Anger regulation in patients with functional neurological disorder: A systematic review.

BACKGROUND: Functional neurological disorder (FND) has been associated with predisposing psychological factors, including dysregulation of anger-related processes. This paper provides a systematic review of the literature on anger regulation in FND. We evaluated anger-related research on patient self-report, observational, and laboratory based measures in FND. The review also addresses adverse childhood experiences and their relation with anger regulation, and the effects of therapies targeting anger regulation in FND. METHODS: MEDLINE, EMBASE, and PsycINFO were searched for both quantitative and qualitative research, published in a peer-reviewed journal with a sample size of at least 5 (registered under Prospero protocol CRD42022314340). RESULTS: A total of 2200 articles were identified. After screening, 54 studies were included in this review (k = 20 questionnaire-based studies, k = 12 laboratory studies, k = 21 using other methods, and k = 1 used both questionnaires and other methods) representing data of 2502 patients with FND. Questionnaire-based studies indicated elevated levels of state anger and trait hostility in patients with FND. Laboratory studies showed a higher tendency to avoid social threat cues, attentional bias towards angry faces, difficulties reliving anger, and preoccupation with frustrating barriers among FND patients versus controls. No specific childhood experiences were identified related to anger regulation in FND, and too few small and uncontrolled studies were available (k = 2) to assess the effects of anger-related interventions in FND. The overall quality of the studies was fair (k = 31) to poor (k = 18). Five studies (k = 5) were rated as having a good quality. CONCLUSIONS: This review suggests that patients with FND have maladaptive anger regulation compared to individuals without FND. The findings also highlight the need for further research on the prevalence and consequences of anger-related processes in the development, diagnosis and treatment of FND.

Alexithymia and facial emotion recognition in patients with functional neurological disorder.

OBJECTIVES: Patients with functional neurological disorder (FND) are known to have difficulties recognizing and processing emotions. Problems recognizing internal emotional states (alexithymia) are common in FND, but little is known about recognizing emotions expressed by other people. This study investigates whether patients with FND have higher levels of alexithymia and reduced facial emotion recognition compared to healthy controls. METHODS: Patients with FND (n = 31, mean age=42.7 [SD=14.8] years, 54.8% women) were compared to healthy controls (n = 33, mean age=45.1 [SD=16.2] years, 63.6% women). The Bermond-Vorst Alexithymia Questionnaire (BVAQ) was used for the assessment of alexithymia and the Ekman 60 Faces Test (EFT) for facial emotion recognition. RESULTS: Patients with FND had higher levels of alexithymia than healthy controls (BVAQ=71.8 [SD=19.8] versus 59.3 [SD=20.3], p = .02, Cohen's d=0.62). Facial emotion recognition did not significantly differ between FND patients and controls (EFT total score FND: 46.1 [SD=5.9], Controls: 47.5 [SD=5.5], p = .34, Cohen's d=0.24). Only recognition of surprise differed between patients and controls (FND: 8.4 [SD=1.8], Controls: 9.2 [SD=1.0), p = .03, Cohen's d= 0.56). Higher levels of alexithymia were associated with poorer facial emotion recognition, but this relationship was not statistically significant (FND: ß= -0.20, p = .28; Controls: ß=-0.03; p = .87). CONCLUSIONS: The current data confirm prior observations that patients with FND have higher alexithymia levels than controls without FND. Difficulties recognizing emotions among patients with FND primarily involves recognition of internal emotional states rather than recognition of facially expressed emotions by others. These findings require replication in a larger and more divers sample.

Adherence to a lifestyle monitoring system in patients with heart disease: protocol for the care-on prospective observational trial.

