Cora Weber

The Perceived Stress Questionnaire (PSQ) reconsidered: validation and reference values from different clinical and healthy adult samples.

Objective: The aim was to translate, revise, and standardize the Perceived Stress Questionnaire (PSQ) by Levenstein et al. (1993) in German. The instrument assesses subjectively experienced stress independent of a specific and objective occasion. Methods: Exploratory factor analyses and a revision of the scale content were carried out on a sample of 650 subjects (Psychosomatic Medicine patients, women after delivery, women after miscarriage, and students). Confirmatory analyses and examination of structural stability across subgroups were carried out on a second sample of 1,808 subjects (psychosomatic, tinnitus, inflammatory bowel disease patients, pregnant women, healthy adults) using linear structural equation modeling and multisample analyses. External validation included immunological measures in women who had suffered a miscarriage. Results: Four factors (worries, tension, joy, demands) emerged, with 5 items each, as compared with the 30 items of the original PSQ. The factor structure was confirmed on the second sample. Multisample analyses yielded a fair structural stability across groups. Reliability values were satisfactory. Findings suggest that three scales represent internal stress reactions, whereas the scale “demands” relates to perceived external stressors. Significant and meaningful differences between groups indicate differential validity. A higher degree of certain immunological imbalances after miscarriage (presumably linked to pregnancy loss) was found in those women who had a higher stress score. Sensitivity to change was demonstrated in two different treatment samples. Conclusion: We propose the revised PSQ as a valid and economic tool for stress research. The overall score permits comparison with results from earlier studies using the original instrument. PSQ = Perceived Stress Questionnaire; ICD = International Classification of Diseases; QoL = quality of life; IBD = inflammatory bowel disease; SEM = structural equation modeling; MSA = multisample analysis; TLI = Tucker-Lewis index; CFI = comparative fit index.

A Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD) — Rationale and design of a multicenter, randomized trial in depressed patients with CAD

OBJECTIVE Depressive symptoms are highly relevant for the quality of life, health behavior, and prognosis in patients with coronary artery disease (CAD). However, previous psychotherapy trials in depressed CAD patients produced small to moderate effects on depression, and null effects on cardiac events. In this multicentre psychotherapy trial, symptoms of depression are treated together with the Type D pattern (negative affectivity and social inhibition) in a stepwise approach. METHODS Men and women (N=569, age 18-75 years) with any manifestation of CAD and depression scores ≥ 8 on the Hospital Anxiety and Depression Scale (HADS), will be randomized (allocation ratio 1:1) into the intervention or control group. Patients with severe heart failure, acutely life-threatening conditions, chronic inflammatory disease, severe depressive episodes or other severe mental illness are excluded. Both groups receive usual medical care. Patients in the intervention group receive three initial sessions of supportive individual psychotherapy. After re-evaluation of depression (weeks 4-8), patients with persisting symptoms receive an additional 25 sessions of combined psychodynamic and cognitive-behavioral group therapy. The control group receives one psychosocial counseling session. Primary efficacy variable is the change of depressive symptoms (HADS) from baseline to 18 months. Secondary endpoints include cardiac events, remission of depressive disorder (SCID) and Type D pattern, health-related quality of life, cardiovascular risk profile, neuroendocrine and immunological activation, heart rate variability, and health care utilization, up to 24 months of follow-up (ISRCTN: 76240576; NCT00705965). Funded by the German Research Foundation.

Short-term effects of espresso coffee on heart rate variability and blood pressure in habitual and non-habitual coffee consumers – A randomized crossover study

