Childhood Adversity and Cumulative Life Stress: Risk Factors for Cancer-Related Fatigue

Epigenome-wide association study of long-term psychosocial stress in older adults

Long-term psychosocial stress is strongly associated with negative physical and mental health outcomes, as well as adverse health behaviours; however, little is known about the role that stress plays on the epigenome. One proposed mechanism by which stress affects DNA methylation is through health behaviours. We conducted an epigenome-wide association study (EWAS) of cumulative psychosocial stress (n = 2,689) from the Health and Retirement Study (mean age = 70.4 years), assessing DNA methylation (Illumina Infinium HumanMethylationEPIC Beadchip) at 789,656 CpG sites. For identified CpG sites, we conducted a formal mediation analysis to examine whether smoking, alcohol use, physical activity, and body mass index (BMI) mediate the relationship between stress and DNA methylation. Nine CpG sites were associated with psychosocial stress (all p < 9E-07; FDR q < 0.10). Additionally, health behaviours and/or BMI mediated 9.4% to 21.8% of the relationship between stress and methylation at eight of the nine CpGs. Several of the identified CpGs were in or near genes associated with cardiometabolic traits, psychosocial disorders, inflammation, and smoking. These findings support our hypothesis that psychosocial stress is associated with DNA methylation across the epigenome. Furthermore, specific health behaviours mediate only a modest percentage of this relationship, providing evidence that other mechanisms may link stress and DNA methylation.

Higher Levels of Multiple Types of Stress Are Associated With Worse State Anxiety and Morning Fatigue Profiles in Patients Receiving Chemotherapy

BACKGROUND

Anxiety and fatigue are common problems in patients receiving chemotherapy. Unrelieved stress is a potential cause for the co-occurrence of these symptoms.

OBJECTIVES

The aims of this study were to identify subgroups of patients with distinct state anxiety and morning fatigue profiles and evaluate for differences among these subgroups in demographic and clinical characteristics, as well as measures of global, cancer-specific, and cumulative life stress and resilience and coping.

METHODS

Patients (n = 1335) completed measures of state anxiety and morning fatigue 6 times over 2 cycles of chemotherapy. All of the other measures were completed prior to the second or third cycle of chemotherapy. Latent profile analysis was used to identify the state anxiety and morning fatigue profiles.

RESULTS

Three distinct joint profiles were identified: Low Anxiety and Low Morning Fatigue (59%), Moderate Anxiety and Moderate Morning Fatigue (33.4%), and High Anxiety and High Morning Fatigue (7.6%). Patients in the 2 highest classes were younger, were less likely to be married/partnered, and had a higher comorbidity burden. All of the stress scores demonstrated a dose-response effect (ie, as anxiety and morning fatigue profiles worsened, stress increased). Patients in the 2 highest classes reported higher rates of emotional abuse, physical neglect, physical abuse, and sexual harassment.

CONCLUSIONS

More than 40% of these patients experienced moderate to high levels of both anxiety and morning fatigue. Higher levels of all 3 types of stress were associated with the 2 highest profiles.

IMPLICATIONS FOR PRACTICE

Clinicians need to perform comprehensive evaluations of patients' levels of stress and recommend referrals to psychosocial services.

Adverse childhood events and mental health problems in cancer survivors: a systematic review

PURPOSE

The purpose of this study was to systematically review the literature on the association between adverse childhood events (ACEs) and mental health problems in cancer survivors.

METHODS

This review was conducted in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Four databases (PubMed, PsychINFO, Web of Science, and Cochrane) were searched on 27-08-2023.

RESULTS

Of the 1413 references yielded by the literature search, 25 papers met inclusion criteria and were reviewed. Most studies were performed in the USA, most included breast cancer survivors, and the number of included participants ranged between 20 and 1343. ACEs were relatively prevalent, with self-report rates ranging between 40 and 95%. Having been exposed to ACEs was a risk factor for heightened levels of emotional distress, anxiety, depressive symptoms, and fatigue during cancer treatment. Results varied depending on the variables included, and per subscale, but were consistent across different cultures and heterogenous patient groups.

CONCLUSION

The association between ACE and mental health outcomes was significant in most studies. In order to improve treatment for this vulnerable population, it may be necessary to screen for ACEs before cancer treatment and adjust treatment, for example, by means of trauma-informed care (TIC), which recognizes and responds to the impact of trauma on individuals seeking healthcare.

Mitigating long-term and delayed adverse events associated with cancer treatment: implications for survivorship

Despite the importance of chemotherapy-associated adverse events in oncology practice and the broad range of interventions available to mitigate them, limited systematic efforts have been made to identify, critically appraise and summarize the totality of evidence on the effectiveness of these interventions. Herein, we review the most common long-term (continued beyond treatment) and late or delayed (following treatment) adverse events associated with chemotherapy and other anticancer treatments that pose major threats in terms of survival, quality of life and continuation of optimal therapy. These adverse effects often emerge during and continue beyond the course of therapy or arise among survivors in the months and years following treatment. For each of these adverse effects, we discuss and critically evaluate their underlying biological mechanisms, the most commonly used pharmacological and non-pharmacological treatment strategies, and evidence-based clinical practice guidelines for their appropriate management. Furthermore, we discuss risk factors and validated risk-assessment tools for identifying patients most likely to be harmed by chemotherapy and potentially benefit from effective interventions. Finally, we highlight promising emerging supportive-care opportunities for the ever-increasing number of cancer survivors at continuing risk of adverse treatment effects.

Predicting the Social-Emotional Competence Based on Childhood Trauma, Internalized Shame, Disability/Shame Scheme, Cognitive Flexibility, Distress Tolerance and Alexithymia in an Iranian Sample Using Bayesian Regression

The purpose of this study was to predict Social Emotional Competence based on childhood trauma, internalized shame, disability/shame scheme, cognitive flexibility, distress tolerance, and alexithymia in an Iranian sample using Bayesian regression. The participants in this research were a sample of 326 (85.3% female and 14.7% male) people living in Tehran in 2021 who were selected by convenience sampling through online platforms. The survey assessments included demographic characteristics (age and gender), presence of childhood trauma, social-emotional competence, internalized shame, the Toronto Alexithymia scales, Young's measure of disability/shame together with measures of cognitive flexibility and distress tolerance. The results from Bayesian regression and Bayesian Model Averaging (BMA) indicated that internalized shame, cognitive flexibility and distress tolerance can be predictive of Social Emotional Competence. These results suggested that Social Emotional Competence can be explained by some important personality factors.

Associations Between Demographic, Clinical, and Symptom Characteristics and Stress in Oncology Patients Receiving Chemotherapy

BACKGROUND

Patients undergoing cancer treatment experience global stress and cancer-specific stress. Both types of stress are associated with a higher symptom burden.

OBJECTIVE

In this cross-sectional study, we used a comprehensive set of demographic, clinical, and symptom characteristics to evaluate their relative contribution to the severity of global and cancer-specific stress.

METHODS

Patients (N = 941) completed study questionnaires before their second or third cycle of chemotherapy.

RESULTS

Consistent with our a priori hypothesis, we found both common and distinct characteristics associated with higher levels of global stress and cancer-specific stress. A significant proportion of our patients had scores on the Impact of Event Scale-Revised suggestive of subsyndromal (29.4%) or probable (13.9%) posttraumatic stress disorder. Four of the 5 stepwise linear regression analyses for the various stress scales explained between 41.6% and 54.5% of the total variance. Compared with various demographic and clinical characteristics, many of the common symptoms associated with cancer and its treatments uniquely explained a higher percentage of the variance in the various stress scales. Symptoms of depression made the largest unique contribution to the percentage of total explained variance across all 5 scales.

CONCLUSION

Clinicians need to assess for global stress, cancer-specific stress, and depression in patients receiving chemotherapy.

IMPLICATIONS FOR PRACTICE

Patients may benefit from integrative interventions (eg, mindfulness-based stress reduction, cognitive behavioral therapy, acupuncture) that simultaneously address stress and symptoms commonly associated with cancer and its treatments.

