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This article provides a selective review of the effects of psychosocial factors and responses to acute mental stress on the onset of acute coronary syndromes. The literature suggests that the relationship between the anatomical severity of coronary artery disease (CAD) and likelihood of subsequent cardiac events, such as myocardial infarction, is not linear. Furthermore, evidence will be provided that the age-dependent associations between psychosocial factors and risk of cardiac events is at least in part mediated through the severity of underlying CAD. Finally, research will be summarized that supports the importance of both chronic psychosocial factors (e.g., low socioeconomic status and/or high hostility) and episodic psychological distress syndromes, such as vital exhaustion and depression. In reviewing this literature, two perspectives will be focused on: (1) the relationship between psychosocial factors and progressive CAD; and (2) the evidence concerning underlying pathophysiological mechanisms.
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PMID:Acute and chronic psychological risk factors for coronary syndromes: moderating effects of coronary artery disease severity. 927 6

The objectives of this study were to compare and contrast indicators of ischemia in a well-characterized group of 196 patients with coronary artery disease, documented angiographically or by verified history of myocardial infarction, and a positive exercise test result. Myocardial ischemia occurs frequently in response to everyday stressors in patients with coronary artery disease. The Psychophysiological Interventions in Myocardial Ischemia study provides a unique opportunity to study neuroendocrine and psychological manifestations of ischemia. Patients with exercise-induced ischemia underwent exercise radionuclide ventriculography and electrocardiographic monitoring and 2 laboratory mental stressors (Speech and Stroop) after being withdrawn from cardiac medications. In addition, 48-hour ambulatory electrocardiograms were recorded during routine daily activities. Patients with a history of angina within the past 3 months reported angina during the bicycle or treadmill test with a much higher frequency than patients without such an anginal history (77% vs 26%). Ejection fraction (EF) responses to the Stroop test were abnormal in 48% of patients with an abnormal EF response to the Speech task, versus 17% in patients with a normal EF response (p <0.01). Seventy-six percent of patients had an abnormal EF response to bicycle exercise. Three indicators of ischemia (ST-segment depression, wall motion abnormality, and EF response) were compared during the same laboratory stressor and across different types of stress tests. Presence of the 3 indicators was only moderately associated during exercise, and only weak or nonsignificant associations occurred among the presence of the 3 ischemic markers during mental stress. Occurrence of the same ischemic markers was moderately associated between the 2 mental stress tasks, but few associations were found between the occurrence of the same ischemic marker during exercise and mental stress. There is a marked heterogeneity of responses to psychological and exercise stress testing using electrocardiography, ambulatory electrocardiography, or radionuclide criteria for ischemia during stress. The heterogeneity may be related to differences in the magnitude or types of physiologic responses provoked and to differences in the sensitivity and specificity of the different tests used to identify ischemia.
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PMID:Heterogeneity among cardiac ischemic and anginal responses to exercise, mental stress, and daily life. 967 Sep 99

We previously found that docosahexaenoic acid (DHA) intake prevents aggression enhancement at times of mental stress. In the present study we investigated changes in aggression under nonstressful conditions. Forty-six students of two universities took either DHA-rich fish oil capsules containing 1.5 g DHA (DHA group: 13 males and 9 females) or control oil capsules containing 97% soybean oil plus 3% of another fish oil (control group: 11 males and 13 females) for 3 mon in a double-blind fashion. At the start and end of the study they took an aggression-estimating test (P-F Study) without a stressor component. DHA (5.9 to 8.5%, P < 0.001) and eicosapentaenoic acid (0.7 to 1.5%, P < 0.001) increased in red blood cell phospholipids in the DHA group, while linoleic acid increased slightly (8.3 to 9.1%, P < 0.002) in the soybean oil control group. In the control group, measured aggression levels decreased from 34.8 to 29.4% (P < 0.005), whereas they remained stable in the DHA group (33.5 to 33.8%). The intergroup differences (-5.4 vs. 0.3%) were marginally significant (P < or = 0.05). Aggression levels were stable in the DHA group whether there was stressor (as previously shown) or not. This effect of DHA appears to be interesting, considering the reported association between a low intake of n-3 fatty acids and depression.
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PMID:Docosahexaenoic acid does not affect aggression of normal volunteers under nonstressful conditions. A randomized, placebo-controlled, double-blind study. 968 68

