Several daily measurements are necessary to reliably assess the cortisol rise after awakening: state- and trait components

The cortisol rise after awakening (CAR) is a frequently applied measure of pituitary-adrenal activity. This measure seems to reflect the acrophase of the diurnal cycle and can easily be assessed in saliva samples, collected by the proband or patient under real life conditions. Since different state and trait factors affect the CAR, we here address the questions (a) to which extent state and trait factors affect the CAR, and (b) how often cortisol measures after awakening have to be taken to obtain reliable results. In this study, we assessed the CAR on 6 consecutive days. After applying structural equation models and correlation analyses, we conclude that (a) the CAR of a single day is determined to a great extent by situational factors and only for a small proportion by trait factors and (b) from two (AUC(t)) to six (AUC(i)) days are necessary to achieve reliable trait measures, since state factors bias data from a single day.

Are stress-induced immunological changes mediated by mood? A closer look at how both desirable and undesirable daily events influence sIgA antibody

This investigation tested a three-path model of mood as a mediator of the relation between stress and immunity. Seventy-two married men completed end-of-day diaries in which they rated their mood for that day and the desirability of the day's events for I2 weeks. Events were coded as either desirable (nonstressful) or undesirable (stressful) in nature. Immunological functioning was assessed by secretory immunoglobulin-A NgA) antibody response lo an oral antigen. Regression analyses indicated that negative mood partially mediated the immunological response to both undesirable and desirable events. Undesirable events lowered antibody levels primarily by increasing negative mood: desirable events increased antibody levels by decreasing negative mood. Evidence for mediation by positive mood beyond that found for negative mood was weak.

Allostatic Load, Perceived Stress, and Health: A Prospective Study in Two Age Groups

Overactivity of the hypothalamus-pituitary-adrenal axis (HPAA) has been observed in the presence of acute stress and, under chronic conditions, in disorders such as depression and anorexia nervosa as well as in cardiovascular and metabolic disorders. However, there may be other stress-related disorders (fatigue, pain, etc) that seem to be associated with mild hypocortisolism. This suggests that two major subtypes of the HPAA response to stress need to be discriminated. In this study, we investigated 76 subjects with and without hypocortisolism, respectively, over a 1-year period. Surprisingly, hypocortisolemic subjects had a lower allostatic load but they scored higher on measures of depression, perceived stress, and physical complaints. We propose a protective role of the hypocortisolemic stress response on cardiovascular and metabolic disorders, particularly in the elderly.

Does the peak-end phenomenon observed in laboratory pain studies apply to real-world pain in rheumatoid arthritics?

Laboratory studies and investigations of patients undergoing painful procedures have compared recalled pain to an average of multiple momentary reports taken throughout the painful experience. This work has shown that recalled ratings of pain are more closely associated with a combination of peak pain and pain proximal to the recall ratings than an average of all momentary reports. However, these studies have examined recalled pain over relatively short periods, usually under 1 hour. In this study of 32 patients with rheumatoid arthritis, momentary pain ratings taken over a 7-day period were compared with pain recalled on the eighth day. Analyses confirmed that a combination of peak and recent pain was a better predictor of recalled patient pain than was a simple average of all momentary pain reports. These results extend our understanding of how individuals remember pain and suggest alternative methods for assessing recalled pain.

Emotional reactivity to daily life stress in psychosis

BACKGROUND

The vulnerability-stress model of psychotic disorders describes, in essence, an interaction between personal vulnerability and environmental stressors. The present study investigated this interaction and studied emotional reactivity to daily life stress as a vulnerability marker for psychotic illness.

METHODS

Patients with psychotic illness (n = 42), their first-degree relatives (n = 47), and control subjects (n = 49) were studied with the Experience Sampling Method (a structured diary technique assessing thoughts, current context, and mood in daily life) to assess (1) appraised subjective stress of daily events and smaller disturbances in daily life and (2) emotional reactivity conceptualized as changes in both negative affect and positive affect.

RESULTS

Multilevel regression analyses showed that an increase in subjective stress was associated with an increase in negative affect and a decrease in positive affect in all groups. However, the groups differed quantitatively in their pattern of reactions to stress. Patients with psychotic illness reacted with more intense emotions to subjective appraisals of stress in daily life than control subjects. The decrease in positive affect in the relatives was similar to that of the patients, while the increase in negative affect in this group was intermediary to that of patients and control subjects.

CONCLUSIONS

Higher levels of familial risk for psychosis were associated with higher levels of emotional reactivity to daily life stress in a dose-response fashion. Subtle alterations in the way persons interact with their environment may constitute part of the vulnerability for psychotic illness.

