Roger J. Booth

Disclosure of trauma and immune response to a hepatitis B vaccination program.

This study investigated whether emotional expression of traumatic experiences influenced the immune response to a hepatitis B vaccination program. Forty medical students who tested negative for hepatitis B antibodies were randomly assigned to write about personal traumatic events or control topics during 4 consecutive daily sessions. The day after completion of the writing, participants were given their first hepatitis B vaccination, with booster injections at 1 and 4 months after the writing. Blood was collected before each vaccination and at a 6-month follow-up. Compared with the control group, participants in the emotional expression group showed significantly higher antibody levels against hepatitis B at the 4 and 6-month follow-up periods. Other immune changes evident immediately after writing were significantly lower numbers of circulating T helper lymphocytes and basophils in the treatment group. The finding that a writing intervention influences immune response provides further support for a link between emotional disclosure and health.

The immunological effects of thought suppression.

Individuals often suppress emotional thoughts, particularly thoughts that arouse negative emotions, as a way of regulating mood and reducing distress. However, recent work has highlighted the complexities and unexpected cognitive and physiological effects of thought suppression. In a study designed to examine the short-term immunological effects of thought suppression, participants wrote about either emotional or nonemotional topics with or without thought suppression. Blood was drawn before and after each experimental session on 3 consecutive days. Results showed a significant increase in circulating total lymphocytes and CD4 (helper) T lymphocyte levels in the emotional writing groups. Thought suppression resulted in a significant decrease in CD3 T lymphocyte levels. The implications of the results for the role of the expression and suppression of emotion in health are discussed.

Effect of Written Emotional Expression on Immune Function in Patients With Human Immunodeficiency Virus Infection: A Randomized Trial

Objectives To determine whether writing about emotional topics compared with writing about neutral topics could affect CD4+ lymphocyte count and human immunodeficiency virus (HIV) viral load among HIV-infected patients. Methods Thirty-seven HIV-infected patients were randomly allocated to 2 writing conditions focusing on emotional or control topics. Participants wrote for 4 days, 30 minutes per day. The CD4+ lymphocyte count and HIV viral load were measured at baseline and at 2 weeks, 3 months, and 6 months after writing. Results The emotional writing participants rated their essays as more personal, valuable, and emotional than those in the control condition. Relative to the drop in HIV viral load, CD4+ lymphocyte counts increased after the intervention for participants in the emotional writing condition compared with control writing participants. Conclusions The results are consistent with those of previous studies using emotional writing in other patient groups. Based on the self-reports of the value of writing and the preliminary laboratory findings, the results suggest that emotional writing may provide benefit for patients with HIV infection.

Psychological Stress Impairs Early Wound Repair Following Surgery

Objective Laboratory studies have demonstrated that psychological stress is associated with slower healing of small superficial wounds. The application of this finding to the clinical environment has not yet been undertaken. In order to do this, we investigated the relationship between psychological stress and wound repair in patients following routine surgery. Methods Forty-seven adults with an inguinal hernia were given a standardized questionnaire assessing psychological stress and worry about the operation before undergoing open incision repair. Wound fluid was collected from 36 participants over the first 20-hour postoperative period. Wound healing was assessed by levels of interleukin-1, interleukin-6, and matrix metalloproteinase-9 in the fluid. Other outcome measures included patient self-reports of recovery, as well as cytokine response to lipopolysaccharide stimulation of peripheral blood. Results Greater preoperative perceived stress significantly predicted lower levels of interleukin-1 in the wound fluid (&bgr; = −0.44, p = 0.03). Greater worry about the operation predicted lower levels of matrix metalloproteinase-9 in the wound fluid (&bgr; = −0.38, p = 0.03) as well as a more painful (&bgr; = 0.51, p = 0.002), poorer (&bgr; = −0.36, p = 0.04), and slower recovery (&bgr; = 0.43, p = 0.01). Conclusions Psychological stress impairs the inflammatory response and matrix degradation processes in the wound immediately following surgery. This finding generalizes previous laboratory research to surgical patients and expands the known influence of stress to connective tissue matrix remodelling processes. These results suggest that in clinical practice, interventions to reduce the patient’s psychological stress level may improve wound repair and recovery following surgery.