BACKGROUND: Lifestyle factors such as physical fitness, dietary habits, mental stress, and sleep quality, are strong predictors of the occurrence, clinical course, and overall treatment outcomes of common cardiovascular diseases. However, these lifestyle factors are rarely monitored, nor used in daily clinical practice and personalized cardiac care. Moreover, non-adherence to long-term self-reporting of these lifestyle factors is common. In the present study, we evaluate adherence to a continuous unobtrusive and patient-friendly lifestyle monitoring system using evidence-based assessment tools. METHODS: In a prospective observational trial (N = 100), the project investigates usability of and adherence to a monitoring system for multiple lifestyle factors relevant to cardiovascular disease, i.e., daily physical activity levels, dietary habits, mental stress, smoking, and sleep quality. Patients with coronary artery disease, valvular disease and arrhythmias undergoing an elective intervention are asked to participate. The monitoring system consists of a secured online platform with a custom-built conversational interface-a chatbot-and a wrist-worn wearable medical device. The wrist-worn device collects continuous objective data on physical activity and the chatbot is used to collect self-report data. Participants collect self-reported lifestyle data via the chatbot for a maximum of 4 days every other week; in the same week physiological data are collected for 7 days for 24 h. Data collection starts one week before the intervention and continues until 1-year after discharge. Via a dashboard, patients can observe their lifestyle measures and adherence to self-reporting, set and track personal goals, and share their lifestyle data with practitioners and relatives. The primary outcome of the trial is adherence to using the integrated platform for self-tracking data. The secondary outcomes include system usability, determinants of adherence and the relation between baseline lifestyle behaviour and long-term patient-relevant outcomes. DISCUSSION: Systematic monitoring during daily life is essential to gain insights into patients' lifestyle behaviour. In this context, adherence to monitoring systems is critical for cardiologists and other care providers to monitor recovery after a cardiac intervention and to detect clinical deterioration. With this project, we will evaluate patients' adherence to lifestyle monitoring technology. This work contributes to the understanding of patient-centered data collection and interpretation, to enable personalized care after cardiac interventions in order to ultimately improve patient-relevant outcomes and reduce health care costs. TRIAL REGISTRATION: Netherlands Trial Registry (NTR) NL9861. Registered 6th of November 2021.

[Patient-tailored approach in tertiary care expert centres using individual dynamic network analysis]. / Maatwerk in hoogspecialistische ggz met individuele dynamische netwerkanalyse.

BACKGROUND: Patients with mental health disorders often have difficulty perceiving associations between multiple symptoms, such as inter-relations between somatic and psychological symptoms. This difficulty may be particularly challenging in patients with complex disorders. Individual dynamic network analysis may provide novel diagnostic and treatment possibilities because it can create a starting point for a personalized approach in complex cases in tertiary mental health care expert centres, where standard protocolized interventions were insufficiently effective. AIM: To explore the possibilities provided by dynamic network technologies in the care of patients in tertiary care expert centres. METHOD: Overview of these possibilities, with a focus on somatic symptom disorder. RESULTS: Intensive longitudinal data can be obtained using a short and personalized questionnaire that is presented via a patient's smartphone a few times per day during several weeks. These data are then converted to patient-specific dynamic symptom networks using time series analysis. These networks display how variations over time in somatic and mental symptoms and other factors (such as specific situations) mutually influence each other in daily life. They also provide information about cause-effect associations. CONCLUSION: Dynamic symptom networks provide insight into the associations between symptoms and other factors and can be used to personalize treatment goals and interventions in tertiary care expert centres. Furthermore, these networks create opportunities to examine the (patient-tailored) effects of personalized interventions.

Multi-modal responses to the Virtual Reality Trier Social Stress Test: A comparison with standard interpersonal and control conditions.

The Trier Social Stress Test (TSST) is a reliable social-evaluative stressor. To overcome limitations of the in vivo TSST, a standardized virtual reality TSST (VR-TSST) was developed. The present study compares the emotional (anxiety) and physiological (heart period and variability) response to a VR-TSST with an in vivo TSST and a control condition. Participants took part in either an in vivo TSST (N = 106, 64% female), VR-TSST (N = 52, 100% female), or a control TSST (N = 20, 40% female). Mixed linear modeling examined response profile differences related to TSST type. While there was an equivalent anxiety response to the in vivo TSST as the VR-TSST, we found a smaller heart period and heart rate variability response in VR-TSST compared to the in vivo TSST, especially in response to the math part of the test. The present findings demonstrate that social evaluative stress can be successfully induced in a VR setting, producing similar emotional and slightly attenuated cardiovascular responses.

Intranasal oxytocin and the stress-buffering effects of social support during experimentally induced pain: The role of attachment security.

