Jennifer E. Graham

Pregnancy-Specific Stress, Prenatal Health Behaviors, and Birth Outcomes

OBJECTIVE Stress in pregnancy predicts earlier birth and lower birth weight. The authors investigated whether pregnancy-specific stress contributes uniquely to birth outcomes compared with general stress, and whether prenatal health behaviors explain this association. DESIGN Three structured prenatal interviews (N = 279) assessing state anxiety, perceived stress, life events, pregnancy-specific stress, and health behaviors. MAIN OUTCOME MEASURES Gestational age at delivery, birth weight, preterm delivery (<37 weeks), and low birth weight (<2,500 g). RESULTS A latent pregnancy-specific stress factor predicted birth outcomes better than latent factors representing state anxiety, perceived stress, or life event stress, and than a latent factor constructed from all stress measures. Controlling for obstetric risk, pregnancy-specific stress was associated with smoking, caffeine consumption, and unhealthy eating, and inversely associated with healthy eating, vitamin use, exercise, and gestational age at delivery. Cigarette smoking predicted lower birth weight. Clinically-defined birth outcomes were predicted by cigarette smoking and pregnancy-specific stress. CONCLUSION Pregnancy-specific stress contributed directly to preterm delivery and indirectly to low birth weight through its association with smoking. Pregnancy-specific stress may be a more powerful contributor to birth outcomes than general stress.

Stress, age, and immune function: toward a lifespan approach.

Both aging processes and psychological stress affect the immune system: Each can dysregulate immune function with a potentially substantial impact on physical health. Worse, the effects of stress and age are interactive. Psychological stress can both mimic and exacerbate the effects of aging, with older adults often showing greater immunological impairment to stress than younger adults. In addition, stressful experiences very early in life can alter the responsiveness of the nervous system and immune system. We review the unique impact of aging and stress on immune function, followed by evidence of interactions between age and stress. Further, we suggest that prenatal or early life stress may increase the likelihood of maladaptive immune responses to stress in late life. An understanding of the interactive effects of stress and age is critical to efforts to determine underlying mechanisms, clarify the directionality of effects, and develop effective interventions in early and late life.

Stress and wound healing.

Over the past decade it has become clear that stress can significantly slow wound healing: stressors ranging in magnitude and duration impair healing in humans and animals. For example, in humans, the chronic stress of caregiving as well as the relatively brief stress of academic examinations impedes healing. Similarly, restraint stress slows healing in mice. The interactive effects of glucocorticoids (e.g. cortisol and corticosterone) and proinflammatory cytokines [e.g. interleukin-1β (IL-1β), IL-1α, IL-6, IL-8, and tumor necrosis factor-α] are primary physiological mechanisms underlying the stress and healing connection. The effects of stress on healing have important implications in the context of surgery and naturally occurring wounds, particularly among at-risk and chronically ill populations. In research with clinical populations, greater attention to measurement of health behaviors is needed to better separate behavioral versus direct physiological effects of stress on healing. Recent evidence suggests that interventions designed to reduce stress and its concomitants (e.g., exercise, social support) can prevent stress-induced impairments in healing. Moreover, specific physiological mechanisms are associated with certain types of interventions. In future research, an increased focus on mechanisms will help to more clearly elucidate pathways linking stress and healing processes.

Rumination and Anxiety Mediate the Effect of Loneliness on Depressed Mood and Sleep Quality in College Students

OBJECTIVE We examined the mechanisms that underlie the observed relationships between loneliness and depressed mood and poor sleep quality in college students. This study was the first to investigate whether rumination and trait anxiety are psychological mechanisms that mediate this relationship. METHODS In Study 1 (n = 1,244), using factor analysis with cross-sectional data, we established that loneliness and rumination are distinct constructs. We then collected survey data in two cross-sectional samples (ns = 300 and 218) and one prospective (n = 334) sample to test whether rumination and anxiety were mediators of the relationship between loneliness and depressed mood and poor sleep quality. Structural equation modeling was used to test the proposed relationships. Participants completed self-report measures of loneliness, rumination, trait anxiety, depressed mood, and sleep quality. In addition, measures of hostility, neuroticism, negative affect, and tobacco use were also assessed and tested as mediators, while social support was assessed and tested as a moderator. RESULTS Consistent across the three studies, we found that rumination and trait anxiety fully mediated the associations between loneliness and depressed mood as well as poor sleep quality; these relationships held after testing all other factors. CONCLUSION This study helps explain how loneliness dynamics relate to poor health and suggests specific points of departure for the development of interventions.

