Kavita Vedhara

Psychological well‐being in patients on ‘adequate’ doses of l‐thyroxine: results of a large, controlled community‐based questionnaire study

objective Over 1% of the UK population is receiving thyroid hormone replacement with l‐thyroxine (T4). However, many patients complain of persistent lethargy and related symptoms on T4 even with normal TSH levels. To date there has been no large study to determine whether this is related to thyroxine replacement or coincidental psychological morbidity. We have therefore attempted to address this issue using a large, community‐based study.

Acute stress, memory, attention and cortisol

An investigation was conducted to explore the relationship between acute changes in cortisol and memory and attention in the context of an acute naturalistic stressor, namely, examination stress. Sixty students (36 male, 24 female) participated in an assessment of self-reported levels of stress, salivary cortisol, short term memory, selective and divided attention and auditory verbal working memory. Assessments were conducted during a non-exam and exam period. The results revealed that the exam period was associated with an increase in perceived levels of stress, but also a significant reduction in levels of salivary cortisol, compared with the non-exam period. This reduction in cortisol was associated with enhanced short-term memory (as measured by the total number of words recalled in a free recall task), impaired attention and an impairment in the primacy effect (a hippocampal-specific index of short term memory), but no significant effects on auditory verbal working memory. It was concluded that the results support the view that cortisol can modulate cognitive processes and that the effects of corticosteroids on cognitive function are selective.

Chronic stress in caregivers of dementia patients is associated with reduced lymphocyte sensitivity to glucocorticoids.

Caring for the chronically ill is associated with chronic distress. In view of the adverse effects of distress on cellular immune function, such distress may have implications for health. Indeed, it has been proposed that the hypothalamic-pituitary-adrenal (HPA) axis is a potential psychobiological mediator of these effects. In this study, we observed that elderly caregivers experienced greater distress and increased salivary cortisol than non-caregivers. In addition, caregivers had blunted mitogen-induced lymphocyte proliferation, lower mitogen-induced IL-2 production, and reduced lymphocyte sensitivity to glucocorticoids. These results indicate that chronic distress is associated with impaired cell-mediated immunity which is, in turn, associated with elevated basal steroid levels and altered steroid immunoregulation at the level of the lymphocyte.

Psychological stress and wound healing in humans: A systematic review and meta-analysis ☆

OBJECTIVE The current review aims to synthesize existing knowledge about the relationship between psychological stress and wound healing. METHODS A systematic search strategy was conducted using electronic databases to search for published articles up to the end of October 2007. The reference lists of retrieved articles were inspected for further studies and citation searches were conducted. In addition, a meta-analysis of a subset of studies was conducted to provide a quantitative estimation of the influence of stress on wound healing. RESULTS Twenty-two papers met the inclusion criteria of the systematic review and a subsample of 11 was included in a meta-analysis. The studies assessed the impact of stress on the healing of a variety of wound types in different contexts, including acute and chronic clinical wounds, experimentally created punch biopsy and blister wounds, and minor damage to the skin caused by tape stripping. Seventeen studies in the systematic review reported that stress was associated with impaired healing or dysregulation of a biomarker related to wound healing. The relationship between stress and wound healing estimated by the meta-analysis was r=-0.42 (95% CI=-0.51 to -0.32) (P<.01). CONCLUSION Attention now needs to be directed towards investigating potential moderators of the relationship, mediating mechanisms underpinning the association, as well as the demonstration of a causal link by the development of experimental interventions in healthy populations.

The role of disclosure in coping with HIV infection

A qualitative investigation was conducted to explore the role of disclosure in HIV infection. Forty homosexual and bisexual men completed a short demographic questionnaire and participated in a one-to-one, semi-structured interview. The interview was designed to address a variety of personal, interpersonal and organizational issues related to their HIV status and participants were invited to talk about their personal experiences from immediately prior to their diagnosis to the time of the interview. The results from the interviews are presented in three sections: immediately post-diagnosis, asymptomatic phase and symptomatic/AIDS phases. The data revealed that disclosing ones HIV status was an acute and recurrent stressor. Immediately post-diagnosis, individuals were more likely to adopt a policy of non-disclosure and this provided them with an opportunity to come to terms with their diagnosis before having to contend with the reactions of others. After this phase, there was evidence that individuals increasingly used disclosure as a mechanism for coping with the disease. Disclosure of ones status was used to increase both practical and emotional support, share responsibility for sex and to facilitate self-acceptance of ones condition. The results from this investigation revealed that disclosure has a dual role in HIV infection acting as both a stressor and a mechanism by which individuals contend with their infection.

Adverse psychosocial factors predict poorer prognosis in HIV disease: A meta-analytic review of prospective investigations

There is a growing epidemiological literature focusing on the association between psychosocial stress and human immunodeficiency virus (HIV) disease progression or acquired immunodeficiency syndrome (AIDS), but inconsistent findings have been published. We aimed to quantify the association between adverse psychosocial factors and HIV disease progression. We searched Medline; PsycINFO; Web of Science; PubMed up to 19 January 2009, and included population studies with a prospective design that investigated associations between adverse psychosocial factors and HIV disease progression or AIDS. Two reviewers independently extracted data on study characteristics, quality, and estimates of associations. The overall meta-analysis examined 36 articles including 100 psychosocial and disease related relationships. It exhibited a small, but robust positive association between adverse psychosocial factors and HIV progression (correlation coefficient as combined size effect 0.059, 95% confidence interval 0.043-0.074, p<0.001). Notably, sensitivity analyses showed that personality types or coping styles and psychological distress were more strongly associated with greater HIV disease progression than stress stimuli per se, and that all of the immunological and clinical outcome indicators (acquired immunodeficiency syndrome stage, CD4+ T-cell decline, acquired immunodeficiency syndrome diagnosis, acquired immunodeficiency syndrome mortality, and human immunodeficiency virus disease or acquired immunodeficiency syndrome symptoms) except for viral load exhibited detrimental effects by adverse psychosocial factors. In conclusion, the current review reveals a robust relationship between adverse psychosocial factors and HIV disease progression. Furthermore, there would appear to be some evidence for particular psychosocial factors to be most strongly associated with HIV disease progression.

