Psychosomatic Medicine

Article Summaries for January 2021 Psychosomatic Medicine, Volume 83, Issue 1 No abstract available

Reduced Heart Rate Variability in Patients With Medically Unexplained Physical Symptoms: A Meta-Analysis of HF-HRV and RMSSD Objective Medically unexplained physical symptoms (MUPS) and related syndromes are common and place a substantial burden on both patients and society. Chronic psychological distress and dysregulation of the autonomic nervous system may be common factors associated with MUPS, although previous studies have reported mixed results. The aims of this meta-analysis are to provide an updated synthesis of studies investigating heart rate variability (HRV) indices associated with autonomic nervous system functioning in three common MUPS syndromes and to explain inconsistencies in previous study findings. Methods Literature search yielded 58 studies comparing HRV indices of reduced parasympathetic activity of healthy individuals with those of patients with chronic fatigue syndrome (npatients = 271), irritable bowel syndrome (npatients = 1005), and fibromyalgia (npatients = 534). Separate random-effects meta-analyses were conducted on studies measuring root mean square of successive differences (RMSSD) and high-frequency HRV (HF-HRV). Results Regardless of syndrome type, patients had significantly lower RMSSD (k = 22, Hedges g = −0.37 [−0.53 to −0.21], p < .001) and HF-HRV (k = 52, Hedges g = −0.69 [−1.03 to −0.36], p < .001) than did healthy individuals. Sample age and publication year explained a substantial variation in RMSSD, whereas controlling for confounders in statistical analyses explained variation in HF-HRV. Conclusions Lower RMSSD and HF-HRV in patients with MUPS versus healthy controls indicates that autonomic nervous system dysregulation, particularly lower parasympathetic activity, may play a role in patients with these conditions. This conclusion may have important implications for the underlying mechanisms and treatment of MUPS and related syndromes.

Socioeconomic Differences in Sympathovagal Balance: The Healthy Life in an Urban Setting Study Objective Alterations in sympathovagal balance are associated with cardiovascular disease. If sympathovagal balance differs across socioeconomic groups, it may reflect a mechanism through which disparities in cardiovascular disease occur. We therefore assessed the association between education and occupation with measures of sympathovagal balance in a large multiethnic sample. Methods We included cross-sectional data of 10,202 South Asian Surinamese, African Surinamese, Ghanaian, Turkish, Moroccan, and Dutch-origin participants from the Healthy Life in an Urban Setting study. Sympathovagal balance was measured by baroreflex sensitivity (BRS) and the standard deviation of the interbeat interval, calculated from changes in blood pressure and interbeat intervals, from 5-minute recordings. We calculated geometric means and estimated the relative index of inequality, using age- and ethnicity-adjusted linear regression, to quantify the association between education and occupation and sympathovagal balance. In addition, we assessed whether the association was consistent across ethnic groups. Results The geometric means of BRS ranged from 8.16 ms/mm Hg (confidence interval [CI] = 7.91–8.43 ms/mm Hg) in low-educated to 14.00 ms/mm Hg (CI = 13.53–14.48 ms/mm Hg) in highly educated women, and from 8.32 ms/mm Hg (CI, 7.97–8.69 ms/mm Hg) in low-educated to 12.25 ms/mm Hg (CI = 11.86–12.66 ms/mm Hg) in highly educated men. High education and occupation were statistically significantly associated with higher BRS and standard deviation of the interbeat interval. Compared with the participants of Dutch origin, a pattern of weaker associations was found in the Surinamese and Ghanaian ethnic groups, but not the Turkish and Moroccan groups. Conclusions There is a clear socioeconomic gradient in measures of sympathovagal balance, indicating that sympathovagal balance may play a role in socioeconomic disparities in cardiovascular morbidity and mortality.

Implicit Affect, Heart Rate Variability, and the Metabolic Syndrome Objective Greater negative affect has been associated with an increased risk of the metabolic syndrome (METs). However, all studies to date have examined this association using explicit affect measures based on subjective ratings of emotional experiences. Prior studies suggest that implicit affect, representing the automatic, prereflective appraisal process involved in conscious emotional experiences, is associated with physiological stress responses independent of explicit affect. Furthermore, low resting heart rate variability (HRV) may increase the risk of stress-related diseases. The goals of this study were to evaluate the associations between implicit and explicit affect and METs and to assess whether these associations were amplified by lower HRV. Methods This secondary analysis of a larger study included 217 middle-aged women who completed measures of implicit affect, explicit affect, high-frequency HRV, and the different components of METs. Results There was a significant interaction between implicit negative affect and HRV predicting METs (odds ratio = 0.57, 95% confidence interval = 0.35–0.92), such that the combination of higher implicit affect and lower HRV was associated with a greater likelihood of METs. Similarly, there was a main effect of implicit negative affect as well as an interaction between implicit negative affect and HRV on the lipid accumulation product (b (standard error) = −0.06 (0.02), 95% confidence interval = −0.11 to −0.02), a combination of waist circumference and triglycerides. Conclusions Higher implicit negative affect in the context of lower HRV may be related to a greater risk of METs. The present findings highlight the relevance of including implicit affect measures in psychosomatic medicine research.