Cancer-related fatigue: Identification of hallmarks to enable refined treatment approaches

OBJECTIVE

Recommendations for fatigue management are commonly given in an undifferentiated manner without further evaluation of patient's specific symptomatology. Thus, we aimed to identify hallmarks of potential fatigue subgroups which might guide more refined treatment.

METHODS

The FiX study assessed fatigue with the EORTC QLQ-FA12 in patients around 2 years after cancer diagnosis (T0) including 15 different entities. After 2 years, a follow-up survey (T1) was conducted. The analyses comprised all patients with prevalent fatigue at T0 (N = 1023). Hierarchical cluster analysis was performed using the Ward method and including the dichotomized factors emotional distress, pain, insomnia, and obesity. Emotional distress, that is, depressive symptoms and anxiety, was assessed by the PHQ-4. Pain and insomnia were based on the according symptom scores of the EORTC QLQ-C30. Analysis of covariance was conducted to investigate the association of the fatigue clusters at T0 with subsequent fatigue at T1.

RESULTS

Four hierarchical clusters were identified. The first cluster comprised patients with moderate-to-severe distress. The remaining fatigue cases were differentiated by obesity and then by pain. Fatigue cases without any of these three symptoms formed the last cluster. Physical, emotional and cognitive fatigue were highest in the distress cluster. Additionally, this cluster was associated with higher physical, emotional and cognitive fatigue at T1 compared to the other clusters.

CONCLUSIONS

Fatigue in conjunction with emotional distress had worse impact, persisted longer, and may require other treatment approaches than fatigue in patients without emotional distress. Obesity and pain may be further distinguishing hallmarks for refined fatigue management.

Effects of Chronic Burden Across Multiple Domains and Experiences of Daily Stressors on Negative Affect

BACKGROUND

Exposure to chronic psychological stress across multiple life domains (multi-domain chronic burden) is associated with poor health. This may be because multi-domain chronic burden influences daily-level emotional processes, though this hypothesis has not been thoroughly tested.

PURPOSE

The current study tested whether (a) multi-domain chronic burden is associated with greater exposure to daily stressors and (b) multi-domain chronic burden compounds negative affect on days with stressors compared to stressor-free days.

METHODS

The MIDUS Study (Wave II) and the National Study of Daily Experiences sub-study were conducted from 2004 to 2006 (N = 2,022). Participants reported on eight life domains of psychological stress used to create a multi-domain chronic burden summary score. For eight consecutive days, participants reported the daily occurrence of stressful events and daily negative affect.

RESULTS

Participants with greater multi-domain chronic burden were significantly more likely to report daily stressors. There was also a significant interaction between multi-domain chronic burden and daily stressors on negative affect: participants with higher multi-domain chronic burden had greater negative affect on stressor days than stressor-free days compared to those with lower multi-domain chronic burden.

CONCLUSION

Participants with higher multi-domain chronic burden were more likely to report daily stressors and there was a compounding effect of multi-domain chronic burden and daily stressors on negative affect. These results suggest that experiencing a greater amount of psychological stress across multiple life domains may make daily stressors more toxic for daily affect.

Equitable Mindfulness: The practice of mindfulness for all

The benefits of mindfulness are well-documented; however, these benefits may not be evenly distributed across communities. Equitable Mindfulness aims to make these benefits accessible to a wider and more inclusive audience. The aim of this study was to investigate the applicability of Equitable Mindfulness and systemic barriers that prevent mindfulness programs from being equitably accessed across communities. Twenty-one participants were recruited for qualitative in-depth interviews during a 2-day mindfulness conference. The constant comparison method was used to iteratively identify and categorize themes that emerged within and across interviews. Five dominant themes emerged from the data as follows: inherent equitability, accessibility, inclusiveness, awareness and knowledge-sharing, and acknowledgement of multiple perspectives. Having an applicable and meaningful term to use when describing mindfulness as an inclusive and equitable practice can facilitate the exploration of a new area of research. There is a need for future initiatives aimed at making mindfulness trainings and programs more equitable and accessible to all, regardless of socioeconomic status, race/ethnicity, or abilities/disabilities.

Imbalance in Sirt1 Alternative Splicing in Response to Chronic Stress during the Adolescence Period in Female Mice

Stressful unpredictable life events have been implicated in numerous diseases. It is now becoming clear that some life periods are more vulnerable than others. As adolescence is a sensitive period in brain development, the long-term effects of stress during this period could be significant. We investigated the long-term effects of exposure to unpredictable chronic mild stress in adolescent mice on alternative splicing of Sirtuin 1. One-month-old mice were exposed to 4 weeks of UCMS and examined for anxiety and cognition at the age of 2, 4 and 6 months. We found a rise in anxious behavior immediately after the exposure to stress. Notably, there was a long-term impairment of performance in cognitive tasks and an imbalance in Sirtuin 1 and TrkB receptor alternative splicing in the stress-exposed mice compared with controls. To conclude, our results show that exposure to unpredictable chronic mild stress during adolescence affects cognition in adulthood. Understanding pathways affiliated with stress may help minimize the long-term emotional effects of an unpredictable, stressful event.

Cancer-related accelerated ageing and biobehavioural modifiers: a framework for research and clinical care

A growing body of evidence indicates that patients with cancer who receive cytotoxic treatments (such as chemotherapy or radiotherapy) have an increased risk of accelerated physical and cognitive ageing. Furthermore, accelerated biological ageing is a suspected driving force behind many of these observed effects. In this Review, we describe the mechanisms of biological ageing and how they apply to patients with cancer. We highlight the important role of specific behavioural factors, namely stress, sleep and lifestyle-related factors such as physical activity, weight management, diet and substance use, in the accelerated ageing of patients with cancer and cancer survivors. We also present a framework of how modifiable behaviours could operate to either increase the risk of accelerated ageing, provide protection, or promote resilience at both the biological level and in terms of patient-reported outcomes.

Chronic difficulties are associated with poorer psychosocial functioning in the first year post-diagnosis in epithelial ovarian cancer patients

OBJECTIVE

Ovarian cancer is characterized by poor prognosis, high levels of distress, disturbed sleep, and compromised quality of life (QOL). Although life stressors have been shown to significantly impact physical and psychological health in cancer populations, no studies have used a high-resolution stress assessment to differentiate effects of acute versus chronic stressors among women with ovarian cancer. We addressed this issue in the present prospective longitudinal study by examining how acute and chronic stress exposure in the year pre-diagnosis relate to depressive symptoms, sleep quality, and QOL over the first year post-diagnosis in women with ovarian cancer.

METHODS

One hundred thirty-seven women completed the Life Events and Difficulties Schedule within a month of initial treatment for suspected ovarian cancer. Depressive symptoms, sleep, and QOL were measured pre-treatment, at six months, and one-year post-diagnosis. Mixed models were used to examine associations of acute and chronic stress pre-diagnosis with (a) change in psychosocial outcomes over the first year post-diagnosis and (b) levels of psychosocial outcomes across all time points.

RESULTS

Both the number and severity of chronic difficulties (but not acute life events) were related to significantly greater depression, and poorer sleep quality and QOL, across all time-points. In contrast, these stress indices were unrelated to changes in psychosocial functioning over time.

CONCLUSIONS

Chronic but not acute stress exposure predicted average levels of depression, sleep, and QOL in the first year post-diagnosis among women with ovarian cancer. Assessing stressors and designing interventions for reducing stress may thus be beneficial for ovarian cancer patients.