Psychotherapy in the managed care health market

The author considers the future of psychotherapy in the managed care health market. He focuses on two interrelated questions. How can the efficacy of psychotherapy be scientifically demonstrated? Can psychotherapy meet the standards of cost-effectiveness set by health plans? He notes that efficacy is not enough in the managed care market, in which health plans also focus on the rational allocation of resources and economies of scale. The author then turns to the question of whether the doctor-patient relationship, which was central to American medicine throughout much of the 20th century, can survive in the current healthcare climate. He reviews the literature on the efficacy of psychotherapy and discusses the criteria for empirically validated treatments proposed by the American Psychological Association. He concludes that there is considerable support for the premise that the personal qualities of the individual therapist that contribute to the formation of the therapeutic alliance are at least as important, if not more important, than the specific method of psychotherapy used. The author concludes that medicine and psychiatry may be neglecting an important and uniquely curative element-the doctor-patient relationship, the human encounter that is the foundation of the art and science of medicine.

Individual differences in the diurnal cycle of salivary free cortisol: a replication of flattened cycles for some individuals

Free cortisol measured in saliva has been shown to have the same diurnal rhythm as serum cortisol, one that typically declines rapidly throughout the waking day. A recent study showed that over 15% of a sample of community individuals who were monitored over two days did not show the typical diurnal rhythm. The present study specifically tested the hypothesis that there is significant between-subject variation (individual differences) in diurnal rhythms using multi-level, random regression models. Analyses of participants from four studies were conducted; studies varied in terms of the number of saliva samples taken per day, the number of days studied, and participants' demographic and health status. Significant individual differences of diurnal cycle in each of the four samples were found. In at least 10% of each sample no significant diurnal cycles was detected; however, the overall mean level of cortisol of those with flat cycles differed among the samples. These results suggest that some people do not have the expected diurnal rhythm of cortisol secretion. It is not clear what the determinants of this finding are or if there are any health consequences of having a flat cycle.

Development of common cold symptoms following experimental rhinovirus infection is related to prior stressful life events

Previous studies of rhinovirus infection indicate that about one third of the persons with confirmed viral infection do not show evidence of cold symptoms. Factors that determine which infected individuals will develop colds are not known. Using a rhinovirus inoculation protocol, the authors explored the possible role of recent life events, current mood, and perceived stress in the development of symptoms in individuals known to be infected. As part of a larger study, 17 subjects were exposed to a rhinovirus and were individually isolated for 5 consecutive days; cold symptoms, mucus weights, and tissue use were monitored on a daily basis during this period. Although all 17 subjects had confirmed rhinovirus infection, only 12 subjects developed clinical colds, as indicated by self-reported symptoms and by objective symptom indices. The average number of reported major life events for the previous year was significantly higher for those who developed colds than for those who did not (p < .05). Measures of affect and perceived stress before the inoculation were not different for those who did and did not develop colds. Complementing recent research demonstrating psychosocial influences on experimental infection rates, these results provide evidence that the development of cold symptomatology in experimentally infected individuals is related to prior life events.

Impact of gender and having children in the household on ambulatory blood pressure in work and nonwork settings: a partial replication and new findings

Ambulatory blood pressure (ABP) has been shown to differ for men and women across work and nonwork settings. For men, ABP is higher at work than at home on workdays or on nonworkdays. For women, ABP levels in different settings depend on whether they have children in the household. Women without children at home exhibit the "male" pattern of higher ABP at work than at home. Women with children at home show either similar ABP levels in the two locations or higher ABP at home. These different patterns have been assumed to represent different stress levels in the two locations, but this assumption has rarely been tested. Also, few studies have examined ABP levels on a nonworkday in women or the effect of having children in the household for men. The present study monitored ABP in men and women during two workdays and one nonworkday. Comparisons were made between ABP levels in three settings (workday at work, workday at home, nonworkday) using mixed random effects regression models. Psychosocial variables (e.g. mood, stress) that might mediate the different ABP patterns were also assessed. ABP differences were analyzed by gender and whether children were living in the household using mixed random effects regression models. Results indicated that diastolic blood pressure was higher at work versus home for men with children and higher at work and on nonworkdays than at home for women without children. ABP did not differ across settings for women with children or men without children. These results were not mediated by mood or stress levels in the three settings.

Modulation of mitogen-activated protein kinases and phosphorylation of Bcl-2 by vinblastine represent persistent forms of normal fluctuations at G2-M1

Microtubule inhibitors, widely used in cancer chemotherapy, induce G2-M arrest and apoptosis and have in common the ability to stimulate Raf-1/Bcl-2 phosphorylation and activate c-Jun NH2-terminal protein kinase (JNK). These signal transduction pathways are thought to be activated in response to microtubule damage to promote apoptosis. However, Bcl-2 phosphorylation has been reported to occur at G2-M in nonapoptotic cells, raising the possibility that this and perhaps other signaling pathways altered by microtubule inhibitors reflect perturbations of normal mitotic events. In this study, we sought to test this hypothesis. We show that Bcl-2 phosphorylation and JNK activation, as well as extracellular response kinase and p38 inactivation, occur not only in response to vinblastine but also as discrete transient events at G2-M phase in untreated synchronized KB-3 cells. Thus, modulation of these pathways is not a response to microtubule damage; rather they occur normally at G2-M, and it is the extent, duration, and/or irreversible nature of the signals that distinguish a preapoptotic cell from one destined to divide. These findings provide novel insight into the relationship between mitotic and apoptotic signaling and the mechanism of action of antimitotic drugs.