BACKGROUND: This study examined whether intranasal oxytocin enhances the stress-buffering effects of social support during experimentally induced pain, taking into account the role of individual differences in attachment security. METHODS: Female participants (N = 193) were randomly assigned to oxytocin (24 IU intranasal) or placebo and to receive support or no support from a friend (2 × 2 factorial design with repeated measures)). Participants underwent the Cold Pressor Task (CPT) and were monitored for heart rate variability (HRV: RMSSD) and heart rate and reported pain levels. The Experiences in Close Relationships Questionnaire was used to measure attachment. RESULTS: Oxytocin reduced RMSSD (p = 0.003, partial ɳ2 = 0.03) and increased heart rate (p = 0.039, partial ɳ2 = 0.03) in individuals who received support, possibly reflecting an enhanced attentional state. Oxytocin did not enhance beneficial effects of social support on perceived pain, but increased pain intensity in avoidantly attached individuals who were supported by a friend (p = 0.009, partial ɳ2 = 0.06). LIMITATIONS: Only female participants were examined. Future studies are needed to determine sex differences in how oxytocin shapes stress-buffering effects of support. CONCLUSIONS: Oxytocin may enhance the salience of social proximity and may be a mechanism underlying previously reported social influences on cardiovascular and mental health. However, oxytocin effects depend on interpersonal insecurities and may trigger discomfort in avoidantly attached individuals. Caution about oxytocin's therapeutic promise is warranted.

Psychological and clinical characteristics of female patients with spontaneous coronary artery dissection.

AIMS: Spontaneous coronary artery dissection (SCAD) is increasingly recognised as a cause of myocardial infarction, but psychological characteristics of patients with SCAD have not yet been extensively investigated. We assessed the prevalence of a broad range of psychological and clinical factors, and their inter-relationships in patients with a history of SCAD. Furthermore, we investigated whether specific clusters of patients with SCAD can be identified. METHODS: Participants were recruited between March and May 2019 from a Dutch SCAD database and completed online questionnaires. Clinical information was verified by review of medical records. Participants were predominantly female (172/183; 94%). Analyses focused on the 172 female patients (mean age 52.0 ± 7.5 years, 37% postmenopausal). RESULTS: The most common comorbidities of SCAD were migraine (52%), fibromuscular dysplasia (FMD; 29%), chronic pain (29%), and tinnitus (28%). Six women (3%) had pregnancy-associated SCAD. Traditional cardiovascular risk factors were rare (<10%), except for hypertension (31%). Psychological assessment indicated high levels of perceived stress (PSS-10 ≥14; 50%), fatigue (FAS-10 ≥22; 56%), and a frequent history of burnout (25%). The prevalence of depression (9%) and anxiety (12%) was relatively low. Three clusters were identified: (A) FMD and chronic non-ischaemic conditions (tinnitus, chronic pain, and irritable bowel syndrome); (B) migraine; and (C) none of these conditions. CONCLUSION: This study shows that perceived stress and fatigue are common in patients with SCAD, in addition to prevalent comorbid FMD, migraine, tinnitus, and non-ischaemic pain conditions. These factors may add to developing tailored rehabilitation programmes for patients with SCAD.

Oxytocin effects on resting-state heart rate variability in women: The role of childhood rearing experiences.

Oxytocin is known for its stress-reducing effects and has been associated with autonomic nervous system measures (ANS) involved in the stress response, such as heart rate variability (HRV). The current study examined the effects of intranasal oxytocin on HRV among women (oxytocin N â€‹= â€‹87, placebo N â€‹= â€‹86) during rest. Results show that oxytocin reduced RMSSD and low frequency (LF)-HRV, but only in women with positive childhood rearing experiences, and not in women with negative childhood experiences. These findings suggest that oxytocin plays a role in ANS regulation and that childhood rearing experiences may influence oxytocin effects on this stress regulating system.

The role of objective cognitive dysfunction in subjective cognitive complaints after stroke.