Toll-like receptor 4 mediates the development of fatigue in the murine Lewis Lung Carcinoma model independently of activation of macrophages and microglia

Cancer-related fatigue at the time of tumor diagnosis is commonly attributed to inflammation associated with the disease process. However, we have previously demonstrated that running wheel deficits occur well before increased expression of proinflammatory cytokines in the liver and brain in a murine model of human papilloma virus-related head and neck cancer (mEER). Further, we have demonstrated that genetic deletion of type I interleukin-1 receptor and MyD88 has no effect. In the current investigation we sought to test the generality of this finding by assessing whether there is a role for toll-like receptor (TLR) 4-dependent inflammation in the fatigue-like behavior observed in mice with Lewis Lung Carcinoma (LLC) or mEER tumors. Genetic deletion of TLR4 attenuated tumor-induced elevations in liver pro-inflammatory cytokine expression in both models. However, it only abrogated wheel running deficits in LLC tumor bearing mice. To determine whether TLR4 signaling in the LLC model involves innate immune cells, mice were treated with the colony stimulating factor (CSF)-1 receptor antagonist PLX-5622 before and throughout tumor development to deplete microglia and peripheral macrophages. Administration of PLX-5622 had no protective effect on wheel running deficits in either mEER or LLC tumor models despite effective depletion of microglia and a down regulation of peripheral proinflammatory cytokine expression. These results indicate that the TLR4 signaling that mediates fatigue-like behavior in LLC mice is not dependent upon microglial or peripheral macrophage activation. Based on the literature and our data demonstrating attenuation of ubiquitin proteasome pathway activation in the gastrocnemius muscle of Tlr4^-/- mice implanted with LLC cells, we interpret our current findings as indication that skeletal muscle TLR4 signaling may be involved. These results are important in that they add to the evidence that tumor-induced fatigue develops independently from classical neuroinflammation.

Life Stress and Suicide in Adolescents

Stress exposure is central to theories of suicide. To advance understanding of the relation between stress and suicide, we examined whether specific, theoretically-pertinent life stressors were differentially related to suicidal thinking versus suicidal behaviors among hospitalized adolescents. Participants were 197 (144 female) adolescents aged 13 to 19 years old (M = 15.61, SD = 1.48) recruited from an acute residential psychiatric treatment program. Participants were categorized into mutually exclusive groups: psychiatric controls (n = 38) with no lifetime history of suicide ideation or suicide attempts, suicide ideators (n = 99) with current ideation and no lifetime attempts, and suicide attempters (n = 60) with a lifetime history of suicide ideation and at least one attempt in the past month. Adolescents completed the Stress and Adversity Inventory for Adolescents (Adolescent STRAIN), which assessed life events and chronic difficulties occurring in five social-psychological categories: Interpersonal Loss, Physical Danger, Humiliation, Entrapment, and Role Change/Disruption. Additionally, they completed a structured interview and symptom questionnaires to capture concurrent psychopathology. Controlling for demographic and clinical covariates, only Interpersonal Loss events distinguished attempters from psychiatric controls (OR = 2.27) and ideators (OR = 1.49); no events or difficulties differentiated ideators from controls. These effects persisted when analyses were restricted to single attempters and when events following the most recent attempt were excluded. The findings elucidate potential social-environmental triggers of suicide. Ultimately, this may improve the identification of ideators most likely to make an attempt, enabling the deployment of targeted early interventions.

Reported history of childhood trauma and stress-related vulnerability: Associations with emotion regulation, executive functioning, daily hassles and pre-sleep arousal

Childhood trauma is associated with poor health outcomes in adulthood. Mechanisms for these associations are not well understood because past studies have focused predominantly on populations that have already developed physical and mental health problems. The present study examined the association between childhood trauma and stress-related vulnerability factors in a healthy adult sample (n = 79; 68% female, mean age = 27.5, SD = 6.5). Emotion regulation difficulties were examined as a potential mediator. Participants completed baseline laboratory assessments of reported childhood trauma, emotion regulation difficulties, prior month sleep quality, baseline impedance cardiography and behavioural tests of executive functioning (EF) and a three-day experience sampling assessment protocol that included sleep diary, reported and objective pre-sleep arousal, daily hassles and reported EF difficulties. Reported history of childhood abuse was significantly associated with difficulties in emotion regulation, self-report and objective pre-sleep arousal, diary-assessed sleep quality, daily hassles and reported EF difficulties. Reported history of childhood neglect was associated with greater pre-sleep arousal and poorer EF-behavioural control. Emotion regulation difficulties mediated the relationship between childhood abuse and reported pre-sleep arousal, daily hassles and reported EF difficulties. In conclusion, history of childhood trauma is associated with a variety of stress-related vulnerability factors in healthy adults that may be viable early intervention targets.

Associations between lifetime stress exposure and prenatal health behaviors

Prenatal health behaviors can strongly influence risk of poor pregnancy birth outcomes. Although stress has been implicated in structuring the likelihood that individuals will engage in various prenatal health behavior patterns, no studies to date have examined life stress exposure occurring across the entire lifespan, and few have investigated how different types of stressors are comparatively associated with these outcomes. To address these issues, we interviewed 164 women at one of two large Midwestern, urban hospitals after delivering their first infant. We used the Stress and Adversity Inventory (STRAIN) to assess women's lifetime stress exposure severity and ordinary least squares regression models to examine associations between participants' life stress exposure and prenatal health behaviors. As hypothesized, greater lifetime stress exposure was associated with engaging in more negative prenatal health behaviors and fewer positive prenatal health behaviors while controlling for relevant sociodemographic factors and current perceived stress levels. These effects were stronger for negative versus positive health behaviors, and they differed substantially as a function of stressor type, exposure timing, and primary life domain. Stressors occurring over the life course thus have negative consequences for prenatal health behaviors, but these effects are not uniform across different types of life stress exposure.

Psychotherapy in pain management: New viewpoints and treatment targets based on a brain theory

The current paper provides an explanation of neurophysiological pain processing based the Dimensional Systems Model (DSM), a theory of higher cortical functions in which the cortical column is considered the binary digit for all cortical functions. Within the discussion, novel views on the roles of the basal ganglia, cerebellum, and cingulate cortex are presented. Additionally, an applied Clinical Biopsychological Model (CBM) based on the DSM will be discussed as related to psychological treatment with chronic pain patients. Three specific areas that have not been adequately addressed in the psychological treatment of chronic pain patients will be discussed based on the CBM. The treatment approaches have been effectively used in a clinical setting. Conclusions focus on a call for researchers and clinicians to fully evaluate the value of both the DSM and CBM.

Mindfulness Predicts Psycho-behavioral Improvement after Breast Cancer Diagnosis: Influence of Childhood Adversity

Mindfulness-based interventions provide psychological benefit after breast cancer diagnosis. The aims of this study were to determine whether within-person change in facets of mindfulness predict psycho-behavioral improvements in women with breast cancer, and to assess the influence of childhood adversity on those improvements. Women randomized to the mindfulness arm of a larger trial were evaluated. Psychometric instruments and the Five Facets of Mindfulness Questionnaire were completed pre-, mid-, at completion, one, and six months post program. A subsample completed the Childhood Trauma Questionnaire. Hierarchical linear modeling revealed that significant change in nonjudgment and nonreactivity to inner experience were associated with more rapid decrease in stress, depressive symptoms, fatigue, sleep disturbance, and more rapid increase in quality of life. For women with greater exposure to childhood adversity, a greater increase in nonreactivity to inner experience significantly associated with greater improvements in stress, depressive symptoms, and quality of life.

Distinct Stress Profiles Among Oncology Patients Undergoing Chemotherapy

CONTEXT

Cancer and its treatment are inherently stressful and stress impacts important patient outcomes. Patients vary considerably in their response to stress. Understanding this variability requires a patient-centered multidimensional approach.

OBJECTIVES

The objectives of this study were to identify and characterize patient subgroups with distinct multidimensional stress profiles (stress appraisal, exposure, and adaptation) during cancer treatment.

METHODS

Among 957 patients undergoing chemotherapy for breast, gastrointestinal, gynecological, or lung cancer, latent profile analysis was performed to identify patient subgroups using concurrent evaluations of global (Perceived Stress Scale) and cancer-specific (Impact of Events Scale-Revised) stress, lifetime stress exposure (Life Stressor Checklist-Revised), and resilience (Connor-Davidson Resilience Scale-10).

RESULTS

Three latent classes were identified: "Normative" (54.3%; intermediate global stress and resilience, lower cancer-related stress, lowest life stress); "Stressed" (39.9%; highest global and cancer-specific stress scores, lowest resilience, most life stress); and "Resilient" (5.7%; lowest global stress, cancer-specific stress comparable to Normative class, highest resilience, intermediate life stress). Characteristics that distinguished the Stressed from the Normative class included the following: younger age, female gender, lower socioeconomic status, unmarried/partnered, living alone, poorer functional status, and higher comorbidity burden. Compared to Stressed patients, Resilient patients were more likely to be partnered, to not live alone, and had a higher functional status. No demographic or clinical characteristics differentiated Normative from Resilient patients. Exposure to specific life stressors differed significantly among the classes.