Open- and Closed-Label Placebo and Nocebo Suggestions About a Sham Transdermal Patch Objective Placebo effects may occur when it is known that an inert substance is given (i.e., open-label placebo). It is not yet clear whether these effects are similar to concealed (i.e., closed-label) placebo effects for itch or whether nocebo effects can be induced under open-label conditions. Methods Healthy volunteers (n = 112) were randomized to an open-label (I) or closed-label (II) positive suggestions group, or an open-label (III) or closed-label (IV) negative suggestions group. Participants were told, as cover story, that a transdermal caffeine patch would be applied that positively influences cognitive abilities and, as a side effect, positively or negatively (depending on group allocation) influences itch. Participants in the open-label groups were given a rationale explaining placebo and nocebo effect mechanisms. Itch (the primary outcome) was induced at baseline and postsuggestions by histamine iontophoresis. Results Analyses of variance revealed significantly lower itch in the positive compared with the negative suggestions groups for both open- and closed-label contexts (all, p ≤ .008, Cohen d ≥ 0.47). Self-rated skin response was less severe after positive versus negative suggestions (all, p ≤ .017, Cohen d ≥ 0.33), but no effects on physical skin response were found (all, p ≥ .23, Cohen d ≤ 0.30). Conclusions Itch can be reduced by positive compared with negative suggestions under both open- and closed-label conditions. These findings indicate that open-label suggestions may potentially be a tool to use placebo effects for self-reported outcomes in clinical practice, for example, by explaining the role of expectancy in treatment. It needs to be investigated further under which circumstances an open-label rationale may impact placebo and nocebo effects. Trial Registration:www.trialregister.nl; NTR7174

The Effect of Temporal Information on Placebo Analgesia and Nocebo Hyperalgesia Objective Expectations are known to be key determinants of placebo and nocebo phenomena. In previous studies, verbal suggestions to induce such expectations have mainly focused on the direction and magnitude of the effect, whereas little is known about the influence of temporal information. Methods Using an experimental placebo and nocebo design, we investigated whether information about the expected onset of a treatment effect modulates the start and time course of analgesic and hyperalgesic responses. Healthy volunteers (n = 166) in three placebo and three nocebo groups were informed that the application of an (inert) cream would reduce (placebo groups) or amplify pain (nocebo groups) after 5, 15, or 30 minutes. Two control groups were also included (natural history and no expectations). Participants' pain intensity rating of electrical stimuli administered before and 10, 20, and 35 minutes after cream application was obtained. Results Mixed-method analysis of variance showed a significant interaction between group and time (F(12,262) = 18.172, p < .001, pη2 = 0.454), suggesting that pain variations differed across time points and between groups. Post hoc comparisons revealed that the placebo and nocebo groups began to show a significantly larger change in perceived pain intensity than the no-expectancy control group at the expected time point (p < .05) but not earlier (p > .05). Once triggered, the analgesic effect remained constant over the course of the experiment, whereas the hyperalgesic effect increased over time. Conclusions Our results indicate that temporal suggestions can shape expectancy-related treatment effects, which, if used systematically, could open up new ways to optimize treatment outcome.

Perceived Social Support and Children's Physiological Responses to Stress: An Examination of the Stress-Buffering Hypothesis Objective The current study aimed to examine the stress-buffering effect of children's perceived social support on their hypothalamic-pituitary-adrenocortical axis and autonomic nervous system reactivity to an acute laboratory stressor. Methods A sample of 150 children (aged 9–13 years, mean [standard deviation] age = 10.69 [0.93] years, 74 girls) reported perceived social support, stressful life events, and underwent the Modified Trier Social Stress Test, during which six saliva samples were collected. A two-piece multilevel growth curve model with landmark registration was used to detect trajectory differences in the reactivity and recovery phases of the stress response and account for individual variation in the timing of poststressor peak hormone concentrations. Results The interaction between stressful life events and perceived social support significantly predicted poststressor peak cortisol levels (β = 0.0805, SE = 0.0328, p = .015) and cortisol recovery slope (β = −0.0011, SE = 0.0005, p = .040). Children with more life events and low social support exhibited the lowest poststressor peak cortisol levels and the flattest cortisol recovery slope. In contrast, children high in stressful life events and high in social support displayed cortisol response profiles more similar to those of children with low stressful life events. Conversely, there were no statistically significant two-way interactions of stressful life events and perceived social support on salivary α-amylase parameters (i.e., poststressor peak [p = .38], reactivity slope [p = .81], and recovery slope [p = .32]). Conclusions These results provide preliminary evidence for the buffering effect of children's perceived social support on the association between life stress and hypothalamic-pituitary-adrenocortical axis response profiles.