Structured writing about stressful events: exploring potential psychological mediators of positive health effects

In a previous study, the authors found that structured writing about stressful events improved symptomatology in 112 patients with rheumatoid arthritis and asthma relative to patients who did not write (J. Smyth, A. Stone, A. Hurewitz, & A. Kaell, 1999). However, little is currently known about the pathways from the intervention to alterations in outcomes. In addition to measuring symptom outcomes after the intervention in the previous study, the authors monitored perceived stress, quality of sleep, affect, substance use, and medication use on a momentary basis for the 7 days prior to writing, during the 3 intervention days, and for the 14 days following the intervention (N = 105). These variables were tested in a secondary data analysis to determine whether they mediated the effects observed in the J. Smyth, A. Stone, et al. study. No evidence was found supporting mediation, and the mechanism underlying structured writing about stressful events remains unknown.

Coping with daily events and short-term mood changes: an unexpected failure to observe effects of coping

This study examined the relationship between coping efforts and stress-related mood changes. Men and women with high levels of work or marital stress reported stress and coping efforts approximately once an hour for 2 days using an electronic diary. Stress episodes were identified as a stress-free time followed by a stressor at the next time point. Analyses examined how appraisals and coping influenced pre- to poststress mood change and how problem appraisals were related to coping efforts. Greater mood changes were associated with appraisals of high stress and high disruptiveness. Appraisals of high control and high desirability were associated with more planning, direct action, and fewer acceptance coping efforts. Coping failed to predict any pre- to poststressor mood changes. Possible explanations for the overall failure of coping to predict momentary mood changes are discussed.

A naturalistic evaluation of cortisol secretion in persons with fibromyalgia and rheumatoid arthritis

OBJECTIVE

To compare cortisol levels, diurnal cycles of cortisol, and reactivity of cortisol to psychological stress in fibromyalgia (FM) and rheumatoid arthritis (RA) patients in their natural environment, and to examine the effect on results of accounting for differences among the groups in psychological stress and other lifestyle and psychosocial variables.

METHODS

Participants were 21 FM patients, 18 RA patients, and 22 healthy controls. Participants engaged in normal daily activities were signaled with a preprogrammed wristwatch alarm to complete a diary (assessing psychosocial- and lifestyle-related variables) or provide a saliva sample (for cortisol assessment). Participants were signaled to provide 6 diary reports and 6 saliva samples on each of two days. Reports of sleep quality and sleep duration were also made upon awakening.

RESULTS

FM and RA patients had higher average cortisol levels than controls; however, there were no differences between the groups in diurnal cycles of cortisol or reactivity to psychological stress. While the groups differed on stress measures, surprisingly, the patient groups reported less stress. Furthermore, statistically accounting for psychosocial- and lifestyle-related differences between the groups did not change the cortisol findings.

CONCLUSION

The results provide additional evidence of hypothalamic-pituitary-adrenal axis disturbance in FM and RA patients. While such elevations are consistent with other studies of chronically stressed groups, the elevations in cortisol in this study did not appear to be due to ongoing daily stress, and there was no evidence of disturbed cortisol reactivity to acute stressors.

Microtubule inhibitors elicit differential effects on MAP kinase (JNK, ERK, and p38) signaling pathways in human KB-3 carcinoma cells

Microtubule inhibitors are widely used in cancer chemotherapy, but the signaling mechanisms that link microtubule disarray to destructive or protective cellular responses are poorly understood. Because members of the mitogen-activated protein kinase (MAPK) family have been implicated in regulation of cell survival and cell death, we examined the extent and kinetics of activation of JNK, ERK, and p38 MAPKs in response to treatment of KB-3 carcinoma cells with several microtubule inhibitors. All four agents tested (vinblastine, vincristine, Taxol, and colchicine) caused significant (6- to 13-fold) activation of JNK, concomitant inactivation of ERK, and a reduction in basal p38 MAPK activity. JNK activation and ERK inactivation occurred prior to caspase 3 activation. The microtubule inhibitors also induced phosphorylation of Raf-1 kinase. SEK-1, upstream of JNK, was also activated and phosphorylated in response to the microtubule inhibitors, and sustained phosphorylation of three endogenous JNK substrates (c-Jun, ATF-2, and JunD) was observed. By comparison, the antitumor agent doxorubicin induced activation of JNK and p38 but had no effect on ERK activity or Raf-1. These data demonstrate that microtubule inhibitors elicit distinct and specific effects on MAPK-mediated signaling pathways and suggest in particular that coordinate and reciprocal alterations in JNK and ERK activities are important facets of the cellular response to microtubule disruption.

