Predicting relapse in Crohn's disease: a biopsychosocial model.

BACKGROUND: Crohn's disease (CD) is a chronic relapsing inflammatory bowel disorder. Both biological and psychosocial factors may modulate the illness experience. AIM: The aim of this study was to identify clinical, biological and psychosocial parameters as predictors of clinical relapse in quiescent CD. METHODS: Patients in medically induced remission were followed prospectively for 1 year, or less if they relapsed. Disease characteristics were determined at baseline. Serum cytokines, anti-Saccharomyces cerevisiae antibodies, C-reactive protein (CRP), erythrocyte sedimentation rate and intestinal permeability were measured every 3 months. Psychological distress, perceived stress, minor life stressors and coping strategies were measured monthly. A time-dependent multivariate Cox regression model determined predictors of time to relapse. RESULTS: 101 patients (60 females, 41 males) were recruited. Fourteen withdrew and 37 relapsed. CRP (HR = 1.5 per 10 mg/l, 95% CI 1.1 to 1.9, p = 0.007), fistulising disease (HR = 3.2, 95% CI, 1.1 to 9.4, p = 0.04), colitis (HR = 3.5 95% CI 1.2 to 9.9, p = 0.02) and the interaction between perceived stress and avoidance coping (HR = 7.0 per 5 unit increase for both scales, 95% CI 2.3 to 21.8, p = 0.003) were predictors of earlier relapse. CONCLUSIONS: In quiescent CD, a higher CRP, fistulising disease behaviour and disease confined to the colon were independent predictors of relapse. Moreover, patients under conditions of low stress and who scored low on avoidance coping (ie, did not engage in social diversion or distraction) were least likely to relapse. This study supports a biopsychosocial model of CD exacerbation.

Predicting early onset of male antisocial behavior from preschool behavior.

METHODS: Data from a large longitudinal study of boys who were between kindergarten and age 13 years were used to (1) test whether Gray's and Cloninger's personality dimensions measured in kindergarten predicted the early onset of stable, highly delinquent behavior; (2) test whether 1, 2, or 3 dimensions were needed; and (3) test the predictive value of a categorical approach. RESULTS: The impulsivity dimension was the best predictor of the early onset of stable, highly delinquent behavior. Anxiety and reward dependence made significant but weaker contributions. The categorical approach corroborated Cloninger's suggestion that boys who are high in impulsivity, low in anxiety, and low in reward dependence would be more at risk for delinquent involvement. Boys who were high in impulsivity and low in anxiety but high in reward dependence were much less at risk for delinquency. Differences in antisocial behavior among extreme kindergarten personality groups were stable from ages 11 to 13 years. CONCLUSIONS: The behavioral activating system appears to be the major dimension underlying the propensity toward early onset of antisocial behavior, but both the behavioral inhibition system and the need for social rewards play important roles. The behavioral style (personality) that results from the interplay of these systems is clearly in place by the kindergarten year. Preventive efforts should target preschool children with at-risk behavior profiles. However, longitudinal-experimental studies with at least yearly assessments between birth and school-entry age are needed to understand the extent to which the behavioral styles are antecedent to preschool disruptive behavior disorders.

Co-morbidity and physician use in fibromyalgia.

OBJECTIVE: To describe comorbidity in women with FM, and to examine the effects of different types of comorbidity on physician use. METHODS: Women (n = 180) with primary FM were evaluated at baseline and 6 months later for self-reported health resource use and covariates. Reported comorbidity was classified into 4 categories: medical, psychiatric, "functional", and unknown. The category for "functional" conditions included disorders that have been classified by previous authors as medically unexplained symptoms such as the irritable bowel and chronic fatigue syndromes. Logistic regression models were developed to examine associations between types of comorbidity and physician use. RESULTS: Comorbid conditions were reported by over 90% of the sample. Total number of comorbid complaints was associated with high number of physician visits. In logistic regression models (controlling for age, ethnicity, education, disability, pain, and psychological vulnerability) medical comorbidity was a much stronger determinant of high number of physician visits than was "functional" comorbidity. CONCLUSIONS: Comorbidity with other disorders, both functional and medical, was high in this sample. Medical and psychiatric comorbidity were stronger determinants of high physician use than "functional" comorbidity.