Objective: Coffee is one of the most widely consumed beverages worldwide. Aim of this study was to investigate short-term effects of espresso coffee on heart rate variability (HRV), a marker of vagal activity, in healthy habitual and non-habitual coffee consumers. Methods: Seventy-seven healthy subjects (38 habitual and 39 non-habitual coffee consumers, 74% women, mean age 26.97 ± 6.88 years) took part in three laboratory sessions in a randomized order. In condition 1, subjects consumed espresso; in condition 2, subjects consumed decaffeinated espresso; and in condition 3, subjects consumed warm water. HRV and blood pressure were assessed at rest before and after ingestion of the respective beverage. Results: HRV was significantly increased after consumption of caffeinated espresso, decaffeinated espresso, or water, indicating increased vagal activity in the course of the experiments. In the habitual coffee consumers, the increase in vagally mediated HRV was significantly lower after consumption of decaffeinated espresso compared to caffeinated espresso. Increases of systolic blood pressure were only found in the non-habitual consumers. Conclusion: We found no evidence for specific short-term effects of caffeinated espresso on vagal activity in healthy subjects. Instead, consumption of decaffeinated espresso inhibited vagal activity in habitual consumers. This may be explained by an attempt of the organism to establish a sympathovagal equilibrium comparable to that after caffeine consumption. In the absence of caffeine-induced sympathetic activation, this may have been achieved by relative vagal withdrawal.

Somatic comorbidity in anorexia nervosa: First results of a 21-year follow-up study on female inpatients.

BackgroundAnorexia nervosa is a severe psychosomatic disease with somatic complications in the long-term course and a high mortality rate. Somatic comorbidities independent of anorexia nervosa have rarely been studied, but pose a challenge to clinical practitioners. We investigated somatic comorbidities in an inpatient cohort and compared somatically ill anorexic patients and patients without a somatic comorbidity. In order to evaluate the impact of somatic comorbidity for the long-term course of anorexia nervosa, we monitored survival in a long-term follow-up.MethodOne hundred and sixty-nine female inpatients with anorexia nervosa were treated at the Charité University Medical Centre, Campus Benjamin Franklin, Berlin, between 1979 and 2011. We conducted retrospective analyses using patients medical and psychological records. Information on survival and mortality were required through the local registration office and was available for one hundred patients. The mean follow-up interval for this subgroup was m = 20.9 years (sd = 4.7, min = 13.3, max = 31.6, range = 18.3). We conducted survival analysis using cox regression and included somatic comorbidity in a multivariate model.ResultsN = 41 patients (24.3%) showed a somatic comorbidity, n = 13 patients (7.7%) showed somatic comorbidities related to anorexia nervosa and n = 26 patients (15.4%) showed somatic comorbidities independent of anorexia nervosa, n = 2 patients showed somatic complications related to other psychiatric disorders. Patients with a somatic comorbidity were significantly older (m = 29.5, sd = 10.3 vs m = 25.0, sd = 8.7; p = .006), showed a later anorexia nervosa onset (m = 24.8, sd = 9.9 vs. m = 18.6, sd = 5.1; p < .000) and a longer duration of treatment in our clinic (m = 66.6, sd = 50.3 vs. m = 50.0, sd = 47; p = .05) than inpatients without somatic comorbidity. Out of 100 patients, 9 patients (9%) had died, on average at age of m = 37 years (sd = 9.5). Mortality was more common among inpatients with somatic comorbidity (n = 6, 66.7%) than among inpatients without a somatic disease (n = 3, 33.3%; p = .03). Somatic comorbidity was a significant coefficient in a multivariate survival model (B = 2.32, p = .04).ConclusionSomatic comorbidity seems to be an important factor for anorexia nervosa outcome and should be included in multivariate analyses on the long-term course of anorexia nervosa as an independent variable. Further investigations are needed in order to understand in which way anorexia nervosa and a somatic disease can interact.

Depressive symptoms and heart rate variability in younger women after an acute coronary event

Objectives We investigated associations between depressive symptoms and reduced heart rate variability (HRV) in women aged 30–65 years after an acute coronary event. Background Younger women have an increased mortality after myocardial infarction compared with men of similar age. Depression was hypothesized to contribute to the poor prognosis, possibly mediated by increased susceptibility to arrhythmias. Methods The Stockholm Female Coronary Risk study comprised of 292 women aged 30–65 years who were consecutively admitted for myocardial infarction or unstable angina pectoris during a 3-year period. Depressive symptoms were assessed by means of a 9-item questionnaire. Women with no or only one depressive symptom were classified as low-depression individuals, those with two or more depressive symptoms as high-depression individuals. HRV data were calculated from 24-h ambulatory electrocardiographic recordings 3–6 months after the initial event. Results Reliable HRV data were obtained from 266 patients. Seventy women were low-depression individuals, and 196 women were high-depression individuals. In univariate analyses, the index of standard deviations of R–R intervals, very low-frequency power, low-frequency power and high-frequency power of HRV were lower in the high-depression individuals. After controlling for potential confounders (diabetes, hypertension, systolic blood pressure, body mass index and β-blocker medication), a significant difference between low and high-depression individuals was maintained for all indices except for high-frequency power. Conclusion The presence of two or more depressive symptoms was associated with reduced HRV in a high-risk group of younger women after an acute coronary event.