Psychosocial stress and social support are associated with prostate-specific antigen levels in men: results from a community screening program

Perceived stress and satisfaction with social support were assessed in 318 men participating in a prostate-specific antigen (PSA) screening program. We predicted that high stress would be associated with high PSA and high social support with low PSA. We also predicted a Stress x Support interaction (buffering). Hypothesized main effects were confirmed and were not explained by recency of previous rectal examinations or current urinary symptoms. There was no evidence of buffering. Stress and social support were not associated with results of digital rectal examinations. These findings raise the possibility that psychosocial factors promote prostate disease through direct physiologic pathways. However, it is also possible that the data reflect effects of stress on health-related behaviors or that stress scores were affected by participants' anticipation of prostate problems on the basis of prior PSA tests or symptoms.

Coping with daily events and short-term mood changes: an unexpected failure to observe effects of coping

This study examined the relationship between coping efforts and stress-related mood changes. Men and women with high levels of work or marital stress reported stress and coping efforts approximately once an hour for 2 days using an electronic diary. Stress episodes were identified as a stress-free time followed by a stressor at the next time point. Analyses examined how appraisals and coping influenced pre- to poststress mood change and how problem appraisals were related to coping efforts. Greater mood changes were associated with appraisals of high stress and high disruptiveness. Appraisals of high control and high desirability were associated with more planning, direct action, and fewer acceptance coping efforts. Coping failed to predict any pre- to poststressor mood changes. Possible explanations for the overall failure of coping to predict momentary mood changes are discussed.

Does trait coping exist? A momentary assessment approach to the evaluation of traits

This study investigated the extent to which momentary reports of coping are a traitlike phenomenon and the validity of a questionnaire assessment of coping style. Participants (N = 96) completed the questionnaire, then monitored stressful events and coping activities for 2 days using a hand-held computer that administered a brief assessment every 40 min. Momentary reports exhibited a sizable traitlike component: Individual differences accounted for 42% of the variance for 2 coping items and 15-30% of the variance for 15 items. The questionnaire assessment of coping style was a poor predictor of average momentary coping; the coping style measure and the aggregated momentary measure of trait coping shared 23% of their variance for religion and 0-12% for the 16 other coping measures. Self-report assessments of trait coping are poor measures of the trait component of momentary coping and very poor predictors of coping in specific situations.

Psychosocial stress and social support are associated with prostate-specific antigen levels in men: results from a community screening program

Perceived stress and satisfaction with social support were assessed in 318 men participating in a prostate-specific antigen (PSA) screening program. We predicted that high stress would be associated with high PSA and high social support with low PSA. We also predicted a Stress x Support interaction (buffering). Hypothesized main effects were confirmed and were not explained by recency of previous rectal examinations or current urinary symptoms. There was no evidence of buffering. Stress and social support were not associated with results of digital rectal examinations. These findings raise the possibility that psychosocial factors promote prostate disease through direct physiologic pathways. However, it is also possible that the data reflect effects of stress on health-related behaviors or that stress scores were affected by participants' anticipation of prostate problems on the basis of prior PSA tests or symptoms.

Daily psychosocial factors predict levels and diurnal cycles of asthma symptomatology and peak flow

This study examines the relationship among psychosocial factors, asthma symptoms, and peak expiratory flow rate (PEFR) in the natural environment. Twenty adult asthmatics wore preprogrammed wristwatches that prompted them to assess PEFR, asthma symptoms, and psychosocial factors five times a day for 10 days. Psychosocial variables (activities, locations, social contacts, mood, and stressors) were strongly related to PEFR and asthma symptoms, suggesting that they may play a more important role in disease expression than has been previously thought. Diurnal cycles of asthma symptoms and PEFR were observed. However, statistically controlling for psychosocial factors eliminated diurnal cycles for PEFR or asthma symptoms, indicating that psychosocial factors are a major contributor to the observed diurnal cycle in PEFR and symptoms. These relationships underscore the need to include psychosocial factors in future asthma research.

Does trait coping exist? A momentary assessment approach to the evaluation of traits

This study investigated the extent to which momentary reports of coping are a traitlike phenomenon and the validity of a questionnaire assessment of coping style. Participants (N = 96) completed the questionnaire, then monitored stressful events and coping activities for 2 days using a hand-held computer that administered a brief assessment every 40 min. Momentary reports exhibited a sizable traitlike component: Individual differences accounted for 42% of the variance for 2 coping items and 15-30% of the variance for 15 items. The questionnaire assessment of coping style was a poor predictor of average momentary coping; the coping style measure and the aggregated momentary measure of trait coping shared 23% of their variance for religion and 0-12% for the 16 other coping measures. Self-report assessments of trait coping are poor measures of the trait component of momentary coping and very poor predictors of coping in specific situations.

Anger expression and ambulatory blood pressure: a comparison of state and trait measures

OBJECTIVES

The goals of this study were (1) to compare trait and state measures of anger expression, (2) to examine associations between situational variables and anger expression, and (3) to examine relationships between trait and state anger expression and ambulatory blood pressure.

METHODS

One hundred college students completed state and trait versions,of the Spielberger (1) anger expression scale. State measures were completed in response to specific anger-provoking situations as they occurred over a 7-day period. Ambulatory blood pressure was recorded on one of these days.