CHANGES IN CIRCULATING LYMPHOCYTE NUMBERS FOLLOWING EMOTIONAL DISCLOSURE: EVIDENCE OF BUFFERING?

In order to assess whether disclosure of emotions through writing about upsetting or traumatic events resulted in changes in blood-associated immune variables over time, healthy volunteers were randomly assigned to write about either emotional issues or trivial topics for 4 consecutive days. Circulating lymphocytes and T lymphocyte subsets (CD4 (helper), CD8 (cytotoxic/suppressor)) as well as a variety of standard hematological markers were measured following the writing intervention and compared with baseline values. In two separate studies (N=40 and N=38), there were reproducible significant differences between the emotional disclosure and control writing groups immediately following the intervention in CD4, CD8 and total circulating lymphocyte numbers but not in CD4/CD8 ratios or any other hematological variables. Circulating lymphocyte numbers in the emotional writing group stayed relatively constant over the time-course of the studies, suggesting that the difference between the groups was due to a transient elevation in postwriting blood lymphocyte numbers in the control group. Self-evaluations immediately before and after each writing session confirmed that the intervention was stressful for subjects in the emotional disclosure group but the effects on circulating lymphocytes were not attributable purely to anxiety-related factors. The results extend our previous observation of changes in immune reactivity following a writing intervention and indicate that the group differences are the result of fluctuations over time in the control group but relative stability in the emotional disclosure group. It is conceivable that such ‘buffering’ of temporal immune variation might be influential in the health-promoting effects of emotional disclosure.

A brief relaxation intervention reduces stress and improves surgical wound healing response: a randomised trial.

Psychological stress has been shown to impair wound healing, but experimental research in surgical patients is lacking. This study investigated whether a brief psychological intervention could reduce stress and improve wound healing in surgical patients. This randomised controlled trial was conducted at a surgical centre. Inclusion criteria were English-speaking patients over 18 years booked to undergo elective laparoscopic cholecystectomy; exclusion criteria were cancellation of surgery, medical complications, and refusal of consent. Seventy five patients were randomised and 15 patients were excluded; 60 patients completed the study (15 male, 45 female). Participants were randomised to receive standard care or standard care plus a 45-min psychological intervention that included relaxation and guided imagery with take-home relaxation CDs for listening to for 3 days before and 7 days after surgery. In both groups ePTFE tubes were inserted during surgery and removed at 7 days after surgery and analysed for hydroxyproline as a measure of collagen deposition and wound healing. Change in perceived stress from before surgery to 7-day follow-up was assessed using questionnaires. Intervention group patients showed a reduction in perceived stress compared with the control group, controlling for age. Patients in the intervention group had higher hydroxyproline deposition in the wound than did control group patients (difference in means 0.35, 95% CI 0.66-0.03; t(43)=2.23, p=0.03). Changes in perceived stress were not associated with hydroxyproline deposition. A brief relaxation intervention prior to surgery can reduce stress and improve the wound healing response in surgical patients. The intervention may have particular clinical application for those at risk of poor healing following surgery.

A Prospective Study on the Influence of a Fast-Track Program on Postoperative Fatigue and Functional Recovery After Major Colonic Surgery

INTRODUCTION Enhanced Recovery After Surgery (ERAS) programs have demonstrated significant reduction in hospital stay for patients undergoing colonic surgery; however, their impact on long-term outcomes, such as postoperative fatigue (POF), has not been fully established. AIM To assess the impact of an ERAS program on POF and recovery following elective open colonic surgery. METHOD In a prospective study, 26 consecutive patients undergoing open colonic surgery under a conventional care plan were compared with 26 consecutive patients in an ERAS program. RESULTS Demographic and clinical characteristics were comparable at baseline. The median duration of total hospital stay (4 versus 7 d, P < 0.001), rates of urinary tract infections (P = 0.028) and ileus (P = 0.042) were significantly smaller in the ERAS group. Postoperatively, POF significantly increased in both groups. However, peak POF score was significantly lower in the ERAS group (P = 0.001). In the first 30 d after surgery, Fatigue Consequence scores were also significantly smaller in the ERAS group. Overall, the total fatigue experience (P = 0.035) and the total fatigue impact (P = 0.005) were significantly smaller in the ERAS group. CONCLUSION The impact of ERAS programs may extend beyond the commonly reported short-term outcomes, and ERAS may accelerate overall recovery and return to normal function.