BACKGROUND AND PURPOSE: Objective cognitive performance (OCP) is often impaired in patients post-stroke but the consequences of OCP for patient-reported subjective cognitive complaints (SCC) are poorly understood. We performed a detailed analysis on the association between post-stroke OCP and SCC. METHODS: Assessments of OCP and SCC were obtained in 208 patients 3 months after stroke. OCP was evaluated using conventional and ecologically valid neuropsychological tests. Levels of SCC were measured using the CheckList for Cognitive and Emotional (CLCE) consequences following stroke inventory. Multivariate hierarchical regression analyses were used to evaluate the association of OCP with CLCE scores adjusting for age, sex and intelligence quotient. Analyses were performed to examine the global extent of OCP dysfunction (based on the total number of impaired neuropsychological tests, i.e. objective cognitive impairment index) and for each OCP test separately using the raw neuropsychological (sub)test scores. RESULTS: The objective cognitive impairment index for global OCP was positively correlated with the CLCE score (Spearman's rho = 0.22, P = 0.003), which remained significant in multivariate adjusted models (ß = 0.25, P = 0.01). Results for the separate neuropsychological tests indicated that only one task (the ecologically valid Rivermead Behavioural Memory Test) was independently associated with the CLCE in multivariate adjusted models (ß = -0.34, P < 0.001). CONCLUSIONS: Objective neuropsychological test performance, as measured by the global dysfunction index or an ecologically valid memory task, was associated with SCC. These data suggest that cumulative deficits in multiple cognitive domains contribute to subjectively experienced poor cognitive abilities in daily life in patients post-stroke.

Psychological distress and personality factors in takotsubo cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy (TCC) is a transient condition characterised by severe left ventricular dysfunction combined with symptoms and signs mimicking myocardial infarction. Emotional triggers are common, but little is known about the psychological background characteristics of TCC. This study examined whether patients with TTC have higher levels of psychological distress (depressive symptoms, perceived stress, general anxiety), illness-related anxiety and distinct personality factors compared with healthy controls and patients with heart failure. METHODS AND RESULTS: Patients with TCC (N = 18; mean age 68.3 ± 11.7 years, 77.8 % women) and two comparison groups (healthy controls: N = 19, age 60.0 ± 7.6, 68.4 % women and patients with chronic heart failure: N = 19, age 68.8 ± 10.1, 68.4 % women) completed standardised questionnaires to measure depression (PHQ­9), perceived stress (PSS-10), general anxiety (GAD-7), illness-related anxiety (WI-7) and personality factors (NEO-FFI and DS-14). Psychological measures were obtained at 23 ± 18 months following the acute TTC event. Results showed that patients with TCC had higher levels of depressive symptoms (5.2 ± 5.2 vs. 2.5 ± 2.4, p = 0.039) and illness-related anxiety (2.1 ± 1.7 vs. 0.7 ± 1.3, p = 0.005) compared with healthy controls. Patients with TCC did not display significantly elevated perceived stress (p = 0.072) or general anxiety (p = 0.170). Regarding personality factors, levels of openness were lower in TCC compared with healthy controls (34.2 ± 4.3 vs. 38.2 ± 5.6, p = 0.021). No differences between TCC and heart failure patients were found regarding the psychological measures. CONCLUSIONS: TCC is associated with higher levels of depressive symptoms, more illness-related anxiety and less openness compared with healthy controls. These data suggest that TCC is associated with adverse psychological factors that may persist well after the acute episode.

Central nervous system involvement in the autonomic responses to psychological distress.

Psychological distress can trigger acute coronary syndromes and sudden cardiac death in vulnerable patients. The primary pathophysiological mechanism that plays a role in stress-induced cardiac events involves the autonomic nervous system, particularly disproportional sympathetic activation and parasympathetic withdrawal. This article describes the relation between psychological distress and autonomic nervous system function, with a focus on subsequent adverse cardiovascular outcomes. The role of the central nervous system in these associations is addressed, and a systematic review is presented of studies examining the association between stress-induced central nervous system responses measured by neuroimaging techniques and autonomic nervous system activation. Results of the systematic review indicate that the primary brain areas involved in the autonomic component of the brain-heart association are the insula, medial prefrontal cortex, and cerebellum (based on 121 participants across three studies that fitted the inclusion criteria). Other areas involved in stress-induced autonomic modulation are the (anterior) cingulate cortex, parietal cortex, somatomotor cortex/precentral gyrus, and temporal cortex. The interaction between central and autonomic nervous system responses may have implications for further investigations of the brain-heart associations and mechanisms by which acute and chronic psychological distress increase the risk of myocardial infarction, cardiac arrhythmias, and sudden cardiac death.