Anger After Childbirth: An Overlooked Reaction to Postpartum Stressors

Other than postpartum depression, little is known about womens emotional responses to childbirth and subsequent stressors. Anger was explored on the basis of theory and evidence that it is a likely emotional response in this context. During their third trimester of pregnancy and approximately six weeks after delivery, 163 participants completed the Beck Depression Inventory and the anger subset of the Affect Balance Scale. A number of childbirth-relevant variables were examined as predictors of postpartum emotional response, controlling for prepartum levels and for the association between anger and depressed mood. As expected, a substantial group of women reported high levels of anger irrespective of depressed mood. Although the majority of variables predicted depressed mood, childcare stress, age, and religious self-identification were independently predictive of postpartum anger (all p values > .05). Implications for research and clinical intervention are discussed.

CHAPTER 36 – Close Relationships and Immunity

Our lives tend to be centered around close relationships with significant others, family, and friends. It is increasingly apparent that the existence and quality of such relationships and the support they provide have a strong impact not only on our psychological wellbeing (Glenn and Weaver, 1981) but also our physical health. A number of prospective studies have reported remarkably similar patterns of increasing risk for allcause mortality with a decreasing number of social ties, even after controlling for sociodemographic characteristics and health (e.g.. Berkman and Syme, 1979; House et al., 1982; Kaplan et al., 1988). The existence and quality of key close relationships, such as marriage, are also predictive of morbidity and mortality from a range of chronic and acute conditions (Johnson et al., 2000; Kiecolt-Glaser and Newton, 2001; Verbrugge, 1979). One key pathway underlying the association between social relationships and health outcomes appears to be changes in immune function (Kiecolt-Glaser, 1999), an area of research which holds great promise for further clarifying the role of close relationships and health and which will be the focus of this chapter. The current review is organized around three aspects of close relationships: social integration, social support, and negative aspects of social ties. These topics map relatively well onto three models by which social relationships can affect health in relation to psychological stress: the main effects model, the stressbuffering model, and the social strain model (Cohen, 2004; Orth-Gomer, 2000; Rook, 1990). In this literature, psychological stress is most often determined by selfreported perceived stress, as well as by objective indicators of life stress and reports of life events. We first present work on social integration, including in this category broad measures of network size as well as studies focused on marital status, a key social tie. In line with the main effects model (Lazarus and Folkman, 1984), measures of social integration are typically associated with health benefits independent of stress (Cohen, 1988; Cohen, 2004). Next, we review literature focused on social support. In contrast to quantitative measures of network size, social support is typically defined as the perception that assistance would be available if and when it is needed, as well as the receipt of assistance during such times. Such assistance can include, but is not limited to, the provision of material aid, assistance with tasks, information, or emotional support. In line with the stress-buffering model, the benefits of perceived social support are frequently seen only (or primarily) when a person encounters stress of a sufficient magnitude (Cohen, 1988). Relevant work on the related constructs of loneliness and intimacy is also covered briefly in this section. Finally, we review work that best fits with the social strain model, which holds that relationships can sometimes serve as a source of stress

Explaining gender differences in the white coat effect.

ObjectivesTo discern whether gender was a unique predictor of the white coat effect (WCE) in a population of normotensives and patients diagnosed with hypertension. MethodsParticipants (n=252) underwent a doctors office visit to have their blood pressure measured. Multiple blood pressure readings were taken by both a research assistant and by the attending physician. In addition, measures of anxiety variables were collected during the visit. Participants then underwent a 36-h ambulatory blood pressure monitoring. ResultsGender was a significant predictor of the systolic WCE, but, as expected, the effect size was small and was no longer significant when age and BMI were included in the regression model. State anxiety emerged as a significant independent predictor of systolic WCE; however, when household income was included in the model it became the only significant independent predictor (&bgr;=0.203, P<0.05), in addition to gender, age, and BMI. ConclusionThis study suggests that the association between gender and the systolic WCE is small, and likely accounted for by other variables including age, BMI, state anxiety, and household income. Thus, gender may be of limited use in helping identify patients who may be more likely to have WCE or white coat hypertension. Gender differences in this area should be interpreted with great caution.

Acute pain speeds skin barrier recovery in healthy men and women

OBJECTIVE Psychological stress is known to impair skin barrier recovery, but little is known about the impact of pain on skin healing processes. Our primary goals were to examine the degree to which acute pain affects recovery from skin barrier disruption, and the potential mediating impact of cortisol and catecholamines. METHODS Healthy non-smokers aged 18-43 (N = 53, 65% women) underwent a 3-minute cold pressor pain stimulus to their foot. Tape-stripping of forearm skin occurred at two separate locations: before (site 1) and after (site 2) the pain stimulus. Transepidural water loss (TEWL) was assessed at baseline (pre-stripping), immediately post-stripping, and at 75 min to determine skin barrier recovery. Cortisol and catecholamine responses were obtained from multiple saliva and plasma samples, respectively. RESULTS Contrary to expectations, greater pain was associated with faster skin barrier recovery, even after controlling for demographics, mood, anxiety, and other factors. Those who reported higher pain showed faster recovery at site 2 compared to a) individuals who experienced lower pain; and b) their own recovery at site 1. Greater increase in norepinephrine (but not in cortisol) was also associated with faster recovery at site 2, and mediated the impact of pain on recovery. DISCUSSION Results bolster evidence that acute pain can affect immune-related processes. It is possible that acute pain may speed recovery from dermal abrasions, although pain is likely to impair recovery from more severe wounds. As pain is an important potential target for clinical intervention, further investigation of pain, stress, and healing processes is warranted.