Cognitive and affective determinants of decisions to attend a group psychosocial support program for women with breast cancer.

Objective: This prospective study assesses the roles of illness beliefs, emotion regulation factors, and sociodemographic characteristics in decisions to participate in a group support program for women recently diagnosed with breast cancer. Method: Women recruited during clinic visits 2 to 4 weeks after diagnosis completed measures of affective and cognitive factors identified by Leventhal’s Common-Sense Model of illness self-regulation: cancer-related distress, avoidance tendencies, beliefs that the breast cancer was caused by stress and altered immunity, and personal control beliefs. Measures of general anxiety and depression, social support, and demographic characteristics were also completed; prognostic status information was obtained from medical records. All women were encouraged to participate in a free, 12-week program offering coping skills training and group support. Participation was recorded by program staff. Results: Of the 110 women, 54 (49%) participated in the group support program and 56 (51%) did not. Logistic regression analyses revealed that participation was predicted by stronger beliefs that the cancer was caused by altered immunity, higher cancer-related distress, lower avoidance tendencies, and younger age. Conclusions: Participation in the group psychosocial support program appeared to be guided by cognitive and affective factors identified by the Common-Sense Model. Psychosocial support programs and informational materials promoting their use may attract more participants if they are tailored to focus on resolving cancer-related distress rather than on general anxiety or depression, appeal to those with high avoidance tendencies, address the role of immune function in cancer progression, and meet the needs of older participants. RCT = randomized controlled trial; CSM = Common-Sense Model; IPQ-R = Illness Perceptions Questionnaire-Revised; RIES = Revised Impact of Events; Scale CES-D = Center for Epidemiologic Studies Depression Scale.

The Use of Reliever Medication in Asthma: The Role of Negative Mood and Symptom Reports

The aim of this study was to investigate the relationships between negative mood, the reporting of asthma symptoms, and the use of short-acting bronchodilators (reliever medication). Forty-two adult asthma patients completed a daily questionnaire over 7 consecutive days. The questionnaire measured negative mood and the number of symptoms patients associated with their asthma. The symptoms included those typical of asthma, as well as nonspecific somatic and distress symptoms. Subjects were also asked to record their daily use of reliever medication and their peak flow values. Data analysis demonstrated that even when controlling for lung function, both asthma symptom labeling and negative mood were related to reliever use. A mediation model suggested that negative mood leads patients to associate a wide range of nonspecific symptoms with their asthma, thereby altering the perception of the severity of the asthma, which in turn influences their use of reliever medication. The results of this study are discussed in relation to asthma self-management strategies.

Examination stress results in altered cardiovascular responses to acute challenge and lower cortisol

The present study examined how cardiovascular and salivary cortisol responses varied in response to an acute challenge in medical students under exam stress versus those not under exam stress. One hundred and twenty-nine medical students were randomly assigned to undertake a CO2 inhalation test either prior to an examination period (exam group) or during a regular academic period (non-exam group). Heart rate (HR) and blood pressure (BP) were measured for 5 min before and 5 min after the task, and salivary cortisol samples were collected 1 min before and 10 and 30 min after the CO2 inhalation test. Participants also completed a questionnaire measuring self-reported perceived stress. The exam group exhibited significantly higher HR reactivity following the CO2 inhalation test and slower systolic blood pressure (SBP) recovery compared with the non-exam group. The exam group also reported higher perceived stress and higher stress scores were related to higher HR reactivity following CO2 inhalation. Female students across both groups exhibited significantly lower SBP reactivity compared with male students. Salivary cortisol levels were consistently lower in the exam group. These findings indicate that ongoing natural stress alters cortisol secretion and cardiovascular responses in the face of an acute stress challenge.