects of IBS severity on mental and physical QoL were mediated by GI-specific anxiety. In addition to GI-specific anxiety, depressive symptoms were also of importance for mental QoL, and somatic symptom severity for physical QoL.

CONCLUSION

QoL is reduced in patients with IBS and GI-specific anxiety, depressive symptoms, and somatic complaints are particularly important for this outcome. Future trials should test the efficacy of psychological interventions specifically targeting these factors in improving QoL in IBS.

Adverse childhood experiences and burn pain: a review of biopsychosocial mechanisms that may influence healing

Adverse childhood experiences (ACEs) affect over half of the adults in the United States and are known to contribute to the development of a wide variety of negative health and behavioral outcomes. The consequences of ACE exposure have been studied in patient populations that include individuals with gynecologic, orthopedic, metabolic, autoimmune, cardiovascular, and gastrointestinal conditions among others. Findings indicate that ACEs not only increase risks for chronic pain but also influence emotional responses to pain in many of these individuals. A growing body of research suggests that these effects may be the result of long-lasting changes induced by ACEs in neurobiological systems during early development. However, one area that is still largely unexplored concerns the effects of ACEs on burn patients, who account for almost 450,000 hospitalizations in the United States annually. Patients with severe burns frequently suffer from persistent pain that affects their well-being long after the acute injury, but considerable variability has been observed in the experience of pain across individuals. A literature search was conducted in CINAHL and PubMed to evaluate the possibility that previously documented ACE-induced changes in biological, psychological, and social processes might contribute to these differences. Findings suggest that better understanding of the role that ACEs play in burn outcomes could lead to improved treatment strategies, but further empirical research is needed to identify the predictors and mechanisms that dictate individual differences in pain outcomes in patients with ACE exposure and to clarify the role that ACE-related alterations play in early healing and recovery from burn injuries.

Longitudinal assessment of the common sense model before and during the COVID-19 pandemic: A large coeliac disease cohort study

OBJECTIVE

Psychosocial factors likely play a substantial role in the well-being of those living with coeliac disease, especially during the COVID-19 pandemic, however, little research has examined well-being in this cohort using an integrated socio-cognitive model. This study had two aims: (1) Examine changes in gastrointestinal symptoms, psychosocial factors, and well-being outcomes (i.e., psychological distress, quality of life [QoL]) associated with the pandemic, (2) Examine the interrelationship of these variables across timepoints using the Common Sense Model (CSM).

METHODS

1697 adults with coeliac disease (Time 1, pre-pandemic; 83.1% female, mean age = 55.8, SD = 15.0 years) and 674 follow-up participants (Time 2, pandemic; 82.8% female, mean age = 57.0, SD = 14.4 years) completed an online questionnaire. Hypotheses were tested using repeated measures MANOVA and cross-lagged panel model analyses.

RESULTS

Participants reported improved QoL, and reduced gastrointestinal symptoms, negative illness perceptions and maladaptive coping from pre-pandemic to during the pandemic. There was no significant change in pain catastrophising or psychological distress. Cross-lagged effects showed gastrointestinal symptoms to predict negative illness perceptions, which in turn were predictive of poorer outcomes across all variables except pain catastrophising. Consistent with the CSM, there was a reciprocal relationship between illness perceptions and QoL over time. Maladaptive coping and pain catastrophising demonstrated limited predictive utility.

CONCLUSION

The COVID-19 pandemic appears to have had a small beneficial effect across several indices of well-being among adults with coeliac disease. Cross-lagged relationships highlight illness perceptions as a predictor of well-being outcomes and a potential target for psychosocial interventions.

Development and Validation of the Gastrointestinal Unhelpful Thinking Scale (GUTs): A Brief Self-Report Measure for Clinical and Research Settings

This article describes the development and validation of the Gastrointestinal Unhelpful Thinking scale. The purpose of the research was to develop the Gastrointestinal Unhelpful Thinking scale to assess in tandem the primary cognitive-affective drivers of brain-gut dysregulation, gastrointestinal-specific visceral anxiety, and pain catastrophizing. The research involved 3 phases which included undergraduate and community samples. In the first phase, an exploratory factor analysis revealed a 15-item 2-factor (visceral sensitivity and pain catastrophizing) scale (N= 323), which then was confirmed in the second phase: N = 399, χ2(26) = 2.08, p = .001, Tucker-Lewis Index = 0.94, comparative fit index = 0.96, standardized root mean square residual = 0.05, and root mean square error of approximation = 0.07. Demonstrating convergent validity, Gastrointestinal Unhelpful Thinking scale total and subscales were strongly correlated with the modified Manitoba Index, Irritable Bowel Syndrome Symptom Severity Scale scores, Visceral Sensitivity Index, and the Pain Catastrophizing Scale. A third phase (N = 16) established test-retest reliability for the Gastrointestinal Unhelpful Thinking scale (total and subscales). The test-retest reliability correlation coefficient for the Gastrointestinal Unhelpful Thinking scale total score was .93 (p < .001) and for the subscales was .86 (p < .001) and .94 (p < .001), respectively. The Gastrointestinal Unhelpful Thinking scale is a brief psychometrically valid measure of visceral anxiety and pain catastrophizing that can be useful for both clinicians and researchers who wish to measure these thinking patterns and relate them to changes in gastrointestinal and psychological symptoms.

Quality of life in coeliac disease: relationship between psychosocial processes and quality of life in a sample of 1697 adults living with coeliac disease

BACKGROUND

Coeliac disease is a chronic gastrointestinal condition associated with an increased risk of psychiatric comorbidity, and diminished quality of life. Ongoing gastrointestinal symptomatology is frequently reported post-diagnosis, despite undertaking a gluten-free diet.