CONCLUSION

A subset of patients warrants intensive psychosocial intervention to reduce stress and improve adaptation to cancer. Intervention efforts may be informed by further study of Resilient patients.

The Stress and Adversity Inventory for Adults (Adult STRAIN) in Brazilian Portuguese: Initial Validation and Links With Executive Function, Sleep, and Mental and Physical Health

It has been widely hypothesized that stressors occurring over the lifespan exert a cumulative impact on health, but little work has directly tested these theories given the difficulty associated with measuring cumulative stress exposure over the lifespan. We addressed this issue in Brazil by translating the Stress and Adversity Inventory for Adults (Adult STRAIN) into Brazilian Portuguese. We then examined the instrument's usability and acceptability; concurrent, discriminant, predictive, and incremental validity; and test-retest reliability. Participants were 330 Brazilian adults (238 women; M age = 32.16; range: 18-76 years old) who completed the Adult STRAIN in Brazilian Portuguese, Childhood Trauma Questionnaire-Short Form (CTQ-SF), and Perceived Stress Scale (PSS). They also completed measures of socioeconomic status, personality, social desirability, negative affect, physical and mental health complaints, sleep quality, executive function, and doctor-diagnosed general health problems and autoimmune disorders. The STRAIN exhibited excellent usability and acceptability and was completed in 16 min and 27 s, on average. It showed good concurrent validity relative to the CTQ-SF and PSS (rs ≥ 0.377) and good discriminant validity, both with and without adjusting for covariates. In addition, the STRAIN significantly predicted all of the health outcomes assessed except for executive function and explained substantial variance in these outcomes over and above the CTQ-SF, PSS, and covariates assessed. Finally, the test-retest reliability indices for total lifetime stressor count and severity were outstanding (r icc = 0.936 and 0.953, respectively, over M = 34.86 days). The Adult STRAIN in Brazilian Portuguese thus exhibits excellent usability and acceptability, good concurrent and discriminant validity, strong predictive and incremental validity across a variety of health outcomes, and outstanding test-retest reliability. We therefore conclude that the STRAIN is a practical, valid, and reliable instrument for researchers and clinicians looking to efficiently assess cumulative lifetime stress exposure in Brazilian Portuguese.

Higher levels of stress and different coping strategies are associated with greater morning and evening fatigue severity in oncology patients receiving chemotherapy

PURPOSE

A cancer diagnosis and associated treatments are stressful experiences for most patients. Patients' perceptions of stress and their use of coping strategies may influence fatigue severity. This study extends our previous work describing distinct profiles of morning (i.e., Very Low, Low, High, and Very High) and evening (i.e., Low, Moderate, High, and Very High) fatigue in oncology patients by evaluating for differences in stress and coping strategies among these fatigue classes.

METHODS

This longitudinal study evaluated for changes in morning and evening fatigue in oncology patients (n = 1332) over two cycles of chemotherapy (CTX). Patients completed measures of cumulative exposure to stressful life events (SLEs) (i.e., the Life Stressor Checklist-Revised), general stress (i.e., Perceived Stress Scale [PSS]), cancer-specific stress (i.e., Impact of Event Scale-Revised [IES-R]), and coping strategies (i.e., Brief Cope). Differences among the latent classes were evaluated using analyses of variance, Kruskal-Wallis, or chi-square tests.

RESULTS

Patients in both the Very High morning and evening fatigue classes reported higher numbers of and a higher impact from previous SLEs and higher PSS scores than the other fatigue classes. The IES-R scores for the Very High morning fatigue class met the criterion for subsyndromal PTSD. Patients in the Very High evening fatigue class used a higher number of engagement coping strategies compared with the Very High morning fatigue class.

CONCLUSIONS

Our findings suggest that interventions to reduce stress and enhance coping warrant investigation to decrease fatigue in patients undergoing CTX.

Fatigue in Multiple Sclerosis Is Associated With Childhood Adversities

Fatigue is a common and disabling symptom in patients with Multiple Sclerosis (PwMS). Its pathogenesis, however, is still not fully understood. Potential psychological roots, in particular, have received little attention to date. The present study examined the association of childhood adversities, specific trait characteristics, and MS disease characteristics with fatigue symptoms utilizing path analysis. Five hundred and seventy-one PwMS participated in an online survey. Standardized psychometric tools were applied. The Childhood Trauma Questionnaire (CTQ) served to assess childhood adversities. Trait variables were alexithymia (Toronto Alexithymia Scale; TAS-26) and early maladaptive schemas (Young Schema Questionnaire; YSQ). Current pathology comprised depression (Beck's Depression Inventory FastScreen; BDI-FS) and anxiety symptoms (State-Trait Anxiety Inventory; STAI-state), as well as physical disability (Patient determined Disease Steps; PDDS). The Fatigue Scale for Motor and Cognitive Functions (FSMC) was the primary outcome variable measuring fatigue. PwMS displayed high levels of fatigue and depression (mean FSMC score: 72; mean BDI-II score: 18). The final path model revealed that CTQ emotional neglect and emotional abuse remained as the only significant childhood adversity variables associated with fatigue. There were differential associations for the trait variables and current pathology: TAS-26, the YSQ domain impaired autonomy and performance, as well as all current pathology measures had direct effects on fatigue symptoms, accounting for 28.2% of the FSMC variance. Bayesian estimation also revealed indirect effects from the two CTQ subscales on FSMC. The final model fitted the data well, also after a cross-validation check and after replacing the FSMC with the Chalder Fatigue Questionnaire (CFQ). This study suggests an association psychological factors on fatigue in Multiple Sclerosis. Childhood adversities, as well as specific trait characteristics, seem to be associated with current pathology and fatigue symptoms. The article discusses potential implications and limitations.

The Stress and Adversity Inventory for Adolescents (Adolescent STRAIN): associations with mental and physical health, risky behaviors, and psychiatric diagnoses in youth seeking treatment

BACKGROUND

Numerous theories have posited that stressors occurring over the lifespan may exert a cumulative effect on psychological and biological processes that increase individuals' risk for a variety of mental and physical health problems. Given the difficulty associated with assessing lifetime stress exposure, however, few empirical studies have directly tested these cumulative risk models of psychopathology and human health.

METHOD

To address this issue, we examined the usability, acceptability, concurrent validity, and predictive validity of the recently developed Stress and Adversity Inventory for Adolescents (Adolescent STRAIN) in 338 youth (M_age  = 15.64; 229 females) seeking mental health treatment.

RESULTS

The Adolescent STRAIN achieved high acceptability and was completed in approximately 25 min (interquartile range: 20-32 min). Concurrent associations with other measures of early adversity (Childhood Trauma Questionnaire-Short Form) and interpersonal stress (Revised Peer Experiences Questionnaire) were very good (rs = .50-.59). In analyses that adjusted for participants' age, sex, and race, the STRAIN was significantly associated with depression, anxiety, and anhedonia severity; general mental and physical health complaints; risky behavior engagement; and number of interviewer-based psychiatric diagnoses (βs = .16-.52; risk ratios = 1.006-1.014). Contrary to classic theories of stress which assume that different stressors exert similar effects on health, substantial differences were observed across the two stressor types, twelve life domains, and five core social-psychological characteristics assessed by the Adolescent STRAIN.

CONCLUSIONS

These data confirm the relevance of lifetime stress exposure for multiple health outcomes in adolescence, which can in turn inform existing theories of lifespan health. Because stress is a common presenting problem in hospitals and clinics, these data also suggest the possibility of using the Adolescent STRAIN to generate stress exposure profiles for case conceptualization and treatment planning purposes.