Low Anxiety Males Display Higher Degree of Salt Sensitivity, Increased Autonomic Reactivity, and Higher Defensiveness

BACKGROUND Psychological parameters such as heightened anxiety and defensiveness are associated with increased cardiovascular morbidity and mortality. Autonomic dysfunction is considered to be an important pathogenetic pathway. Little research has been done regarding potential links between emotional factors and salt sensitivity. The aim of the present study was to determine whether subjects with different levels of trait anxiety differ in the degree of salt sensitivity and autonomic reactivity to a mental stress task. METHODS Seventy-two young normotensive men were phenotyped for salt sensitivity and underwent a standardized mental stress test and psychological assessment. According to their trait anxiety test scores, they were classified as low-, moderate- or high-anxiety subjects. A measure of defensiveness was used to assess self-deceptive tendencies. RESULTS Low-anxiety subjects displayed a higher degree of salt sensitivity compared to moderate- and high-anxiety subjects (P < 0.001), increased heart rate (HR) and electrodermal responses to the stressor compared to moderate-anxiety subjects (P < 0.01 and P < 0.05 respectively) and elevated levels of self-deception compared to moderate- and high-anxiety subjects (P < 0.001). CONCLUSION Low-anxiety subjects were characterized by a higher degree of salt sensitivity and increased autonomic responsiveness. Defensiveness was also shown to be elevated in this group and might be the underlying psychological trait explaining these findings. Future research on the associations of anxiety and cardiovascular risk should implement measurement of defensiveness in order to identify these subjects at potential risk for cardiovascular disease despite self-reports of low anxiety.

Acute psychological stress increases peripheral blood CD3+CD56+ natural killer T cells in healthy men: possible implications for the development and treatment of allergic and autoimmune disorders.

Abstract Acute psychological stress has primarily been investigated regarding its effects on conventional lymphocytes such as natural killer (NK) cells and CD4+ and CD8+ T cells. However, it might be important to focus on more “specialized” lymphocyte subsets, playing a role, for instance, in allergic conditions and autoimmunity, to identify links between stress, the immune system and somatic diseases. Using flow cytometry we determined frequencies of circulating T helper (Th)1-type (CD226+) and Th2-type (CRTH2+) T cells, γδ T cells, conventional CD56+ natural killer T (NKT) cells and invariant NKT cells (iNKT) in healthy young males (N = 31; median age 26 years) undergoing a laboratory computer-based stressor lasting 12 min. We found that acute psychological stress induced a prolonged increase in CD4+ and CD8+ T cells expressing a Th2 phenotype. We also detected an acute increase in CD4− and CD8− double negative γδ T cells. Finally, we found that the well-known increase in NK cells under stressful conditions was paralleled by a significant increase in numbers of conventional CD56+ NKT cells. In contrast, numbers of iNKT was not altered by stress. This study adds further evidence to a psychoneuroimmunological model proposing that under stressful conditions certain lymphocyte subsets, including iNKT and less mature T cells, are retained in lymphoid tissues while antigen-experienced effector-type T cells with a Th2 phenotype, γδ T cells and conventional CD56+ NKT cells are mobilized into the peripheral blood. We suggest that in the case of frequent stress exposure, this might result in the promotion of, for example, allergic conditions.