RESULTS

Moderate correlations were observed between trait and state anger expression. Significant associations were found between a number of situational variables and state anger expression scales. Neither trait nor state anger expressions scales were related to blood pressure levels.

CONCLUSIONS

These results indicate that trait and state measures of anger expression are not equivalent and that situational factors play an important role in anger expression. Situational variability may be an important factor in determining the health consequences of anger expression.

Rheumatoid arthritis patients show weather sensitivity in daily life, but the relationship is not clinically significant

While the majority of rheumatoid arthritis (RA) patients report that their pain is influenced by the weather, studies examining the impact of weather on RA pain have yielded equivocal results. It is not clear from the existing studies if the mixed results are due to limited statistical power (e.g. small sample sizes and restricted variability in weather indices) or the failure to consider individual differences. The current study addressed these weaknesses by having 75 RA patients (mean age = 52.7; 71% female) record their daily pain severity for 75 consecutive days. Objective weather indices including temperature, barometric pressure, relative humidity, and percentage of sunlight were obtained for the same dates from a local weather service. The results indicate that for the entire sample, pain levels were highest on cold, overcast days and following days with high barometric pressure. Pain levels also increased as a function of change in relative humidity from one day to the next. Individual difference analyses revealed significant variability between patients in their weather sensitivity patterns. In general, patients with higher levels of self-reported pain demonstrated more weather sensitivity. When considering the magnitude of these effects, however, weather variables accounted for only a small amount of change in pain scores. This pattern was true even for patients with the most pronounced pain-weather relationships. Thus, although weather sensitivity was found, the effect sizes were not clinically meaningful.

Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial

CONTEXT

Nonpharmacological treatments with little patient cost or risk are useful supplements to pharmacotherapy in the treatment of patients with chronic illness. Research has demonstrated that writing about emotionally traumatic experiences has a surprisingly beneficial effect on symptom reports, well-being, and health care use in healthy individuals.

OBJECTIVE

To determine if writing about stressful life experiences affects disease status in patients with asthma or rheumatoid arthritis using standardized quantitative outcome measures.

DESIGN

Randomized controlled trial conducted between October 1996 and December 1997.

SETTING

Outpatient community residents drawn from private and institutional practice.

PATIENTS

Volunteer sample of 112 patients with asthma (n = 61) or rheumatoid arthritis (n = 51) received the intervention; 107 completed the study, 58 in the asthma group and 49 in the rheumatoid arthritis group.

INTERVENTION

Patients were assigned to write either about the most stressful event of their lives (n = 71; 39 asthma, 32 rheumatoid arthritis) or about emotionally neutral topics (n = 41; 22 asthma, 19 rheumatoid arthritis) (the control intervention).

MAIN OUTCOME MEASURES

Asthma patients were evaluated with spirometry and rheumatoid arthritis patients were clinically examined by a rheumatologist. Assessments were conducted at baseline and at 2 weeks and 2 months and 4 months after writing and were done blind to experimental condition.

RESULTS

Of evaluable patients 4 months after treatment, asthma patients in the experimental group showed improvements in lung function (the mean percentage of predicted forced expiratory volume in 1 second [FEV1] improved from 63.9% at baseline to 76.3% at the 4-month follow-up; P<.001), whereas control group patients showed no change. Rheumatoid arthritis patients in the experimental group showed improvements in overall disease activity (a mean reduction in disease severity from 1.65 to 1.19 [28%] on a scale of 0 [asymptomatic] to 4 [very severe] at the 4-month follow-up; P=.001), whereas control group patients did not change. Combining all completing patients, 33 (47.1%) of 70 experimental patients had clinically relevant improvement, whereas 9 (24.3%) of 37 control patients had improvement (P=.001).

CONCLUSION

Patients with mild to moderately severe asthma or rheumatoid arthritis who wrote about stressful life experiences had clinically relevant changes in health status at 4 months compared with those in the control group. These gains were beyond those attributable to the standard medical care that all participants were receiving. It remains unknown whether these health improvements will persist beyond 4 months or whether this exercise will prove effective with other diseases.

Managed care, liability, and ERISA

Congress originally passed ERISA to secure the contractual benefits negotiated between employers and employees. In 1974, when the statute quickly moved through Congress, no one realized what its eventual significance for health care would be. Certainly no one expected that ERISA preemption would allow MCHPs to reduce professional standards of care while being protected from liability. The Department of Labor believes that it was never the intention of Congress to preempt ordinary damage claims for malpractice. There are now chinks in the legal armor of ERISA created by activists' courts as in the Dukes case. Even conservative Judges recognize the injustice of results, such as Corcoran. The American medical profession has traditionally complained about malpractice litigation and the wastefulness of defensive medicine. Perhaps ERISA will make the profession recognize that malpractice liability can serve a useful purpose.