We found an association between low levels of 17-Ketosteroid Sulfates (17-KS-S) in subjects under psychosocial stress. Stress associated with overwork and lack of sleep resulted in decreased levels of 17-KS-S and an increase in 17-Hydroxycorticosteroids (17-OHCS) levels. Alleviation of stress condition was associated with a restoration of the ratio of 17-KS-S/17-OHCS resulting from a slow increase in 17-KS-S and a decrease in 17-OHCS. In subjects with severe mental stress the ratio of 17-KS-S/17-OHCS showed markedly reduced values with a transient marked increase in 17-OHCS. There was a decrease in the levels of 17-KS-S in depressives, which was more pronounced during severe depression. There was no significant difference in 17-OHCS levels. In a cohort experiencing bereavement, there was a reduction in the levels of 17-KS-S, which remained low for about 50 days. With time, the level of 17-KS-S returned to the basal level established prior to spousal death. In this case, there was no significant change in the levels of 17-OHCS. Persistent severe stress over several months in a physician, led to a Herpes Zoster outbreak and Arrhythmia, resulting in hospital admission. The levels of 17-KS-S gradually decreased over this time reaching 1/3 of the normal baseline value, while 17-OHCS levels remained within normal ranges. These results suggest that measurement of 17-KS-S is indispensable for current research on psychosocial stress.
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PMID:[17-KS sulfate as a biomarker in psychosocial stress]. 969 61

U.S. military forces are increasingly involved in a variety of multinational peacekeeping and humanitarian assistance missions. How well combat-trained units and soldiers adapt to these new roles will determine U.S. success in such operations, as well as the future health and readiness of the force. In preparing soldiers for such missions, it is critical that leaders and health care providers have a clear understanding of the nature of the stressors they are likely to encounter. This report summarizes findings from a longitudinal, descriptive case study of a U.S. Army medical unit performing a peacekeeping mission in the former Yugoslavia. The goal of the investigation was to identify key sources of stress and to delineate the effect of these stressors on the health, morale, and mental readiness of soldiers. Findings suggest a range of psychological stressors that varies somewhat across operational phases of a peacekeeping mission. Furthermore, the degree of stress experienced in various areas correlates significantly with depression, psychiatric symptoms, and low reported morale. The range of stressors is reduced and summarized in a conceptually derived model of five underlying dimensions of psychological stress salient to soldier adaptation in peacekeeping operations: isolation, ambiguity, powerlessness, boredom, and danger/threat. This model provides a useful heuristic for organizing thinking about stress in peacekeeping operations and leads to several recommendations for "countermeasures" that organizational leaders can take to maintain soldier psychological readiness during peacekeeping operations.
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PMID:Dimensions of psychological stress in peacekeeping operations. 975 82

Cardiac disease and depression affect a significant number of individuals every year, and developing effective treatment for depression in cardiac disease could have a substantial impact on public health. Several studies have shown that depression increases cardiac morbidity and mortality and total costs of care and is associated with a poor psychosocial outcome. Psychopharmacological treatment trials have shown that tricyclic antidepressants have antiarrhythmic effects, prolong cardiac conduction, and cause orthostatic hypotension, but do not impair left ventricular function, even in patients with underlying left ventricular impairment. Tricyclic antidepressants are efficacious in treating depression but have a higher rate of cardiovascular complications than other antidepressants, with orthostatic hypotension being the most common complication. Recent small clinical trials with bupropion and selective serotonin reuptake inhibitors (SSRIs) indicate that they are efficacious and have a more benign cardiovascular side-effect profile, although large studies need to be performed to establish their safety and efficacy. Most psychosocial studies have focused on cardiac patients in general and not specifically on depressed cardiac patients. Studies of cardiac patients have shown that stress, social isolation, and lower income and educational levels are associated with a poorer cardiac outcome. A large meta-analysis of randomized, controlled trials of psychosocial interventions in nondepressed cardiac patients found that a diverse array of psychosocial interventions decreased morbidity and mortality. However, one recent psychosocial treatment trial of post-myocardial infarction (MI) patients has shown increased mortality in women in the intervention arm of the trial. There have been several recent studies showing that mental stress induces cardiac ischemia, that mental stress-induced cardiac ischemia is associated with a higher rate of adverse cardiac events than exercise-induced ischemia, and that with stress management training, patients show significant reductions in ischemic responses to mental stress. Currently, there are two large studies underway examining pharmacological and psychotherapeutic treatment of post-MI depressed and/or socially isolated patients. These large clinical trials are needed to determine if effective treatment of depression can modify the increased risk for mortality and morbidity associated with depression in cardiac disease. Hopefully, the development of effective treatment for depressed cardiac patients will decrease their morbidity and mortality and enhance their overall quality and enjoyment of life.
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PMID:Major Depression and Heart Disease: Treatment Trials. 1008 96