Psychosocial Work Factors of the Job Strain Model and All-Cause Mortality: The STRESSJEM Prospective Cohort Study Objective The objectives were to examine the prospective associations between psychosocial work factors of the job strain model and all-cause mortality in a national representative cohort of French employees using various measures of time-varying exposure. Methods The study was based on a sample of 798,547 men and 697,785 women for which data on job history from 1976 to 2002 were linked to mortality data from the national death registry. Psychosocial work factors from the validated job strain model questionnaire were imputed using a job-exposure matrix. Three time-varying measures of exposure were explored: current, cumulative, and recency-weighted cumulative exposure. Cox proportional hazards models were performed to study the associations between psychosocial work factors and mortality. Results Within the 1976–2002 period, 88,521 deaths occurred among men and 28,921 among women. Low decision latitude, low social support, job strain, isostrain, high strain, and passive job were found to be risk factors for mortality. The model using current exposure was the best relative-quality model. The associations of current exposure to job strain and mortality were found to have hazard ratios of 1.30 (95% confidence interval [CI] = 1.24–1.36) among men and 1.15 (95% CI = 1.06–1.25) among women. The population fractions of mortality attributable to job strain were 5.64% (95% CI = 4.56%–6.71%) among men and 4.13% (95% CI = 1.69%–6.71%) among women. Conclusions This study supports the role of the psychosocial work factors of the job strain model on all-cause mortality. Preventive intervention to improve the psychosocial work environment may help to prevent mortality in working populations.

An Intervention to Change Illness Representations and Self-Care of Individuals With Type 2 Diabetes: A Randomized Controlled Trial Objective Suboptimal self-care by individuals with diabetes mellitus (DM) is a significant public health concern. The common-sense model (CSM) proposes that illness representations are associated with coping and health outcomes across various conditions. The present study examined the efficacy of a CSM-based intervention in improving illness representations, self-care, self-care self-efficacy, use of adaptive coping strategies, and glycated hemoglobin among individuals with type 2 DM (T2DM). Methods A two-arm randomized controlled trial was used. A total of 455 T2DM patients were recruited from an outpatient DM clinic and randomized to an intervention group that consisted of five weekly group-based education sessions or a control group that received five weekly educational booklets. Evaluation was conducted at baseline and at 1- and 6-month follow-up. Results The 2 × 3 linear mixed-model analysis using a modified intention to treat revealed a significant time by condition interaction effect on level of self-care (F(2,840) = 7.78, p < .001), self-care self-efficacy (F(1.89,794.57) = 14.40, p < .001), and use of adaptive coping strategies (F(1.94,812.93) = 4.75, p = .010) in which participants in the intervention group reported greater improvement in such aspects compared with those in the control group. A significant time effect was observed in some dimensions of illness representations. No significant effect was found in glycated hemoglobin. Participants reported positive feedback to the intervention and perceived improvement in various domains. Conclusions The CSM-based intervention was effective in improving self-care and coping among DM patients. The intervention also demonstrated high feasibility and acceptability. Findings provided important insights in improving health-related outcomes for patients with T2DM using the CSM framework.

Longitudinal Course of Depressive, Anxiety, and Posttraumatic Stress Disorder Symptoms After Heart Surgery: A Meta-Analysis of 94 Studies Objective This study aimed to analyze the longitudinal course of depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms in patients with cardiac disease after heart surgery (HS). Methods We conducted a systematic review and random-effects meta-analysis of cohort studies in patients undergoing HS, measuring anxiety, depressive, and PTSD symptoms before and at least 30 days thereafter. Subgroup and meta-regression analyses, investigation of publication bias, and quality assessment were undertaken. Results We included 94 studies relating to 15,561 patients. HS included coronary artery bypass graft surgery, valve replacement, implantable cardioverter-defibrillator placement, left ventricular assist device placement, heart transplantation, and other types of HS. Across studies, symptoms of depression (g = 0.32; 95% confidence interval [CI] = 0.25 to 0.39; p < .001) and anxiety improved after HS (g = 0.52; 95% CI = 0.43 to 0.62; p < .001), whereas PTSD symptoms worsened (g = −0.42; 95% CI = −0.80 to −0.04; p = .032). The reduction of depression and anxiety levels was more pronounced for patients with underlying coronary artery disease and heart failure and persisted for 1 year after HS, whereas the increase in PTSD symptoms returned to baseline after 6 months. Depression improvement was inversely associated with older age, diabetes, hypertension, and dyslipidemia and positively with baseline heart failure. No additional clinical or demographic variables were associated with the course of anxiety symptoms. Quality of included studies was low overall. Publication bias was nonsignificant. Conclusions Depressive and anxiety symptoms improve for 1 year after HS, whereas PTSD symptoms might worsen. Older patients and those with metabolic comorbidities, valve disease, or ventricular arrhythmias are at higher risk for continued depressive and anxiety symptoms and should be monitored closely.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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