Eating disturbances in white and minority female dieters

OBJECTIVE

This study examined disordered eating, attitudes about weight and appearance, self-esteem, weight loss, and reasons for weight regain in a sample of white, black, Asian, and Hispanic female dieters.

METHOD

In this cross-sectional descriptive study, we scrutinized survey responses of a large number of households subscribing to Consumer Reports magazine. Females (N = 9,971) between 21 and 65 years old (M = 42.9, SD = 10.4) with a mean body mass index (BMI) of 27.2 (SD = 6.2) were selected for comparisons.

RESULTS

Ethnic groups were different in terms of age, BMI, household income, and marital status. Therefore, these variables were used as covariates in the analyses. More black women were overweight and purged compared to the other groups. Asian women valued the beneficial role of exercise in weight control more, while black women were more inclined to attribute weight gain to cravings and slow metabolism. The groups did not differ in terms of binge eating, attitudes about weight and appearance, self-esteem, the number of attempts to lose weight, and the reasons for their failures.

CONCLUSIONS

This study suggests that unhealthy eating attitudes and practices may be similar for women who diet, irrespective of ethnic background. However, the generalizability of these findings is limited by the inherent sampling bias.

A comparison of coping assessed by ecological momentary assessment and retrospective recall

Recent research suggests that retrospective coping assessments may not correspond well with day-to-day reports. The authors extended this work by examining the correspondence between short-term (within 48 hr) retrospective coping reports and momentary reports recorded via a palm-top computer close in time to when the stressor occurred. There was relatively poor correspondence between the 2 assessments. Some reports of momentary coping were not reported retrospectively, and some coping reported retrospectively was not reported at the time the stressor occurred. Cognitive coping was more likely to be underreported retrospectively; behavior coping was overreported. Participants were consistent in their discrepancies, but there was no correspondence between discrepancy rates and demographic or personality variables.

A comparison of coping assessed by ecological momentary assessment and retrospective recall

Recent research suggests that retrospective coping assessments may not correspond well with day-to-day reports. The authors extended this work by examining the correspondence between short-term (within 48 hr) retrospective coping reports and momentary reports recorded via a palm-top computer close in time to when the stressor occurred. There was relatively poor correspondence between the 2 assessments. Some reports of momentary coping were not reported retrospectively, and some coping reported retrospectively was not reported at the time the stressor occurred. Cognitive coping was more likely to be underreported retrospectively; behavior coping was overreported. Participants were consistent in their discrepancies, but there was no correspondence between discrepancy rates and demographic or personality variables.

Stressors and mood measured on a momentary basis are associated with salivary cortisol secretion

Effects of past, current, and anticipated naturalistic daily stressors and of affect on salivary cortisol levels were examined. Participants (120) reported on stressors and affect 6 x /day in response to a preprogrammed wristwatch. Twenty min after each assessment they took a sample of saliva for cortisol analysis. Both the experience of a current stressor and anticipating a stressor were associated with increased salivary cortisol levels. Average increases in cortisol were relatively low, but inter-individual variability in this response existed. Stressors also were associated with lower positive affect and higher negative affect. Negative affect was associated with higher cortisol levels and positive affect was associated with lower cortisol levels. Daily stressors were not significant predictors of cortisol secretion when affect was controlled. Momentary assessment of daily stressors and of salivary cortisol proved to be a useful tool for examining psychoendocrinological processes in the natural environment.

Strategies for analyzing ecological momentary assessment data

Studies incorporating repeated observations of momentary phenomena are becoming more common in behavioral and medical science. Analysis of such data requires the use of statistical techniques that are unfamiliar to many investigators. Some common ways of analyzing momentary data are reviewed--aggregation strategies, repeated measures analysis of variance, pooled within-person regression, and two-stage estimation procedures for multilevel models--and are found to be usually suboptimal, possibly leading to incorrect inferences. A broad class of statistical models for multilevel data that can address many research questions typically asked of momentary data are then described. Analytic issues that merit careful consideration include the scaling of momentary variables, allowance for serial autocorrelation of residuals, and the treatment of coefficients that vary across individuals as fixed versus random effects.

Strategies for analyzing ecological momentary assessment data

Studies incorporating repeated observations of momentary phenomena are becoming more common in behavioral and medical science. Analysis of such data requires the use of statistical techniques that are unfamiliar to many investigators. Some common ways of analyzing momentary data are reviewed--aggregation strategies, repeated measures analysis of variance, pooled within-person regression, and two-stage estimation procedures for multilevel models--and are found to be usually suboptimal, possibly leading to incorrect inferences. A broad class of statistical models for multilevel data that can address many research questions typically asked of momentary data are then described. Analytic issues that merit careful consideration include the scaling of momentary variables, allowance for serial autocorrelation of residuals, and the treatment of coefficients that vary across individuals as fixed versus random effects.