Anxiety as Predictor of the Cortisol Awakening Response in Patients with Coronary Heart Disease

BackgroundAnxiety is associated with worse outcomes in patients with coronary heart disease (CHD). A dysregulation of the HPA axis is a potential mechanism linking psychological factors and coronary disease. No study has yet investigated the relationship between anxiety and cortisol among patients with established CHD.PurposeThe aim of this study was to assess the association between anxiety and the cortisol awakening response in patients with CHD.MethodFour salivary cortisol samples were used to assess two measures of the cortisol awakening response (CAR) in 47 patients with established CHD. Anxiety was measured using the Hospital Anxiety and Depression Scale (HADS).ResultsHigher anxiety values were associated with a higher total output of cortisol in the first hour after awakening (AUCg, area under the curve with respect to ground) (p = 0.04) and a nonsignificant trend towards a more pronounced increase (AUCi, area under the curve with respect to increase) (p = 0.08). In patients who had a history of myocardial infarction (MI), the cortisol output was lower compared to patients who had no previous MI (p = 0.02). In linear regression analyses, anxiety emerged as significant predictor of AUCg and AUCi after controlling for MI, ejection fraction (LVEF, left ventricular ejection fraction), and depression.ConclusionsOur results provide further indications for an association between anxiety and a dysregulation of the HPA axis. History of MI emerged as second predictor of cortisol output in the morning.

Autonomic effects of suggestive placebo interventions to increase or decrease blood pressure: A randomized controlled trial in healthy subjects

OBJECTIVE Placebo effects on pain and other subjective parameters are well-established, but the evidence for placebo effects on autonomic functions is scarce. Our randomized-controlled trial aimed to investigate autonomic responses after a suggestive placebo intervention intended to increase or decrease blood pressure (BP). METHODS 92 healthy subjects inhaled a placebo spray with the prior suggestion that it contained an effective drug to either increase or decrease BP, or the information that a placebo was administered (controls). BP, heart rate, stroke volume, peripheral resistance, heart rate variability and skin conductance level were monitored 30min before and after placebo administration. The expected and the subjectively perceived drug effect were measured by means of visual analog scales. RESULTS We found no statistically significant differences between the groups with respect to BP, heart rate, stroke volume, total peripheral resistance and heart rate variability responses to the verbal suggestions. Skin conductance response was more pronounced in the BP decrease group compared with controls (p=0.04), but this finding might be due to chance, given the multiple tests. Within the total study sample, BP, total peripheral resistance, low frequency power of heart rate variability and skin conductance were significantly higher after the placebo spray independent of the associated suggestions. Subjects in the BP increase and BP decrease condition had higher ratings of the expected and the subjectively perceived drug effect compared with controls (all p<0.05). CONCLUSION We found no evidence that specific verbal suggestions during placebo interventions affect BP in healthy subjects.

Prevalence of mental disorders among depressed coronary patients with and without Type D personality. Results of the multi-center SPIRR-CAD trial

OBJECTIVE Type D personality, as with formal mental disorders, is linked to increased mortality in coronary heart disease (CHD). Our aim was to determine the prevalence of mental disorders among depressed CHD patients with and without Type D personality. METHODS Depressive symptoms (HADS, HAM-D), Type D personality (DS-14) and mental disorders based on DSM-IV (SCID I and II) were assessed. Results were calculated by Kruskal-Wallis tests, Fishers exact tests and logistic regression analyses. RESULTS 570 CHD patients were included (age 59.2±9.5years; male 78.9%, HADS-D depression 10.4±2.5; HAM-D 11.3±6.6; Type D 60.1%). 84.8% of patients with Type D personality and 79.3% of non-Type D patients suffered from at least one mental disorder (p=0.092), while 41.8% of Type D positives and 27.8% of Type D negatives had at least two mental disorders (p=0.001). Patients with Type D personality significantly more often had social phobia [odds ratio (95% confidence interval): 3.79 (1.1 to 13.12); p=0.035], dysthymia [1.78 (1.12 to 2.84); p=0.015], compulsive [2.25 (1.04 to 4.86); p=0.038] or avoidant [8.95 (2.08 to 38.49); p=0.003] personality disorder. CONCLUSIONS Type D personality among depressed CHD patients is associated with more complex and enduring mental disorders. This implies higher treatment demands. TRIAL REGISTRATION ISRCTN 76240576; NCT00705965.