Predictors of physical outcomes in pediatric bone marrow transplantation.

The purpose of the present study was to investigate the hypothesis that family factors, in conjunction with clinical factors, are associated with physical outcomes in pediatric BMT. A prospective study of 68 pediatric patients (mean age = 7.5 years; ranging from 4 months to 18 years) undergoing BMT was carried out over a 6.5 year period. Physicians rated initial prognosis on a (0-5) scale which incorporated the child's diagnosis, known risk factors, and type of donor. Both parents individually completed two psychometrically sound questionnaires assessing family well-being and marital satisfaction. Cox proportional hazards survival analyses were performed to determine predictors of death (44% of the patients died). Potential predictor variables included were: initial prognosis, type of transplant, patient's age, socioeconomic status, marital satisfaction and family status, and family stress. Initial prognosis, as estimated by the physician, (RR = 0.62, 95% CI = 0.40, 0.97) was the best predictor of survival. Initial clinical factors are clearly critical in outcomes for pediatric BMT patients.

The role of stress in functional disability among women with systemic lupus erythematosus: a prospective study.

OBJECTIVE: In the last decade, the biopsychosocial approach has been applied to systemic lupus erythematosus (SLE) to understand the multiple factors involved in the disease course. This study examined the link between stress and changes in functional disability as assessed by the Stanford Health Assessment Questionnaire (HAQ) in women with SLE. METHODS: Forty-two women with SLE were assessed at baseline and 8 months later. Major stress (Life Events), minor stressors (Hassles), depression (Beck Depression Inventory), disease activity (Systemic Lupus Activity Measure), and functional disability were collected at both time points, while demographic and disease damage variables (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index) were collected once at baseline. RESULTS: Mean HAQ scores at baseline (0.52) and followup (0.46) indicated mild disability and remained fairly stable, although individual variation was observed (mean change -0.07; range -1.25-0.5). Demographic (age, education) and disease (duration, activity, damage) variables were not related to 8-month changes on the HAQ. Of the baseline stress measures, greater negative life events in the preceding 6 months was correlated with reduced functional ability (r = 0.42) 8 months later. Individual changes in depressed mood over the 8-month period were correlated (r = 0.33) with changes in functional ability. Hierarchical multiple regression revealed that after controlling for baseline HAQ scores and changes in depressed mood, baseline negative life events remained a significant predictor of changes in functional ability. CONCLUSION: We found that the major short-term determinants of functional disability were not demographic- or disease-related factors, but rather stress caused by negative life events. Comprehensive treatment of SLE requires management of life stress.

Psychosocial contributors to mental and physical health in patients with systemic lupus erythematosus.

OBJECTIVE: To delineate psychosocial and systemic lupus erythematosus (SLE)-related medical factors that contribute to the mental and physical health of SLE patients. METHODS: In a cross-sectional study, 44 women completed standardized instruments assessing daily hassles, social support, psychologic distress, and quality of life and underwent a physician examination to assess disease activity and disease damage. Four multiple linear regression analyses were computed to identify factors associated with the following outcomes: patient-perceived psychologic distress and global physical health and physician-assessed disease activity and damage. Variables entered into the regression analyses were: hassles severity, types of social support, SLE disease activity and damage, age, disease duration, education, ethnicity, and global psychologic distress (for the outcomes of self-perceived global physical health and disease activity and damage). RESULTS: The best model explaining global psychologic distress included hassles severity and self-esteem social support. The best model explaining patients' perceptions of their global physical health included hassles severity and tangible social support. Psychologic distress accounted for a significant proportion of variance in both disease activity and damage. CONCLUSION: High stress (assessed by hassles severity), poor social support, and psychologic distress--potentially modifiable variables--are associated with the mental and physical health of SLE patients.

Quality of life in systemic lupus erythematosus patients during more and less active disease states: differential contributors to mental and physical health.