Psychosocial factors and secretory immunoglobulin A

This review focuses on studies that have examined the relation between psychosocial factors and secretory immunoglobulin A (s-IgA). Several studies have examined the relation between s-IgA and stressful circumstances ranging from major life events to minor daily events. The findings from these studies were often contradictory, since different experimenters reported different stress-related changes in s-IgA. The effects of stress reduction interventions, such as relaxation and imagery, on s-IgA levels have also been examined. Although these studies indicate that various interventions are associated with increases in s-IgA levels, methodological refinements are needed before more definitive conclusions can be made. The possibility that the relation between stress and s-IgA may be moderated by personality characteristics or mediated by psychological distress was supported in some studies. The review concludes with suggestions for future research.

The experience of rheumatoid arthritis pain and fatigue: examining momentary reports and correlates over one week

OBJECTIVE

To evaluate the daily experience of patients with rheumatoid arthritis (RA) in an ecologically valid manner; Ecological Momentary Assessment (EMA) was employed. Diurnal cycles and within-day variation of self-reported pain and fatigue were examined as were relationships between pain, fatigue, daily stressful events, and sleep.

METHODS

Thirty-five patients with RA were alerted with an electronic beep 7 times per day for 7 consecutive days. Assessments were recorded at each beep. Upon awakening each day, sleep information was reported.

RESULTS

There were large individual differences in variation of pain and fatigue. Stressors were associated with increased pain but not fatigue. Subjects with poor sleep had higher levels of pain and fatigue. Diurnal cycles of pain and fatigue were found, yet were observed for only some patients (37% and 34%, respectively).

CONCLUSION

The use of EMA deepens our understanding of the pain and fatigue experienced by RA patients. This method may help identify subgroups of patients who are highly "psychoreactive" to environmental stimuli and/or who have diurnal patterns to their symptoms. It may also be used to improve existing instruments.

Individual differences in the diurnal cycle of cortisol

This study investigated individual differences in the diurnal cycle of cortisol and explored their relation to several psychosocial variables and to upper-respiratory symptoms. Cortisol and daily experience were assessed for 2 days in 109 healthy employed and unemployed community residents (mean age = 36.4 +/- 12.1, 69% female); self-report upper respiratory illness (URI) symptoms were assessed for an additional 10 days. Fifty-six (51%) participants showed typical declines in cortisol during both days, 19 (17%) showed no significant diurnal pattern on both days, and 34 (31%) showed different diurnal patterns on the 2 days. Individuals with no cycles did not differ from those with normal or inconsistent cycles on demographic factors, baseline psychological measures, health behaviors, or daily experiences over the two assessment days. Individuals without cortisol cycles, however, reported fewer URI symptoms than the remaining subjects. That 17% of our sample did not exhibit diurnal cycles of cortisol was surprising, given established views of normal endocrine function. Although average daily level of cortisol is related to a number of psychosocial and psychiatric factors (e.g. stress and depression), pattern of diurnal cycle was not related to any demographic or psychosocial measures in this study. The finding that flat cycles were related to fewer reports of URI symptoms suggests that perturbations in cycle may be related to processes associated with symptom susceptibility or symptom expression.

Emotional expression and physical health: revising traumatic memories or fostering self-regulation?

Health benefits derived from personal trauma disclosure are well established. This study examined whether disclosing emotions generated by imaginative immersion in a novel traumatic event would similarly enhance health and adjustment. College women, preselected for trauma presence, were randomly assigned to write about real traumas, imaginary traumas, or trivial events. Yoked real-trauma and imaginary-trauma participants wrote about real-trauma participants' experiences. Imaginary-trauma participants were significantly less depressed than real-trauma participants at immediate posttest, but they were similarly angry, fearful, and happy. Compared with control group participants, both trauma groups made significantly fewer illness visits at 1-month follow-up; however, real-trauma participants reported more fatigue and avoidance than did the other groups. Imaginary-trauma group effects could reflect catharsis, emotional regulation, or construction of resilient possible selves.

Reactive effects of diary self-assessment in chronic pain patients

Several studies of experimental and acute clinical pain have indicated reactive effects of self-assessment on pain intensity and tolerance. A recent study of chronic pain patients (vonBaeyer 1994), however, failed to show these effects. The present investigation sought to determine whether reactive effects can be produced in chronic pain patients by an intensive self-assessment protocol. Using the methodology of ecological momentary assessment (EMA; Stone and Shiffman 1994), thirty-five chronic rheumatoid arthritis patients completed diaries of pain and mood seven times a day for 1 wk. Eighteen patients were included in the final sample because they responded to at least half of the number of hourly prompts for each of the 7 days. Using repeated measures analysis of the daily means, no significant effects of time were found for any measures. Reactive effects that result in an average change in pain levels over time, therefore, do not appear to be produced by intensive self-assessment in a naturalistic context. Results are discussed in terms of cognitive and behavioral theories of pain reactivity.

Emotional expression and physical health: revising traumatic memories or fostering self-regulation?