PURPOSE

To examine the role of psychosocial factors in mediating the relationship between gastrointestinal symptoms and quality of life, using a cross-sectional structural equation modelling mediation analysis guided by the Common-Sense Model.

METHODS

1697 adults with coeliac disease (83.1% female, mean age = 55.79, SD = 14.98 years) completed an online questionnaire. Measures included gluten-free diet adherence, gastrointestinal symptoms, illness perceptions, coping, gastrointestinal-specific anxiety, pain catastrophising, psychological flexibility, psychological distress, and quality of life.

RESULTS

A structural equation model was developed explaining 50.6% of the variation in quality of life and demonstrating good fit (χ2 (2) = 8.54, p = .014, χ2/N = 4.27, RMSEA = 0.04, SRMR = 0.01, CFI = 0.999, TLI = 0.98, GFI = 0.999). Gastrointestinal symptoms directly affected quality of life, and indirectly, via negative illness perceptions, maladaptive coping, pain catastrophising, and psychological distress.

CONCLUSION

Psychosocial processes may affect adjustment in coeliac disease by mediating the relationship between gastrointestinal symptoms and quality of life. Individuals living with coeliac disease may benefit from interventions targeting maladaptive psychosocial factors.

Experiential avoidance is associated with medical and mental health diagnoses in a national sample of deployed Gulf War veterans

A substantial minority of deployed Gulf War veterans developed posttraumatic stress disorder (PTSD), depression, and several chronic illnesses. Although military combat and exposure to certain nuclear, biological, and chemical agents (NBCs) increase risk for post-deployment health problems, they do not fully explain many Gulf War veteran health diagnoses and are not viable treatment targets. Experiential avoidance (EA; one's unwillingness to remain in contact with unpleasant internal experiences) is a modifiable psychosocial risk factor associated with PTSD and depression in veterans as well as pain and gastrointestinal diseases in the general population. In this study, we recruited a national sample of deployed Gulf War veterans (N = 454) to test the hypothesis that greater EA would be significantly associated with higher lifetime odds of PTSD, depression, "Gulf War Illness" (GWI/CMI), and other chronic illnesses common in this veteran cohort. Participants completed a self-report battery assessing demographic, military-related, and health-related information. Multivariate analyses showed that after adjusting for age, sex, race, combat exposure, and NBC exposure, worse EA was associated with higher lifetime odds of PTSD, depression GWI/CMI, gastrointestinal problems, irritable bowel syndrome, arthritis, fibromyalgia, and chronic fatigue syndrome (ORs ranged 1.25 to 2.89; effect sizes ranged small to large), but not asthma or chronic obstructive pulmonary disease. Our findings suggest medical and mental health providers alike should assess for EA and potentially target EA as part of a comprehensive, biopsychosocial approach to improving Gulf War veterans' health and wellbeing. Study limitations and future research directions are also discussed.

Social factors and pain worsening: a retrospective cohort study

BACKGROUND

Pain, specifically chronic pain, is a major public health issue worldwide with considerable health-related consequences and large economic impact. The relation between socioeconomic status and pain occurrence is well established. However, little is known on the relation between socioeconomic factors and worsening of pain, including progression from non-chronic pain to chronic pain.

METHODS

To assess the relation between socioeconomic status and pain worsening, we used the Stockholm Public Health Cohort Study from 2006 to 2014 and analysed data of 9721 participants who completed follow-up. The adjusted incidence rate ratios (IRRs) of moderate and severe pain worsening episodes were computed, using a pain amplification model, which encompasses spreading, somatisation, and psychological distress components. Multiple imputation analysis was performed subsequently to adjust for cohort attrition.

RESULTS

Compared with non-skilled workers, self-employed subjects (IRR=1.18; 95% confidence interval [CI], 1.01-1.39) and non-manual employees were at higher risk of moderate worsening (lower non-manual employees: IRR=1.21; 95% CI, 1.03-1.41; intermediate non-manual employees: IRR=1.26; 95% CI, 1.10-1.44; higher non-manual employees: IRR=1.25; 95% CI, 1.08-1.45). This risk increase was limited to worsening starting at stage 0 (non-chronic pain). No association was found between socioeconomic status and severe pain worsening.

CONCLUSION

Our results support a moderate association between intermediate and high socioeconomic status, and moderate pain worsening. This association could be explained by the heterogeneous composition of the socioeconomic variable used in this cohort, and by changes in exposure and other time-varying covariables' status during follow-up.

Cardiac-specific experiential avoidance predicts change in general psychological well-being among patients completing cardiac rehabilitation

Previous studies have shown that experiential avoidance (EA) is associated with physical and psychological well-being in medical and non-medical samples. The aims of the present study were to evaluate the reciprocal association between psychological well-being and EA over time among cardiac rehabilitation (CR) patients with moderately to severely low levels of psychological well-being. Pre-CR data on demographic characteristics, measures of psychological well-being, and cardiac-specific EA were collected from 915 CR patients, as well as post-CR psychological well-being and EA data, from 800 of these patients. A cross-lagged model was estimated to examine the relationship between EA and psychological well-being among patients with moderately to severely low levels of psychological well-being based on questionnaire scores. Both EA and psychological well-being significantly changed during CR and were negatively associated with each other at both pre- and post-CR. Results from cross-lagged structural equation modeling supported a nonreciprocal association between EA and psychological well-being during CR. Pre-CR assessment of EA in patients showing low levels of well-being at the beginning of CR could help to identify patients at risk for worse psychological outcomes. EA could be a promising target of psychological treatments administered during CR.