The Role of Ineffective Emotion Regulation in Problem Drinking Varies by Emotional Disposition, Delinquency, and Gender of South Korean Adolescents

This study examined the role of emotion regulation (ER) strategies and emotional disposition in problem drinking of adolescent offenders (n = 303) and non-offending peers (n = 287) from South Korea. The participants completed a questionnaire assessing problem drinking, positive and negative emotion, emotional intensity, and use of problem solving, support seeking, and avoidant ER strategies. Problem drinking was positively associated with negative emotion, emotional intensity, and support-seeking ER in both groups, and avoidant ER among offenders only. Support-seeking ER accounted for the association between positive emotion and drinking in both groups, and avoidant ER further accounted for the association between positive emotion and drinking among offenders. Only among female offenders was the association between emotional intensity and drinking explained by support-seeking ER. The results imply that intervention to improve ER effectiveness, taking into account emotional disposition, delinquency differences, and gender, may help lessen problem drinking among adolescents.

Response to Letter to the Editor regarding ''Olfactory influences on mood and autonomic, endocrine, and immune function''

Dear Editor, We appreciated your request to respond to the critique about our recent olfactory study (Kiecolt-Glaser JK, Graham JE, Malarkey WB, Porter K, Lemeshow S, Glaser R. Olfactory influences on mood and autonomic, endocrine, and immune function. Psychoneuroendocrinology. Apr 2008;33(3):328–339) from Kamyar M. Hedayat, MD, FAAP (Attending, Center for Complimentary Medicine, Attending, Division of Critical Care, Department of Pediatrics, Advocate Lutheran Children’s Hospital, Chicago, IL, President and Chief Medical Officer, Aroma MD, LLC) and Michael Tsifansky, MD (Attending and Director of Research, Division of Critical Care, Department of Pediatrics, Advocate Lutheran Children’s Hospital, Chicago, IL) We can understand how the critique’s first author, the president of a medical aromatherapy company, would certainly have preferred seeing more positive findings from a study such as ours. The critique suggested that we had not cited a number of clinical trials that supported the efficacy of essential oils in humans by inhalation or enteral administration. Unfortunately, empirical reports cannot exhaustively review literature and remain within the journal’s space constraints. Enteral use was well beyond the scope of our report, as was an exhaustive review of odors we had not used, leaving only one relevant positive paper in the list of references they provided, the report by Atsumi and Tonsaki. We were also faulted for not including our gas chromatography or mass spectrometry (GC/MS) data. We would have been happy to provide the data had the editor or reviewers requested it, but our article already included 7 figures. In fact, the careful characterization of essential oils by such means is the clear exception, rather than the rule in this literature (and, indeed, notably absent in the reports cited by Hedayat and Tsifansky). Hedayat and Tsifansky suggested that our choice of essential oils was based on a single book by two aromatherapists with no formal medical training; however, as we had noted in the final paragraph of our paper, we chose lemon and lavender precisely because they are widely-used purported stimulant and relaxant odors, and health benefits have been repeatedly ascribed to them, particularly lavender. They note that lavender’s record for pain control is even worse than we described, and they cite additional studies that provide further negative data related to lavender’s effects on pain and physiological changes (in accord with our data); we stand by our assertion that lavender is touted as an analgesic in aromatherapy publications. We appreciate the fact that these authors identified an error in our Methods section. Lemon (Citron limon) essential oil was indeed obtained by mechanical compression, not steam distillation. Arguing that exposing subjects to essential oils over a period of hours leads to receptor desensitization, Hedayat and Tsifansky said that positive clinical findings are found with no more than 20 minutes of exposure. This is an interesting point, but the physiological changes following initial odor administration in our protocol were nonsignificant, just as they were throughout the later portions of the sessions. These authors further suggest that the time period of exposure could have led simultaneously to irritation, but this is not consistent with the pattern of positive mood increases we reported with lemon oil, nor with the similar pattern of mood changes reported between water and lavender oil. Finally, as we noted in our paper, the same odor is used over a period of several hours in most clinical applications of aromatherapy, and thus our paradigm provided relevant data on results that might be expected from typical aromatherapy practices. In sum, although we appreciate the comments by Hedayat and Tsifansky, we must disagree with their conclusions. Sincerely, Janice K. Kiecolt-Glaser, PhD, Jennifer E. Graham, PhD, William B. Malarkey, MD, Kyle Porter, M.A.S, Stanley Lemeshow, PhD, and Ronald Glaser, PhD