In a prospective controlled trial on 46 patients undergoing lumbar discectomy, three classes of variables (medical data including MRI-identified morphological abnormalities, general psychological factors and psychosocial aspects of work) were analyzed with regard to their predictive value for the outcome of lumbar disc surgery at 2 year follow-up. Multiple regression analyses were used to identify the best predictor variables of four different outcome measures (i.e. pain relief, reduction of disability in daily activities, return to work and surgical outcome). MRI-identified nerve root compromise and social support from the spouse were independent predictors of pain relief 2 years after surgery (R2 = 0.40, P < 0.01). Return to work 2 years after surgery was best predicted by depression and occupational mental stress (R2 = 0.36, P < 0.001). MRI-identified extent of herniation and depression were significant predictors of a good surgical outcome after lumbar discectomy (R2 = 0.61, P < 0.001). This study has demonstrated that the outcome of discectomy is critically dependent on which outcome variables are selected and that different sorts of predictor variables have a distinct influence on the various outcome variables. Obvious morphological alterations (i.e. disc extrusions, nerve root compromise) proved to be significant predictors of postoperative pain relief and improvement of disability in daily activities justifying a surgical treatment approach in these cases. The most important finding of this study was that return to work was not influenced by any clinical findings or MR-identified morphological alterations, but solely by psychological factors (i.e. depression) and psychological aspects of work (i.e. occupational mental stress).
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PMID:The impact of clinical, morphological, psychosocial and work-related factors on the outcome of lumbar discectomy. 1020 36

Psychological stress is believed to be implicated in the etiology of affective disorders such as anxiety and depression. To date, a wide range of behavioral responses including analgesia and motor suppression induced by various physiological stressors such as footshock, forced swimming and immobilization have been investigated in animals. However, there is little information concerning behavioral changes in psychological stress. This article describes the experimental procedures and the characteristics of motor suppression in psychological stress, defined as conditioned fear stress (CFS). Mice exhibit a marked suppression of motility when they are re-placed in the same environment in which they had previously received an electric footshock. This motor suppression is regarded as a conditioned emotional response to the environment associated with previous footshock. The motor suppression in CFS is attenuated by sigma receptor agonists such as (+)-N-allylnormetazocine and dextromethorphan, whereas typical anxiolytics (diazepam and chlordiazepoxide) and antidepressants (imipramine and fluoxetine) have no effect. These findings suggest that the CFS model may be useful for investigating the pathogenesis of affective disorders, particularly those considered to be treatment resistant, and for developing their novel therapeutic drugs.
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PMID:[The psychological stress model using motor suppression]. 1020 85