OBJECTIVE: To identify determinants of mental and physical health as a function of disease state in patients with systemic lupus erythematosus (SLE). METHODS: A sample of 129 SLE patients (mean age 42.01 years; SD 11.09) was recruited from 9 immunology/rheumatology clinics across Canada. Patients completed questionnaires assessing psychological distress, social support, coping, stress, and health-related quality of life. Physicians rated disease activity (using the revised Systemic Lupus Activity Measure; SLAM-R) and damage (using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index). Mental and physical health composite scores were derived from the Medical Outcomes Study Short Form 36. Patients were subdivided into more active (SLAM-R > or = 10; n = 38) or less active disease states (n = 91). RESULTS: Better mental health was predicted by more education and less emotion-oriented coping in the patients in a more active disease state (P = 0.0001; R2 = 0.46). Better mental health was predicted by less stress, less emotion-oriented coping and more task-oriented coping in patients during a less active disease state (P = 0.0001; R2 = 0.45). Better physical health was predicted by more emotion-oriented coping in patients in a more active disease state (P = 0.04; R2 = 0.11). Better physical health was predicted by less stress and younger age in patients during a less active disease state (P = 0.0001; R2 = 0.20). CONCLUSION: The positive association between emotion-oriented coping and better physical health in patients during a more active disease state suggests that this style of coping may be more adaptive in situations that are considered uncontrollable (e.g., SLE flare). Predictors of mental health were similar to those found in the literature, especially for SLE patients in a less active disease state.

Is having an alcoholic father hazardous for children's physical health?

Five hundred and ninety-nine French-Canadian pre-adolescent children for whom the alcoholic status of the parents was known were subdivided into eight groups, according to family structure (intact, non-intact), alcoholic status of the father (alcoholic, non-alcoholic) and gender of the target child (girl, boy). ANCOVAs were conducted (controlling for income, a factor which contributes to illness) for health-related variables in order to test the hypothesis that children of alcoholic fathers have more physical health problems compared to children without alcoholic fathers. Data pertaining to use of medical services, serious and minor illnesses and pregnancy-related events were analysed. It was found that overall, pre-adolescent children of alcoholics were not more ill than children of non-alcoholics. There were, however, some differences worthy of note. Children of alcoholics had significantly lower birthweights than the children of non-alcoholics. Boys in non-intact alcoholic families were of shorter stature than the other children. A three-way interaction showed that daughters of alcoholics and sons of non-alcoholics living in non-intact families were more likely to have used psychologists' services, as were sons of alcoholics in intact families. The results were discussed in terms of the heterogeneity of alcoholic families as well as the need to identify subgroups of children of alcoholics who are at risk.

Personal and familial characteristics of resilient sons of male alcoholics.

This study compared sons of male alcoholics (SOMAs) who had no problems with those who were abusing substances, those who had school problems, those who were delinquent and those who were multiproblem. Corresponding groups of non-SOMAs were also included. Groups were compared at ages 6, 10, 12 and 14 years on teacher- and peer-rated aggressiveness, hyperactivity, inattention, anxiety and prosociality; parent-rated temperament; parents' disciplinary practices; school performance; family socio-economic status; self-reported substance (ab)use and delinquency; and school performance (from school records). Differences between SOMAs and non-SOMAs were small. According to teachers and peers, no problem SOMAs and non-SOMAs were less aggressive-oppositional, inattentive and hyperactive than problem SOMAs and non-SOMAs. These effects differed as a function of age, however. Also, no problem SOMAs and non-SOMAs performed better in school than boys in the problem groups. We discuss the relevance of these findings for identifying factors that render children resilient and for early screening to select truly at risk SOMAs for prevention programs.

Predicting boys' early-onset substance abuse from father's alcoholism, son's disruptiveness, and mother's parenting behavior.