Changes in heart rate and heart rate variability before ambulatory ischemic events(1).

OBJECTIVES: The aim of this study was to determine the time course of autonomic nervous system activity preceding ambulatory ischemic events. BACKGROUND: Vagal withdrawal can produce myocardial ischemia and may be involved in the genesis of ambulatory ischemic events. We analyzed trajectories of heart rate variability (HRV) 1 h before and after ischemic events, and we examined the role of exercise and mental stress in preischemic autonomic changes. METHODS: Male patients with stable coronary artery disease (n = 19; 62.1 +/- 9.3 years) underwent 48-h ambulatory electrocardiographic monitoring. Frequency domain HRV measures were assessed for 60 min before and after each of 68 ischemic events and during nonischemic heart rate-matched control periods. RESULTS: High-frequency HRV decreased from -60, -20 to -10 min before ischemic events (4.8 +/- 1.3; 4.6 +/- 1.3; 4.4 +/- 1.2 ln [ms(2)], respectively; p = 0.04) and further from -4, -2 min, until ischemia (4.4 +/- 1.3; 4.1 +/- 1.3; 3.7 +/- 1.2 ln [ms(2)]; p's < 0.01). Low frequency HRV decreases started at -4 min (p < 0.05). Ischemic events occurring at high mental activities were preceded by depressed high frequency HRV levels compared with events at low mental activity (p = 0.038 at -4 min, p = 0.045 at -2 min), whereas the effects of mental activities were not observed during nonischemic control periods. Heart rate variability measures remained significantly decreased for 20 min after recovery of ST-segment depression when events were triggered by high activity levels. CONCLUSIONS: Autonomic changes consistent with vagal withdrawal can act as a precipitating factor for daily life ischemia, particularly in episodes triggered by mental activities.

Effects of mental stress on coronary epicardial vasomotion and flow velocity in coronary artery disease: relationship with hemodynamic stress responses.

OBJECTIVES: This study examines the prevalence and hemodynamic determinants of mental stress-induced coronary vasoconstriction in patients undergoing diagnostic coronary angiography. BACKGROUND: Decreased myocardial supply is involved in myocardial ischemia triggered by mental stress, but the determinants of stress-induced coronary constriction and flow velocity responses are not well understood. METHODS: Coronary vasomotion was assessed in 76 patients (average age 59.9 +/- 10.4 years; eight women). Coronary flow velocity responses were assessed in 20 of the 76 patients using intracoronary Doppler flow. Repeated angiograms were obtained after a baseline control period, a 3-min mental arithmetic task and administration of 200 microg intracoronary nitroglycerin. Arterial blood pressure (BP) and heart rate assessments were made throughout the procedure. RESULTS: Mental stress resulted in significant BP and heart rate increases (p < 0.001). Coronary constriction (>0.15 mm) was observed in 11 of 59 patients with coronary artery disease (CAD) (18.6%). Higher mental stress pressor responses were associated with more constriction in diseased segments (rdeltaSBP = -0.26, rdeltaDBP = -0.30, rdeltaMAP = -0.29; p's < 0.05) but not with responses in nonstenotic segments. The overall constriction of diseased segments was not significant (p > 0.10), whereas a small but significant constriction occurred in nonstenotic segments (p = 0.04). Coronary flow velocity increased in patients without CAD (32.2%; p = 0.008), but not in patients with CAD (6.4%; p = ns). Cardiovascular risk factors were not predictive of stress-induced vasomotion in patients with CAD. CONCLUSIONS: Coronary vasoconstriction in angiographically diseased arteries varies with hemodynamic responses to mental arousal. Coronary flow responses are attenuated in CAD patients. Thus, combined increases in cardiac demand and concomitant reduced myocardial blood supply may contribute to myocardial ischemia with mental stress.

Frailty in older adults: evidence for a phenotype.

BACKGROUND: Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established. METHODS: To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality. RESULTS: Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline). CONCLUSIONS: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.

Associations of subclinical cardiovascular disease with frailty.