Detection of systemic inflammation in severely impaired chronic pain patients and effects of a multimodal pain rehabilitation program

Background and aims

Recent research indicates a previously unknown low-grade systemic or neurogenic inflammation in groups of chronic pain (CP) patients. Low-grade inflammation may have an important role in symptoms that have previously not been well depicted: widespread pain, tiredness and cognitive dysfunctions frequently seen in severely impaired CP patients. This study aimed to investigate the plasma inflammatory profile in a group of very complex CP patients at baseline and at a 1-year follow-up after participation in a cognitive behavior therapy (CBT)-based multimodal pain rehabilitation program (PRP).

Methods

Blood samples were collected from 52 well-characterized CP patients. Age- and sex-matched healthy blood donors served as controls. The samples were analyzed with a multiple Proximal Extension Analysis allowing a simultaneous analysis of 92 inflammation-related proteins consisting mainly of cytokines, chemokines and growth-factors. At follow-up, 1-year after participation in the RPR samples from 28 patients were analyzed. The results were confirmed by a multi-array technology that allows quantitative estimation.

Results

Clear signs of increased inflammatory activity were detected in the CP patients. Accepting a false discovery rate (FDR) of 5%, there were significant differences in 43/92 inflammatory biomarkers compared with the controls. In three biomarkers (CXCL5, SIRT2, AXIN1) the expression levels were elevated more than eight times. One year after the PRP, with the patients serving as their own controls, a significant decrease in overall inflammatory activity was found.

Conclusions

Our results indicate that the most impaired CP patients suffer from low-grade chronic systemic inflammation not described earlier with this level of detail. The results may have implications for a better understanding of the cluster of co-morbid symptoms described as the “sickness-syndrome” and the wide-spread pain seen in this group of patients. The decrease in inflammatory biomarkers noted at the follow-up after participation in the PRP may reflect the positive effects obtained on somatic and psycho-social mechanisms involved in the inflammatory process by a rehabilitation program. Besides the PRP, no major changes in medication or lifestyle factors were implemented during the same period. To our knowledge, this is the first study reporting that a PRP may induce inflammatory-reducing effects. Further studies are needed to verify the objective findings in CP patients and address the question of causality that remains to be solved.

Implications

The findings offer a new insight into the complicated biological processes underlying CP. It may have implications for the understanding of symptoms collectively described as the “sickness-syndrome” – frequently seen in this group of patients. The lowering of cytokines after the participation in a PRP indicate a new way to evaluate this treatment; by measuring inflammatory biomarkers.

Cancer-Related Fatigue and Associated Factors in Young Adult Cancer Patients

Purpose: Cancer-related fatigue (CRF) is a highly burdensome and long-lasting symptom of cancer and its therapy. This study aims to examine the severity of CRF in its different dimensions and to assess medical and sociodemographic factors associated with CRF in young adults with cancer (adolescents and young adults [AYAs]). Methods: Patients with malignant cancer (diagnosed within the last 4 years) aged 18-39 years at diagnosis were assessed. CRF was measured using the European Organisation for Research and Treatment of Cancer Quality of Life Fatigue Module (EORTC QLQ-FA12) Questionnaire. Sociodemographic and medical data were collected with self-report questionnaires. Descriptive analyses, cluster analysis, and multiple regression analysis were used to examine CRF in AYAs. Results: In total, n = 577 patients were included. Respondents' fatigue scores were highest for the physical subscale (mean = 45.6; standard deviation [SD] = 28.2), followed by the emotional (mean = 26.7; SD = 28.8) and cognitive dimensions (mean = 19.7; SD = 22.7). Female participants, patients with an additional disease, and patients with financial problems resulting from having cancer reported significantly higher fatigue scores for all three of the subscales (R² range: 0.10-0.22). Testicular cancer patients had the lowest CRF scores for every dimension. Breast and gynecological cancer patients had the highest emotional and cognitive fatigue scores. Conclusion: Medical variables such as cancer site and therapy scheme seem to have little influence. Caregivers should assess CRF in AYAs independent of their medical characteristics. Reducing additional burdens may represent a way of reducing CRF in AYA cancer patients.

Greater Lifetime Stress Exposure Predicts Blunted Cortisol but Heightened DHEA Responses to Acute Stress

Although prior research has examined how early adversity and chronic stress exposure relate to hypothalamic-pituitary-adrenal (HPA) axis responses to acute stress, to date, no studies have examined how stressors occurring over the entire lifespan predict such responses. To address this issue, we recruited 61 healthy young adults and measured their exposure to 55 different types of acute life events and chronic difficulties occurring over the lifespan. In addition, we characterized differences in participants' HPA axis responses to acute stress by measuring their salivary cortisol and DHEA responses to the Trier Social Stress Test for Groups. Greater cumulative stress exposure was associated with a blunted cortisol response, but a heightened DHEA response, to the acute stressor. Moreover, it was participants' exposure to these stressors (i.e., lifetime count), not their perceived severity, which predicted their cortisol and DHEA responses to acute stress. Furthermore, differential effects were observed by stress exposure domain. Notably, only adulthood and marital/partner stressors significantly predicted cortisol responses to acute stress, whereas stress was more uniformly associated with DHEA responses to the acute stressor. These results thus reveal how cumulative stress exposure is associated with HPA axis responsivity to acute stress, while highlighting the fact that different stressors may have substantially different associations with these biological outcomes.

The role of neuro-immune interactions in cancer-related fatigue: Biobehavioral risk factors and mechanisms

Fatigue is a common and distressing symptom in both patients with cancer and cancer survivors. There is substantial variation in the severity and persistence of cancer-related fatigue that may be driven by individual differences in host factors, including characteristics that predate the cancer experience as well as responses to cancer and its treatment. This review examines biobehavioral risk factors linked to fatigue and the mechanisms through which they influence fatigue across the cancer continuum, with a focus on neuro-immune processes. Among psychosocial risk factors, childhood adversity is a strong and consistent predictor of cancer-related fatigue; other risk factors include history of depression, catastrophizing, lack of physical activity, and sleep disturbance, with compelling preliminary evidence for loneliness and trait anxiety. Among biologic systems, initial work suggests that alterations in immune, neuroendocrine, and neural processes are associated with fatigue. The identification of key risk factors and underlying mechanisms is critical for the development and deployment of targeted interventions to reduce the burden of fatigue in the growing population of cancer survivors. Given the multidimensional nature of fatigue, interventions that influence multiple systems may be most effective.

Testing a biobehavioral model of fatigue before adjuvant therapy in women with breast cancer

BACKGROUND

Fatigue is one of the most common and disabling side effects of cancer and its treatment. Although research typically has focused on fatigue that occurs during and after treatment, patients may experience fatigue even before treatment onset. The current study was designed to identify biobehavioral risk factors associated with fatigue before adjuvant therapy in women with early-stage breast cancer.

METHODS

Patients with stage 0 to stage IIIA breast cancer (270 women) were recruited before the onset of adjuvant or neoadjuvant therapy with radiotherapy, chemotherapy, and/or endocrine therapy. Host factors that may influence fatigue were identified from an empirically based, biobehavioral model and assessed using self-report questionnaires, medical record review, and blood collection (for genetic data). Fatigue was assessed by questionnaire. Linear regression analyses were used to evaluate the association between host factors and dimensions of fatigue, with general fatigue as the primary dimension of interest.

RESULTS

Fatigue was elevated at the pretreatment assessment compared with published controls. Bivariate analyses identified demographic, cancer-related, and biobehavioral correlates of fatigue. In the multivariable model, predictors of general fatigue included younger age, lower educational level, lower cancer stage, and history of childhood maltreatment (all P values <.05), with the full model accounting for approximately 18.4% of the variance in fatigue. Secondary analyses identified common and specific predictors of emotional, mental, and physical dimensions of fatigue.

CONCLUSIONS

Among women who have not yet initiated treatment of breast cancer, demographic and psychosocial factors are associated with elevated fatigue and could be used to identify at-risk patients for early intervention.

Fatigue after breast cancer treatment: Biobehavioral predictors of fatigue trajectories

OBJECTIVE

Fatigue is a common side effect of cancer treatment, but there is considerable variability in fatigue severity and persistence among survivors. This study aimed to characterize longitudinal trajectories of fatigue after breast cancer treatment and to identify predictors of varying fatigue trajectories.