Sons of male alcoholics (SOMAs) are said to be at risk for alcoholism. The present study examined 4 groups of 13-year-old boys: SOMAs with and without disruptive behaviors, disruptive boys who were not SOMAs, and control participants. The classification of disruptive was based on 7-year longitudinal data, and father's alcoholism was determined by standardized tests. Mother's nurturance and promotion of autonomy were assessed in a laboratory setting; boys' substance abuse was measured by self-report methods in the same year as the observation. Boys with disruptive behaviors showed the most substance abuse; no effect of father's alcoholism was found. Disruptive boys' mothers were significantly less nurturant and demanded obedience rather than promoted autonomy. A multiple regression analysis revealed that the boys' disruptive behavior and the mother's lack of nurturance predicted early-onset substance abuse.

A study of barriers to the engagement of significant others in adult addiction treatment.

Using the focus group methodology, this study identified personal and structural barriers to the engagement of significant others in an outpatient addictions treatment program. Twenty-eight significant others (family members, other kin, and friends) associated with 21 patients participated in one of three focus group sessions. The cut-and-paste technique was used to analyze the narrative data. Improving communication and reconnecting patients with a supportive community were forms of support identified. Patients' willingness to accept support and therapists' invitation to involve significant others in the treatment were identified as necessary precursors to their initial involvement. Providing educational and therapeutic support to significant others were endorsed as important elements in maintaining their involvement. Offering a diversity of therapeutic services beyond standard office hours, providing home visits and child care were viewed as facilitators for their involvement. It became apparent that support providers tended to resent having their own needs ignored. Feelings of isolation, fatalism, loneliness, ignorance, and fear were expressed by significant others. Theoretical and practical implications of the findings are discussed.

Mother-son interactions in disruptive and nondisruptive adolescent sons of male alcoholics and controls.

OBJECTIVE: The goal of the study was to describe mother-son relations in adolescent sons of male alcoholics. METHOD: Eighty-two mother-son dyads were observed interacting in a laboratory setting. They were subdivided into four groups: sons of male alcoholics (SOMAs) with and without behavioral problems, boys who were not SOMAs but had behavioral problems, and controls. Disruptive boys were included and distinguished from SOMAs because while there is often co-occurrence of these two problems they are not always found in the same individual. RESULTS: It was found that the biological mothers of the disruptive boys were less supportive and nurturing of their sons than were the other mothers. They were also rated as less mature, more anxious, and less confident in themselves as parents. There were no significant findings for the SOMAs or their mothers, whose interactions resembled the control group. CONCLUSIONS: It is possible that sons of male alcoholics' differences may be due to the disruptiveness of the boys rather than to their family alcoholic status per se.

Paternal alcoholism, paternal absence and the development of problem behaviors in boys from age six to twelve years.

OBJECTIVE: The purpose of this study was to examine the association between paternal alcoholism, paternal absence, and the development and stability of behavioral problems in boys, from kindergarten to the end of elementary school. METHOD: A sample of 642 boys originating from low socioeconomic status (SES) families was used. Paternal alcoholism was established using the Short Michigan Alcohol Screening Test. Behavioral problems (opposition, hyperactivity, inattention, physical aggression and anxiety) were assessed by teachers' reports when the boys were 6 and 12 years old. Four groups of boys were created on the basis of paternal alcoholism (nonalcoholic, alcoholic) and family structure (intact families, nonintact/father-absent families). RESULTS: Consistent with personality theories of alcoholism, results showed that a propensity for physical aggression and low anxiety best distinguished sons of male alcoholics (SOMAs) from non-SOMAs at both ages (6 and 12 years), even when SES was controlled. In addition, SOMAs were more oppositional and hyperactive than non-SOMAs at both ages. No significant effects were observed for family structure or age, or an interaction between these factors and paternal alcoholism in the multivariate analysis. CONCLUSIONS: The results suggest that problem behaviors in SOMAs begin early and persist over time, and that paternal alcoholism and family structure are not associated with changes in boys' behaviors between kindergarten and the end of elementary school in this population, at least in the sample used.

Can Childhood Behavioural Characteristics Predict Adolescent Boys' Health?: A Nine-year Longitudinal Study.