Psychosocial and clinical determinants of compliance with occlusion therapy for amblyopic children

Aims The objective of this study was to determine the extent that psychosocial and clinical variables influence parental compliance with occlusion therapy (eye patching) in children with amblyopia.Methods Children (n = 151) receiving occlusion therapy (eye patching) for the treatment of amblyopia were recruited from five orthoptic clinics in Bristol, UK. Parents completed a questionnaire based on Rogers’ (1983) Protection Motivation Theory (PMT). The parents (n = 105) were also followed up 2 months later. Clinical data, including measures of visual acuity, were also recorded. Compliance with eye patching was assessed through self-report accounts of parents. Stepwise regression analyses were used to determine the factors predictive of compliance with eye patching.Results Self-reported compliance with eye patching at study entry revealed that only 54% of parents were achieving orthoptists’ recommendations to patch their child. Perceived self-efficacy was positively associated with compliance and perceived prohibition of the child’s activities were negatively associated with compliance. At follow-up, past behaviour accounted for the largest proportion of explained variance in patching behaviour followed by response efficacy, and prohibition of the child’s activities.Conclusion The present findings may serve to inform interventions aimed at enhancing current orthoptic practice to improve compliance in amblyopic children. The importance of ‘self-efficacy’ and past behaviour suggests that consultations with parents exhibiting higher levels of success with patching may elicit strategies that could be shared with parents experiencing difficulties with patching their children. In addition, it is possible that the perceived efficacy of the treatment could be enhanced if orthoptists emphasised evidence of improvements in visual acuity which may, in turn, foster the maintenance of eye patching.

The measurement of stress-related immune dysfunction in psychoneuroimmunology

In recent years there has been a dramatic increase in research dedicated to the psycho-behavioural modulation of immune function, i.e. the field of Psychoneuroimmunology (PNI). This has led, necessarily, to the use of several in vitro and in vivo techniques in attempts to delineate the relationship between these two phenomena. However, since the fields inception, considerable uncertainty has existed over the significance of the immune outcomes detected and this has been compounded by the equivocal nature of some of the published data. A great deal of this uncertainty could, however, be overcome if a clearer understanding was achieved on the advantages and limitations conferred by the manifold immune assays described in the literature. This would, in turn, encourage their more appropriate use within PNI. Hence, in this review we describe the rationale behind, and offer an evaluation of, some of the more frequently used in vitro and in vivo immunological and virological techniques. We hope that a clear understanding of the rationale behind such assays and their inherent advantages and limitations will inform the discussion of the significance of stress-related immune impairment.

Psychosocial factors associated with indices of cortisol production in women with breast cancer and controls

The present study was designed to (i) explore which psychosocial factors were associated with indices representing the early morning peak, diurnal cortisol rhythm and area under the curve (AUC); (ii) examine whether the relationships between psychosocial functioning and these cortisol indices were consistent and (iii) explore whether these relationships were influenced by the clinical status of the participant. Newly diagnosed breast cancer patients (n = 85) and healthy control women (n = 59) were recruited. State and trait measures of psychosocial functioning (i.e. anxiety, depression, distress, neuroticism, extraversion, marital satisfaction and mastery) were undertaken. In addition, all participants provided four saliva samples (on waking, 30 min later, between 11 and 1 p.m., before lunch and between 8 and 10 p.m., at least 2h after evening meal) over two consecutive days to assess cortisol levels. The results highlighted the divergent nature of the four cortisol indices; revealed the presence of some significant relationships between the psychosocial measures and the cortisol indices; but highlighted inconsistencies in the relationships evident for patients and those observed for control women.

The four-dimensional stress test: Psychological, sympathetic–adrenal–medullary, parasympathetic and hypothalamic–pituitary–adrenal responses following inhalation of 35% CO2

BACKGROUND Hypercapnia is a threat to homeostasis and results in neuroendocrine, autonomic and anxiogenic responses. The inhalation of carbon dioxide (CO2) may, therefore, provide a good paradigm for exploring the pathways by which stress can lead to increased susceptibility to ill-health through physiological and psychological stress reactivity. The current study was designed, therefore, to assess the psychological and physiological responses to the inhalation of CO2. METHODS Healthy participants (N = 24) inhaled a single vital capacity breath of a mixture of CO2 (35%) and oxygen (65%). Blood pressure and heart rate were recorded for 5 min before and after the test and blood and saliva samples were taken immediately before and 2, 10, 20 and 30 min post-inhalation for the measurement of noradrenaline, salivary and serum cortisol and salivary alpha amylase. In addition, psychosomatic symptoms were recorded immediately before and after the test. The same protocol was repeated 4-6 weeks later at the same time of day. RESULTS A single inhalation of CO2 increased blood pressure, noradrenaline, salivary alpha amylase and psychosomatic symptoms, but decreased heart rate at both testing sessions. Analyses of salivary cortisol data revealed that 70% of the sample could be reliably classified as either responders (i.e. demonstrated a post-CO2 cortisol increase) or non-responders (i.e. responded with a decrease or no change in cortisol following CO2) at both test sessions. Responders also perceived the test to be more aversive than non-responders. CONCLUSIONS Inhalation of 35% CO2 reliably stimulated the key mechanisms involved in the human stress response. The inter-individual differences in the reactivity of the hypothalamic-pituitary-adrenal axis were also related to differences in the perception of the test.