METHODS

Women (N = 191) from the Mind-Body Study completed assessments after primary treatment for early stage breast cancer and at regular follow-ups that occurred up to 6 years after treatment (M = 4.3 years). Growth mixture models were used to characterize fatigue trajectories, and demographic, medical, and biobehavioral risk factors were examined as predictors of trajectory group.

RESULTS

Five trajectories were identified, characterized as High, Recovery, Late, Low, and Very Low fatigue. The High and Recovery groups (40% of sample) evidenced elevated fatigue at posttreatment that declined in Recovery but persisted in the High group. In bivariate analyses, trajectory groups differed significantly on depressive symptoms, sleep disturbance, childhood adversity, body mass index, and the inflammatory marker soluble TNF receptor type II, which were higher in the High and/or Recovery groups. In multivariate models, depressive symptoms and childhood adversity distinguished High and Recovery from other groups. Rates of chemotherapy were higher in the Recovery than in the High or Late group, whereas rates of endocrine therapy were higher in the High than in the Recovery group.

CONCLUSIONS

There are distinct longitudinal trajectories of fatigue after breast cancer treatment. Psychological factors are strongly associated with adverse fatigue trajectories, and together with treatment exposures may increase risk for cancer-related fatigue. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Impaired mental health and low-grade inflammation among fatigued bereaved individuals

BACKGROUND

Fatigue is a common symptom in stressed individuals. Bereavement is a major life event that has been associated with impaired mental health. Little research has investigated the prevalence of fatigue and its inflammatory correlates in bereaved individuals.

OBJECTIVES

To assess fatigue prevalence and its relationship with mental health outcomes and markers of inflammation, as indexed by C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) in bereaved individuals.

METHODS

Seventy-eight-bereaved adults were examined for fatigue (SF-36 energy/vitality scale), perceived stress (PSS), depression (CES-D), sleep quality (PSQI), pain (SF-36 pain scale), and general health (SF-36 general), and their serum levels of CRP, IL-6 and TNF-α were measured. Group differences between fatigued versus non-fatigued individuals were estimated using analysis of covariance (ANCOVA), with adjustment for body mass index (BMI).

RESULTS

Fatigued bereaved individuals (33%; SF-36 energy/vitality score 0-45) had significantly higher CRP levels (p < .05) as compared to non-fatigued bereaved individuals and reported higher levels of pain (p < .001), greater stress (p < .001), depression (p < .001), and sleeping problems (p < .001), as well as poorer social functioning (p < .001) and general health (p < .001) than those in the non-fatigued group. No group differences were found for IL-6 and TNF-α.

CONCLUSIONS

Fatigued bereaved individuals showed elevated systemic inflammation as measured by CRP in comparison to non-fatigued bereaved individuals. They were also more likely to report mental health problems that co-occur with fatigue in the context of immune activation. Continued research is needed to help clarify the involvement of inflammatory markers in the development of fatigue in a larger sample of bereaved adults.

Emotion Regulation Compensation Following Situation Selection Failure

We conducted two within-subjects experiments to determine whether people use alternative emotion regulation (ER) strategies to compensate for failure of situation selection, a form of ER in which one chooses situations based on the emotions those situations afford. Participants viewed negative and neutral (Study 1, N = 58) or negative, neutral, and positive pictures (Study 2, N = 90). They indicated for each picture whether they wanted to terminate presentation (Study 1) or view it again (Study 2). We manipulated the outcome of this decision to be congruent with participants' wishes (success) or not (failure), and measured self-reported ER strategies and emotional responses. Although participants terminated negative situations more often than neutral situations (Study 1), or chose to view positive pictures more frequently than neutral, and neutral more frequently than negative (Study 2), there was little evidence of compensation in the wake of situation selection failure. Overall, we conclude that although people choose situations based on affect (i.e., attempt to end or avoid high-arousal negative situations and pursue high-arousal pleasant ones), they do not generally use the alternative ER strategies that we assessed (rumination, reappraisal, distraction) to compensate when the situations they select fail to materialize in this experimental context.

More than a feeling: A unified view of stress measurement for population science

Stress can influence health throughout the lifespan, yet there is little agreement about what types and aspects of stress matter most for human health and disease. This is in part because "stress" is not a monolithic concept but rather, an emergent process that involves interactions between individual and environmental factors, historical and current events, allostatic states, and psychological and physiological reactivity. Many of these processes alone have been labeled as "stress." Stress science would be further advanced if researchers adopted a common conceptual model that incorporates epidemiological, affective, and psychophysiological perspectives, with more precise language for describing stress measures. We articulate an integrative working model, highlighting how stressor exposures across the life course influence habitual responding and stress reactivity, and how health behaviors interact with stress. We offer a Stress Typology articulating timescales for stress measurement - acute, event-based, daily, and chronic - and more precise language for dimensions of stress measurement.

Assessing Lifetime Stress Exposure Using the Stress and Adversity Inventory for Adults (Adult STRAIN): An Overview and Initial Validation

OBJECTIVE

Numerous theories have proposed that acute and chronic stressors may exert a cumulative effect on life-span health by causing biological "wear and tear," or allostatic load, which in turn promotes disease. Very few studies have directly tested such models, though, partly because of the challenges associated with efficiently assessing stress exposure over the entire life course. To address this issue, we developed the first online system for systematically assessing lifetime stress exposure, called the Stress and Adversity Inventory (STRAIN), and describe its initial validation here.

METHODS

Adults recruited from the community (n = 205) were administered the STRAIN, Childhood Trauma Questionnaire-Short Form, and Perceived Stress Scale, as well as measures of socioeconomic status, personality, social desirability, negative affect, mental and physical health complaints, sleep quality, computer-assessed executive function, and doctor-diagnosed general health problems and autoimmune disorders.

RESULTS

The STRAIN achieved high acceptability and was completed relatively quickly (mean = 18 minutes 39 seconds; interquartile range = 12-23 minutes). The structure of the lifetime stress data best fit two latent classes overall and five distinct trajectories over time. Concurrent associations with the Childhood Trauma Questionnaire-Short Form and Perceived Stress Scale were good (r values = .147-.552). Moreover, the STRAIN was not significantly related to personality traits or social desirability characteristics and, in adjusted analyses, emerged as the measure most strongly associated with all six of the health and cognitive outcomes assessed except current mental health complaints (β values = .16-.41; risk ratios = 1.02-1.04). Finally, test-retest reliability for the main stress exposure indices over 2-4 weeks was excellent (r values = .904-.919).

CONCLUSIONS

The STRAIN demonstrated good usability and acceptability; very good concurrent, discriminant, and predictive validity; and excellent test-retest reliability.

Strength through adversity: Moderate lifetime stress exposure is associated with psychological resilience in breast cancer survivors

Stress research typically emphasizes the toxic effects of stress, but recent evidence has suggested that stress exposure, in moderation, can facilitate resilience. To test whether moderate stress exposure promotes psychological resilience to cancer, we examined the relationship between lifetime stress exposure prior to cancer diagnosis and postdiagnosis psychological functioning among 122 breast cancer survivors. Lifetime acute and chronic stress was assessed using an interview-based measure, and psychological functioning was assessed using measures of cancer-related intrusive thoughts and positive and negative affect. Results indicated that acute stress exposure was associated with cancer-related intrusive thoughts in a quadratic fashion (p = .016), such that participants with moderate acute stress reported fewer intrusive thoughts compared to those with low or high acute stress. Similarly, a quadratic relationship emerged between acute stress exposure and positive affect (p = .009), such that individuals with moderate acute stress reported the highest levels of positive affect. In contrast, acute and chronic stress were related to negative affect in a positive, linear fashion (ps < .05). In conclusion, moderate stress exposure was associated with indicators of psychological resilience among breast cancer survivors, supporting stress exposure as a key factor influencing adjustment to breast cancer and providing evidence for stress-induced resilience in a novel population.