Similar to the setting of other chronic, debilitating diseases, considerable psychoeducational support of the patient's family and other caregivers represents an often-overlooked component of appropriately thorough care. Nearly three of four persons caring for an individual with PD report psychological stress and anxiety, which are exacerbated by concerns about progression of the disease. Counseling for PD caregivers can be dispensed particularly effectively through individual psychological counseling as well as PD support and community self-help groups that assist caregivers in sharing concerns and promote a sense they are understood by others. Through such measures, which may be delivered effectively by nurse practitioners, PD caregivers can develop effective coping strategies for disease related stressors. Empirical results show the most common stressors are: anxiety, concern about the future, impatience or intolerance, loss of autonomy, sleep disturbances, diminished time and opportunity for recreation and social contact, and anger. These sequelae often ensue when the PD patient evidences depression, advanced dementia, or psychosis, each of which can severely constrain communication. Caregivers often must also contend with two other adverse psychological phenomena: cognitive dissonance surrounding placement of the patient in a nursing home and learned helplessness, which may predispose to depressive states. Other often unmet needs of the "hidden victims" of PD include compromised immune function, social stigmata, and financial difficulties. Respite care may be useful in reducing the stress associated with these and other problems frequently affecting caregivers.
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PMID:Depression, psychosis, and dementia: impact on the family. 1022 6

Longitudinal studies are difficult to do well. Too short a study and the results may be meaningless. Too long a study and the subjects cannot be found, money runs out, and research methods become seriously out of date. Despite these problems, there have been some longitudinal studies done that have greatly advanced our understanding of the nature and the treatment of psychopathology in childhood. Without these studies, much less would be known about the clinical course of important disorders, the effects of treatments, and the various risk and protective factors. None of these studies has been perfect. Some longitudinal studies did not focus on quite the right questions, some produced contradictory results, and others produced results that were hard to interpret. What have we learned from the longitudinal studies reviewed in this Group for the Advancement of Psychiatry (GAP) report? Many of the things that we have learned have been surprising--even counterintuitive. Pre- and perinatal insults need not necessarily lead to serious consequences in later life. Premature infants, if raised in nondeprived settings, are not likely to be mentally retarded or learning disabled. Today, of course, premature infants who would not have been kept alive 15 years ago are surviving. Will this advancement led to an untoward outcome? We do not know. New longitudinal studies need to be done. Certain serious illnesses emerging later in childhood may be associated with a greater risk of psychopathology. This risk is true at least for those with asthma. Psychological factors, such as psychological stress, also may lead to exacerbation of asthmatic attacks. Whether other illnesses are associated with a greater risk of psychopathology simply has not been studied adequately. Infant temperamental characteristics can be classified and measured; however, they appear to predict little in terms of later personality development or psychopathology. Although temperamental characteristics measured in infancy correlate poorly with temperamental characteristics measured at age 4 or 5 years, they appear to be much more stable and correlate well with temperament at ages 8 and 12 years. Some of these temperamental characteristics, particularly aggressivity and negativity at age 5 years, are serious risk factors for behavioral psychopathology at age 8 or 12 years and, possibly, at later ages as well. Aggressive, negative 5-year-olds do not necessarily grow out of their problems. Their problems are important and should be dealt with when children are age 5 years. What does appear important is early language development. Delays in language development or developmental language disorders are risk factors for later psychopathology. Fifty percent of school-age children with language problems requiring speech and language therapy also have diagnosable psychopathology. Hyperactivity and short attention span are characteristics that tend to persist in later childhood--even adulthood. Alone, each of these characteristics may not be a risk factor for later psychopathology, but, when accompanied by oppositional behavior and conduct disorder, the outcome is detrimental to the child. Many studies have shown that children with these comorbid problems are at risk later for becoming delinquent and antisocial. Conduct disorder in childhood, which is much more common in males, is a risk factor for later delinquency, even if it is not associated with hyperactivity. Again, early intervention is important. The effects of comorbidity in this instance can be serious. Comorbidity in general, especially as children grow older, leads to adverse social, academic, and psychopathological outcomes. Depression does occur in children, in all of its adult manifestations. Mania, in contrast, is rarely seen in children younger than age 12 years. Depression in school-age children can be severe or mild. In contrast to adolescents with depression, depressed children are most likely to have somatic compla
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PMID:In the long run...longitudinal studies of psychopathology in children. Committee on Child Psychology. Group for the Advancement of Psychiatry. Report no.143. 1023 Feb 87


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