BACKGROUND: Frail health in old age has been conceptualized as a loss of physiologic reserve associated with loss of lean mass, neuroendocrine dysregulation, and immune dysfunction. Little work has been done to define frailty and describe the underlying pathophysiology. METHODS: Frailty status was defined in participants of the Cardiovascular Health Study (CHS), a cohort of 5,201 community-dwelling older adults, based on the presence of three out of five clinical criteria. The five criteria included self-reported weight loss, low grip strength, low energy, slow gait speed, and low physical activity. We examined the spectrum of clinical and subclinical cardiovascular disease in those who were frail (3/5 criteria) or of intermediate frailty status (1 or 2/5 criteria), compared to those who were not frail (0/5). We hypothesized that the severity of frailty would be related to a higher prevalence of reported cardiovascular disease (CVD), as well as to a greater extent of CVD, measured by noninvasive testing. RESULTS: Of 4,735 eligible participants, 2,289 (48%) were not frail, 299 (6%) were frail, and 2.147 (45%) were of intermediate frailty status. Those who were frail were older (77.2 yrs) compared to those who were not frail (71.5 yrs) or intermediate (73.4 yrs) (p < .001). Frailty status was associated with clinical CVD and most strongly with congestive heart failure (odds ratio [OR] = 7.51 (95% confidence interval [CI] = 4.66-12.12). In those without a history of a CVD event (n = 1.259), frailty was associated with many noninvasive measures of CVD. Those with carotid stenosis >75% (adjusted OR = 3.41), ankle-arm index <0.8 (adjusted OR = 3.17) or 0.8-0.9 (adjusted OR = 2.01), major electrocardiography (ECG) abnormalities (adjusted OR = 1.58), greater left ventricular (LV) mass by echocardiography (adjusted OR = 1.16), and higher degree of infarct-like lesions in the brain (adjusted OR = 1.71), were more likely to be frail compared to those who were not frail. The overall associations of each of these noninvasive measures of CVD with frailty level were significant (all p < .05). CONCLUSIONS: Cardiovascular disease was associated with an increased likelihood of frail health. In those with no history of CVD, the extent of underlying cardiovascular disease measured by carotid ultrasound and ankle-arm index, LV hypertrophy by ECG and echocardiography, was related to frailty. Infarct-like lesions in the brain on magnet resonance imaging were related to frailty as well.

Assessment and treatment of depression in coronary artery disease patients.

Depressive symptoms occur frequently among patients with coronary artery disease (CAD), with prevalence estimates ranging from 15 to 30%. Risk ratios for first and recurrent cardiac events related to depression are comparable to well-established CAD risk factors and range from 2 to 7. The commonly atypical nature of depression in individuals with CAD plays an important role in the under diagnosis of depression in these patients. This review indicates that presence of atypical and subclinical depression, as well as of clinical major depressive disorders, significantly increase the risk of cardiac events. Pathophysiological mechanisms include altered autonomic nervous system activity, increased tendency toward blood coagulation, and elevated low-grade inflammation. Evidence suggests that depression in CAD patients does not reflect anatomical CAD severity or use of anti-ischemic medications. In addition to these pathophysiological pathways, depression affects CAD progression via adverse health behaviors such as smoking, poor compliance, and reduced exercise levels. Initial screening for depressive disorders can be accomplished using questionnaires, but structured clinical interview are preferred for definite diagnosis of depression. Optimal treatment of depression in CAD generally involves both psychological and pharmacological interventions that affect both depression and its biological correlates relevant to CAD progression.

Frontal electrocortical and cardiovascular reactivity during happiness and anger.

The present study investigated electrocortical and cardiovascular reactivity during positive and negative emotion, and examined the relation of asymmetric frontal lobe activation to cardiovascular responses. Participants were 30 healthy, right-handed university students (mean age, 23.9; 60% female; 76% Caucasian). Electroencephalographic (EEG), blood pressure (BP), and heart rate (HR) responses were assessed while subjects engaged in laboratory tasks (personally-relevant recall tasks and film clips) designed to elicit happiness or anger. Happiness-inducing tasks evoked more prominent left than right frontal EEG activation, and greater left frontal EEG activation than anger-inducing tasks. However, anger-inducing tasks were, on average, associated with comparable left and right frontal EEG activation. Irrespective of emotional valence, cardiovascular activation was more pronounced during personally-relevant recall tasks than during the viewing of film clips. During anger recall, both greater left frontal EEG response (r=-0.46, P<0.02) and greater right frontal EEG response (r=-0.45, P<0.02) were correlated significantly with increased HR reactivity during the task. In addition, a right lateralized frontal EEG response during anger-inducing tasks was associated with greater concomitant systolic BP (P<0.03) and diastolic BP (P<0.008) reactivity. Exploratory analyses also indicated that men who displayed a left lateralized frontal EEG response during happiness-inducing tasks showed the greatest concomitant systolic BP and HR reactivity (P's<0.03). These findings suggest that asymmetric frontal EEG responses to emotional arousal may elicit different patterns of cardiovascular reactivity in healthy adults.