Biobehavioral Pathways to Cancer Incidence, Progression, and Quality of Life

Cancer research within the fields of psychoneuroendocrinology and psychoneuroimmunology has made substantial progress in understanding how psychological factors impact cancer. Although the pathways by which stress “gets under the skin” to impact cancer incidence, progression, and quality of life are not yet fully understood, the answers to key questions about how stressful life events and the negative emotions they generate can impact cancer initiation, progression, and survivorship have advanced quite dramatically. In this review, we summarize the state of the science in a way that is accessible to a broad audience. We then discuss future directions in cancer research, with a focus on ways psychological science can contribute to the next generation of cancer care.

Diurnal cortisol rhythms, fatigue and psychosocial factors in five-year survivors of ovarian cancer

Fatigue is a challenge in ovarian cancer survivorship and greatly impacts quality of life. In other cancer populations, fatigue has been associated with abnormal diurnal cortisol patterns. However, little is known about biological and behavioral factors in 5+-year ovarian cancer survivors and potential mechanisms underlying persistent fatigue have not been investigated in this population. Moreover, relationships between neuroendocrine and psychosocial factors in 5+-year ovarian cancer survivors have not been studied. We addressed these issues by examining relationships between diurnal cortisol rhythms, fatigue, life stress, and social support in 30 survivors of ovarian cancer who were assessed at least 5 years (mean=6.20years) following their primary diagnosis. Flatter diurnal cortisol slopes were associated with higher levels of fatigue, suggesting a role for HPA-axis dysregulation in sustained fatigue experienced by survivors. Moreover, greater cumulative lifetime stressor exposure (p=0.023) and stressor severity (p=0.004) were associated with flatter diurnal cortisol slopes, while higher social attachment (p=0.001) was associated with steeper diurnal cortisol slopes. These findings suggest that ovarian cancer survivors with greater lifetime stress exposure or lower social attachment may be at increased risk for circadian rhythm disruption, which in turn is associated with fatigue. Future research should examine relationships of clinical stage and inflammatory cytokines to cortisol rhythms and fatigue in long-term ovarian cancer survivors, as well as investigating the clinical significance of abnormal diurnal cortisol profiles in this population.

Differential effects of childhood trauma subtypes on fatigue and physical functioning in chronic fatigue syndrome

OBJECTIVE

There is wide consensus that childhood trauma plays an important role in the aetiology of chronic fatigue syndrome (CFS). The current study examines the differential effects of childhood trauma subtypes on fatigue and physical functioning in individuals suffering from CFS.

METHODS

Participants were 155 well-documented adult, predominantly female CFS patients receiving treatment at the outpatient treatment centre for CFS of the Antwerp University Hospital in Belgium. Stepwise regression analyses were conducted with outcomes of the total score of the Checklist Individual Strength (CIS) measuring fatigue and the scores on the physical functioning subscale of the Medical Outcomes Short Form 36 Health Status Survey (SF-36) as the dependent variables, and the scores on the five subscales of the Traumatic Experiences Checklist (TEC) as the independent variables.

RESULTS

The patients' fatigue (β=1.38; p=0.025) and physical functioning scores (β=-1.79; p=0.034) were significantly predicted by childhood sexual harassment. There were no significant effects of emotional neglect, emotional abuse, bodily threat, or sexual abuse during childhood.

CONCLUSION

Of the childhood trauma subtypes investigated, sexual harassment emerged as the most important predictor of fatigue and poor physical functioning in the CFS patients assessed. These findings have to be taken into account in further clinical research and in the assessment and treatment of individuals coping with chronic fatigue syndrome.

Childhood maltreatment, psychological resources, and depressive symptoms in women with breast cancer

Childhood maltreatment is associated with elevated risk for depression across the human lifespan. Identifying the pathways through which childhood maltreatment relates to depressive symptoms may elucidate intervention targets that have the potential to reduce the lifelong negative health sequelae of maltreatment exposure. In this cross-sectional study, 271 women with early-stage breast cancer were assessed after their diagnosis but before the start of adjuvant treatment (chemotherapy, radiation, endocrine therapy). Participants completed measures of childhood maltreatment exposure, psychological resources (optimism, mastery, self-esteem, mindfulness), and depressive symptoms. Using multiple mediation analyses, we examined which psychological resources uniquely mediated the relationship between childhood maltreatment and depressive symptoms. Exposure to maltreatment during childhood was robustly associated with lower psychological resources and elevated depressive symptoms. Further, lower optimism and mindfulness mediated the association between childhood maltreatment and elevated depressive symptoms. These results support existing theory that childhood maltreatment is associated with lower psychological resources, which partially explains elevated depressive symptoms in a sample of women facing breast cancer diagnosis and treatment. These findings warrant replication in populations facing other major life events and highlight the need for additional studies examining childhood maltreatment as a moderator of treatment outcomes.

Childhood stress and birth timing among African American women: Cortisol as biological mediator

Preterm birth (PTB) occurs among 1:11U.S. white women and 1:7.5 African American women and is a significant driver of racial disparities in infant mortality. Maternal stress is the most common clinical phenotype underlying spontaneous PTB. Specific patterns of stress and biological mediators driving PTB remain unclear. We examined the effect of childhood stress on birth timing among African American women and evaluated maternal cortisol elevation as a biological mediator. A prospective observational design was employed, with a single study visit at 28-32 weeks gestation and medical record review. The Stress and Adversity Inventory was administered, which provides a comprehensive estimate of childhood stress, stress in adulthood, and five core characteristic subscales (interpersonal loss, physical danger, humiliation, entrapment, role disruption). Venipuncture was performed between 11:00am and 4:00pm and plasma cortisol quantified by ELISA. Analyses controlled for stress in adulthood. Among a final sample of 89, cumulative childhood stress predicted birth timing (p=0.01). The association was driven by stress related to interpersonal loss and physical danger, with support for maternal cortisol as a biological mediator (ab=0.02, 95% CI [0.001, 0.045]; ab=0.02, 95% CI [0.001, 0.043], respectively). Results were similar, overall, in sub-group analyses among spontaneously laboring women (n=53); however, role disruption arose as an additional predictor, as mediated by cortisol elevations (ab=0.03, 95% CI [0.005, 0.074]). Of note, cortisol was no longer supported as a mediator linking physical danger to birth timing after adjusting for sleep quality and hours awake prior to venipuncture (ab=0.02, 95% CI [-0.0001, 0.046]). We provide preliminary evidence that, independent of stress in adulthood, childhood stress of specific core characteristics may shape birth timing, with cortisol elevation as a biological mediator. Further investigation is warranted and may bolster the development of biologically-informed screening tools for the prediction and targeted prevention of stress-related PTB.

Cancer-related fatigue in adolescents and young adults: A systematic review of the literature

Adolescents and young adults with cancer (AYA) represent a specific age cohort dealing with the disease in a stage of life characterized by development, upheavals, and establishment. The aim of this study was to point out the state of research on how AYA are affected by cancer-related fatigue (CRF).

RESULTS

Twelve articles were included. CRF was found to be higher in AYA than in either of the comparison groups, healthy peers and older cancer patients. Most included studies did not measure CRF with multidimensional, fatigue-specific instruments.

CONCLUSION

We found a gap in research concerning CRF in AYA. The existing findings suggest that CRF is a significant issue for AYA cancer patients. However, less is known about the prevalence, severity, and impact of CRF in AYA, and their treatment. This should be considered in future research, and risk and prevention factors should be ascertained. Multidimensional and fatigue-specific measuring tools should be used to do this.

Lifetime Stress Exposure and Health: A Review of Contemporary Assessment Methods and Biological Mechanisms

Life stress is a central construct in health research because it is associated with increased risk for a variety of serious mental and physical health problems, including anxiety disorders, depression, cardiovascular disease, autoimmune disorders, Alzheimer's disease, certain cancers, and other diseases of aging. In this review, we examine how lifetime stress exposure contributes to elevated disease risk, and explore ongoing measurement and scientific issues related to this topic. To accomplish these goals, we first review existing instruments that have been developed for assessing perceived stress, self-reported life events, interviewer-assessed life stressors, and lifetime stress exposure. Next, we describe laboratory-based tasks that have been used for characterizing individual differences in psychological and biological stress reactivity. These methods have yielded an enormous amount of data showing how life stress influences the activity of the hypothalamic-pituitary-adrenal axis, hypothalamic-pituitary-gonadal axis, sympathetic-adrenal-medullary axis, and immune system, and how such processes can in turn cause allostatic load and biological embedding of the stress effect at the level of the human brain and genome. At the same time, many critical measurement and scientific issues remain unresolved, and we discuss these topics last while describing some pressing issues and opportunities for future research on stress and health.