Health benefits derived from personal trauma disclosure are well established. This study examined whether disclosing emotions generated by imaginative immersion in a novel traumatic event would similarly enhance health and adjustment. College women, preselected for trauma presence, were randomly assigned to write about real traumas, imaginary traumas, or trivial events. Yoked real-trauma and imaginary-trauma participants wrote about real-trauma participants' experiences. Imaginary-trauma participants were significantly less depressed than real-trauma participants at immediate posttest, but they were similarly angry, fearful, and happy. Compared with control group participants, both trauma groups made significantly fewer illness visits at 1-month follow-up; however, real-trauma participants reported more fatigue and avoidance than did the other groups. Imaginary-trauma group effects could reflect catharsis, emotional regulation, or construction of resilient possible selves.

Persistent high cortisol responses to repeated psychological stress in a subpopulation of healthy men

The present study tested the hypothesis that some subjects may not readily show habituation of adrenocortical stress responses to repeated psychological stress. Twenty healthy male subjects were each exposed five times to the same, brief psychosocial stressor (public speaking and mental arithmetic in front of an audience) with one stress session per day. Salivary cortisol levels were assessed as an index of adrenocortical stress responses. For the total group, cortisol levels were significantly elevated on each of the 5 days. The mean response decreased from day 1 to day 2; however, no further attenuation could be observed on the remaining days. Cluster analysis revealed two groups of subjects who showed completely different response kinetics. In the first group (N = 13), termed "low responders," cortisol levels were elevated on day 1 only. Day 2 to 5 cortisol levels were unaltered. In contrast, subjects in the second group ("high responders") displayed large increases to each of the five experimental treatments. This group had no significant response decrement from day 1 to day 2 to 4 and only a marginal response difference between day 1 and day 5. Discriminant analysis revealed that a combination of five personality scales plus the scores on a symptoms checklist significantly discriminated between high and low responders. With this discriminant function, all 20 subjects were correctly classified to the two groups. These results are discussed with a focus on the possible impact of adrenocortical response types on health and disease.

Effect of chronic stress associated with unemployment on salivary cortisol: overall cortisol levels, diurnal rhythm, and acute stress reactivity

This study examined the effect of chronic stress associated with unemployment on the magnitude of salivary cortisol excretion, on the diurnal rhythm of cortisol, and on cortisol reactivity to acute naturalistic stressors using Experience Sampling Methodology (ESM). Employed (N = 60) and unemployed (N = 60) subjects were studied for 2 days. Subjects were beeped 6 times per day by a preprogrammed wristwatch to assess acute stressors; 25 minutes after each ESM-beep, subjects were beeped a second time for saliva samples. The groups did not differ in their overall cortisol excretion or in cortisol reactivity to acute daily stressors. Compared to employed subjects, unemployed subjects had a diurnal pattern of cortisol excretion with relatively higher morning and lower evening levels. Subjects' daily activities and their locations were associated with diurnal rhythm differences.

Association between daily coping and end-of-day mood

Research indicates that self-reports of coping with stressful occurrences are associated with psychological and health outcomes. However, measures of coping may be biased by retrospective distortion as they assess coping over relatively long periods. In this study, a sample of 79 men completed a coping assessment daily for several weeks about the day's most "bothersome" problem. Repeated daily measurement of coping allowed analysis of within-subject effects of coping efforts. Same-day mood reported by the men (targets) and reports of the men's mood by their spouses (observers) were outcome variables. Within-subject analyses indicated that catharsis and social supports were associated with increased negative affect, whereas use of acceptance was associated with less negative affect. Use of distraction, acceptance, and relaxation were associated with increased positive affect. These findings held for target- and observer-reported mood.

Daily events are associated with a secretory immune response to an oral antigen in men

To examine a hypothesized link between daily stressful events and secretory immunoglobulin A (sIgA) antibody, 96 adults from the community completed daily event questionnaires and gave daily saliva samples for up to 12 weeks. They also ingested a capsule of a novel protein to challenge their secretory immune systems. The questionnaire yielded measures of negative and positive experiences, of their content, and of negative and positive affect. On a within-subjects, day-to-day basis, reporting more desirable events was related to more sIgA antibody, and reporting more undesirable events was related to less. Desirable events also had lagged (1 and 2 days), positive effects on sIgA levels. Undesirable work events and desirable leisure and household events were more strongly related to sIgA than events in other categories. Positive affect related directly to sIgA, and negative mood related inversely to same-day sIgA.

Daily events are associated with a secretory immune response to an oral antigen in men

To examine a hypothesized link between daily stressful events and secretory immunoglobulin A (sIgA) antibody, 96 adults from the community completed daily event questionnaires and gave daily saliva samples for up to 12 weeks. They also ingested a capsule of a novel protein to challenge their secretory immune systems. The questionnaire yielded measures of negative and positive experiences, of their content, and of negative and positive affect. On a within-subjects, day-to-day basis, reporting more desirable events was related to more sIgA antibody, and reporting more undesirable events was related to less. Desirable events also had lagged (1 and 2 days), positive effects on sIgA levels. Undesirable work events and desirable leisure and household events were more strongly related to sIgA than events in other categories. Positive affect related directly to sIgA, and negative mood related inversely to same-day sIgA.