Association between depression and mortality in older adults: the Cardiovascular Health Study.

BACKGROUND: Studies of the association between depressive symptoms and mortality in elderly populations have yielded contradictory findings. To address these discrepancies, we test this association using the most extensive array of sociodemographic and physical health control variables ever studied, to our knowledge, in a large population-based sample of elderly individuals. OBJECTIVE: To examine the relation between baseline depressive symptoms and 6-year all-cause mortality in older persons, systematically controlling for sociodemographic factors, clinical disease, subclinical disease, and health risk factors. METHODS: A total of 5201 men and women aged 65 years and older from 4 US communities participated in the study. Depressive symptoms and 4 categories of covariates were assessed at baseline. The primary outcome measure was 6-year mortality. RESULTS: Of the 5201 participants, 984 (18.9%) died within 6 years. High baseline depressive symptoms were associated with a higher mortality rate (23.9%) than low baseline depression scores (17.7%) (unadjusted relative risk [RR], 1.41; 95% confidence interval [CI], 1.22-1.63). Depression was also an independent predictor of mortality when controlling for sociodemographic factors (RR, 1.43; 95% CI, 1.23-1.66), prevalent clinical disease (RR, 1.25; 95% CI, 1.07-1.45), subclinical disease indicators (RR, 1.35; 95% CI, 1.15-1.58), or biological or behavioral risk factors (RR, 1.42; 95% CI, 1.22-1.65). When the best predictors from all 4 classes of variables were included as covariates, high depressive symptoms remained an independent predictor of mortality (RR, 1.24; 95% CI, 1.06-1.46). CONCLUSIONS: High levels of depressive symptoms are an independent risk factor for mortality in community-residing older adults. Motivational depletion may be a key underlying mechanism for the depression-mortality effect.

Relationship between left ventricular mass and hemodynamic responses to physical and mental stress.

OBJECTIVE: Increased left ventricular mass (LVM) is predictive of future cardiac morbidity and mortality. Although casual and ambulatory blood pressure (BP) predict LVM, other hemodynamic determinants of LVM are incompletely understood. The present study examines laboratory-induced hemodynamic responses (to exercise, cold, and mental stress) and 24-hour ambulatory measures as predictors of LVM. METHODS: Thirty-six healthy non-hypertensive subjects (mean age 33.9 +/- 9.4 years; 23 women, 13 men) were tested with mental stress, cold pressor, and treadmill exercise in the laboratory and 24-hour ambulatory BP monitoring. LVM was measured using two-dimensional targeted M-mode echocardiography and indexed for body surface area (LVMI). RESULTS: All laboratory tasks produced significant hemodynamic responses (p's < 0.01). Systolic blood pressure responses to mental stress (r = 0.42, p < 0.01) and cold pressor (r = 0.34, p < 0.05) were significantly related to LVM. After adjusting for body size, the mental stress-induced SBP responses was the only significant predictor of LVMI (r = 0.32, p < 0.05). Exercise SBP responses were associated to LVMI in men (r = 0.63, p = 0.02), but not in women (r = 0.02, p = n.s.). Multivariate regression analyses revealed that SBP during mental stress was significantly predictive of LVMI (beta = 0.65, p = 0.05), independent of baseline SBP, 24-hour ambulatory SBP, and other control variables. CONCLUSION: The present results indicate that SBP responses to mental stress are significantly related to LVM among healthy individuals, independently of baseline SBP, 24-hour ambulatory BP, age, body size, and sex. Blood pressure responses to exercise show a robust association with LVM in men but not in women. Hemodynamic responses elicited during laboratory tasks may therefore reveal important information about the pathophysiological processes involved in the development of cardiac end-organ damage.