Measuring lifetime stress exposure and protective factors in life course research on racial inequality and birth outcomes

There has been a long-standing interest in better understanding how social factors contribute to racial disparities in health, including birth outcomes. A recent emphasis in this context has been on identifying the effects of stress exposure and protective factors experienced over the entire lifetime. Yet despite repeated calls for a life course approach to research on this topic, very few studies have actually assessed how stressors and protective factors occurring over women's lives relate to birth outcomes. We discuss this issue here by describing how challenges in the measurement of lifetime stress exposure and protective factors have prevented researchers from developing an empirically-based life course perspective on health. First, we summarize prevailing views on racial inequality and birth outcomes; second, we discuss measurement challenges that exist in this context; and finally, we describe both new tools and needed tools for assessing lifetime stress exposure and suggest opportunities for integrating information on stress exposure and psychosocial protective factors. We conclude that more studies are needed that integrate information about lifetime stress exposures and the protective factors that promote resilience against such exposures to inform policy and practice recommendations to reduce racial disparities in birth outcomes.

Low lifetime stress exposure is associated with reduced stimulus-response memory

Exposure to stress throughout life can cumulatively influence later health, even among young adults. The negative effects of high cumulative stress exposure are well-known, and a shift from episodic to stimulus–response memory has been proposed to underlie forms of psychopathology that are related to high lifetime stress. At the other extreme, effects of very low stress exposure are mixed, with some studies reporting that low stress leads to better outcomes, while others demonstrate that low stress is associated with diminished resilience and negative outcomes. However, the influence of very low lifetime stress exposure on episodic and stimulus–response memory is unknown. Here we use a lifetime stress assessment system (STRAIN) to assess cumulative lifetime stress exposure and measure memory performance in young adults reporting very low and moderate levels of lifetime stress exposure. Relative to moderate levels of stress, very low levels of lifetime stress were associated with reduced use and retention (24 h later) of stimulus–response (SR) associations, and a higher likelihood of using context memory. Further, computational modeling revealed that participants with low levels of stress exhibited worse expression of memory for SR associations than those with moderate stress. These results demonstrate that very low levels of stress exposure can have negative effects on cognition.

Better executive function under stress mitigates the effects of recent life stress exposure on health in young adults

Executive function is a neuropsychological construct that enables controlled cognitive processing, which has been hypothesized to enhance individuals' resilience to stress. However, little empirical work has directly examined how executive function under different conditions mitigates the negative effects of stress exposure on health. To address this issue, we recruited 110 healthy young adults and assessed their recent life stress exposure, executive function in either a stressful or non-stressful context, and current health complaints. Based on existing research, we hypothesized that individuals exhibiting better executive function following a laboratory-based stressor (but not a control task) would demonstrate weaker associations between recent stress exposure and health because they perceived recent life stressors as being less severe. Consistent with this hypothesis, better executive function during acute stress, but not in the absence of stress, was associated with an attenuated link between participants' recent life stress exposure and their current health complaints. Moreover, this attenuating effect was mediated by lesser perceptions of stressor severity. Based on these data, we conclude that better executive function under stress is associated with fewer health complaints and that these effects may occur by reducing individuals' perceptions of stressor severity. The data thus suggest the possibility of reducing stress-related health problems by enhancing executive function.

Psychological Manifestations of Early Childhood Adversity in the Context of Chronic Hematologic Malignancy

BACKGROUND

Myeloproliferative neoplasms (MPNs), a group of chronic hematologic malignancies, carry significant physical and psychological symptom burdens that significantly affect patients' quality of life.

OBJECTIVES

We sought to identify the relationship between early childhood adversity (ECA) and psychological distress in patients with MPNs, as ECA may compound symptom burden.

METHODS

Patients with MPNs were assessed for ECA (i.e., the Risky Families Questionnaire-subscales include abuse/neglect/chaotic home environment), distress (i.e., Distress Thermometer and Problem List), anxiety (i.e., Hospital Anxiety and Depression Scale-Anxiety [HADS-A]), depression (i.e., Hospital Anxiety and Depression Scale-Depression [HADS-D]), meeting standardized cutoff thresholds for distress (i.e., Distress Thermometer and Problem List≥ 4 or ≥ 7)/anxiety (HADS-A ≥8)/depression (HADS-D ≥ 8), and demographic factors.

RESULTS

A total of 117 participants completed the study (78% response rate). ECA was associated with depression (p < 0.000), anxiety (p < 0.000), and distress (p < 0.000) and problem list variables emotional (p < 0.000), physical (p = 0.004), family (p = 0.01), and spiritual (p = 0.01) by bivariate analysis and only with distress (HADS) (p = 0.038) on multivariate analysis. ECA was associated with meeting cutoff threshold criteria for distress (p = 0.007), anxiety (p = 0.001), and depression (p = 0.02). ECA subscale variables abuse and chaotic home environment were associated with psychological outcomes. ECA was higher based on disease subtypes with greater symptom burden (other > polycythemia vera > myelofibrosis > essential thrombocythemia) (p = 0.047) and taking an antidepressant (p = 0.011).

CONCLUSION

ECA is associated with psychological distress and meets screening criteria for anxiety and depression in patients with MPNs. ECA may help to explain individual patient trajectories, and further understanding may enhance patient-centered care among patients with MPNs.

Life Stress and Health: A Review of Conceptual Issues and Recent Findings

Life stress is a central construct in many models of human health and disease. The present article reviews research on stress and health, with a focus on (a) how life stress has been conceptualized and measured over time, (b) recent evidence linking stress and disease, and (c) mechanisms that might underlie these effects. Emerging from this body of work is evidence that stress is involved in the development, maintenance, or exacerbation of several mental and physical health conditions, including asthma, rheumatoid arthritis, anxiety disorders, depression, cardiovascular disease, chronic pain, human immunodeficiency virus/AIDS, stroke, and certain types of cancer. Stress has also been implicated in accelerated biological aging and premature mortality. These effects have been studied most commonly using self-report checklist measures of life stress exposure, although interview-based approaches provide a more comprehensive assessment of individuals' exposure to stress. Most recently, online systems like the Stress and Adversity Inventory (STRAIN) have been developed for assessing lifetime stress exposure, and such systems may provide important new information to help advance our understanding of how stressors occurring over the life course get embedded in the brain and body to affect lifespan health.

Engaging in Rather than Disengaging from Stress: Effective Coping and Perceived Control

Being able to cope effectively with stress can help people to avoid negative consequences for their psychological well-being. The purpose of this study was to find out why some coping strategies are effective in reducing the negative effect of stressors on well-being and some are not. We argue that the degree to which such coping strategies engage or disengage people from stressful incidents is related to their perceived control of the situation that, in turn, is positively associated with their psychological well-being. We thus propose that the relationship between coping and psychological well-being is mediated by the extent of perceived sense of control. We collected cross-sectional data from a large heterogeneous sample (N = 543) in the Netherlands. We assessed seven different coping strategies, perceived control, and psychological well-being. Our results indeed revealed that strategies reflecting more engaged coping such as active confronting and reassuring thoughts, were associated with more sense of control and therefore to psychological well-being. In contrast, strategies reflecting disengagement coping, such as passive reaction pattern, palliative reaction, and avoidance, were associated with less perceived control, which in turn was negatively associated with psychological well-being. Results regarding the coping strategies expressing emotions and seeking social support were less straightforward, with the former being negatively associated with perceived control and psychological well-being, even though this strategy has stress engaging elements, and the latter only showing a positive indirect effect on psychological well-being via perceived control, but no positive main effect on well-being. These findings are discussed from the perspective of stress being an environment-perception-response process.