Nine-year longitudinal data were used to group participants in terms of the stability of the boys' disruptiveness and/or anxiety. In addition to annual assessment, 625 boys were interviewed between the ages 14 and 16 years to measure healthy and risky behaviours, as well as health outcomes. A logistic regression showed significant group effects for risky health behaviours (e.g. unsafe sex, alcohol abuse). Boys with stable disruptive characteristics were most likely and boys with stable anxious characteristics were least likely to engage in risky behaviours. As for health outcomes, boys with stable disruptive characteristics used health services more often. The boys with anxious characteristics reported more chronic minor health problems and were hospitalized more for non-psychiatric problems during the past year.

Predictors of outcome in drug treatment of adolescent inpatients.

Little is known about for whom treatment is most effective and how to match adolescent clients to substance-abuse treatment. 280 adolescents treated in a multifaceted program participated. Of these, 128 did not complete treatment prior to termination of the 2-mo. inpatient phase. They were significantly different from clients who completed treatment measures of alienation, social maladaptation, aggression, and lower occupational status of the father. Of those who completed inpatient treatment and remained in the study at 1-mo. postdischarge (n = 69) two groups were formed, those who improved and those who either remained the same or worsened in terms of substance abuse. For those who improved factors which differentiated them were identification with middle-class values, tendency to be older, initial difficulty identifying emotions, and depressive symptoms at intake. Clients who did not change or worsened were distinguished by more social anxiety, depressive symptoms, and troubling thoughts at intake. These results suggest that individual characteristics may identify cases who are more likely to benefit from treatment.

Weathering storms: a cohort study of how participation in a mindfulness-based stress reduction program benefits women after breast cancer treatment.

INTRODUCTION: A growing number of psychosocial interventions are being offered to cancer patients during and after their medical treatment. Here, we examined whether Mindfulness-Based Stress Reduction (MBSR), a stress management course, helps women to cope better with stress and illness once their breast cancer treatment is completed. Our aim was to understand how MBSR may benefit those who participate in the course. METHODS: Our cohort study enrolled 59 women in an 8-week MBSR program. They completed "before and after" questionnaires pertaining to outcomes (stress, depression, medical symptoms) and process variables (mindfulness, coping with illness, sense of coherence). Paired t-tests examined changes from before to after the MBSR course. Changes in mindfulness were correlated with changes in post-MBSR variables, and a regression analysis examined which variables contributed to a reduction in stress after program participation. RESULTS: Adherence to the program was 91%. Participants reported significant reductions in stress (p < 0.0001), depression (p < 0.0001), and medical symptoms (p < 0.0001), and significant improvements in mindfulness (p < 0.0001), coping with illness (p < 0.0001), and sense of coherence (p < 0.0001). Changes in mindfulness were significantly related to changes in depression, stress, emotional coping, and sense of coherence. Increases in mindfulness and sense of coherence predicted reductions in stress. CONCLUSIONS: It appears that learning how to be mindful is beneficial for women after their treatment for breast cancer.

A randomized clinical trial of an individualized home-based exercise programme for women with fibromyalgia.

OBJECTIVE: To determine the efficacy of a 12-week individualized home-based exercise programme on physical functioning, pain severity and psychological distress for women with fibromyalgia (FM). METHODS: Seventy-nine women with a primary diagnosis of FM were randomized to a 12-week individualized home-based moderate-intensity exercise programme or to a usual care control group. Outcomes were functional capacity (Fibromyalgia Impact Questionnaire), pain severity and psychological distress. Outcomes were measured at study entry, at the end of the 12-week intervention, and at 3 and 9 months following completion of the intervention. RESULTS: On the basis of intention-to-treat analyses, a significant improvement in functional capacity at 3 and 9 months following treatment for participants in the exercise group who were more functionally disabled at study entry was observed. At both 3 and 9 months post-treatment, the mean estimated benefit of the intervention was more than 10 points [-12.3 (95% CI, -21.9 to -2.8); -10.8 (95% CI, -21.5 to -0.2)]. Compared with the control group, statistically significant improvements in upper body pain were evident in the exercise group at post-treatment. These between-group differences in upper body pain were maintained at 3 and 9 months post-treatment. No statistically significant group differences on lower body pain and psychological distress were found. CONCLUSIONS: Home-based exercise, a relatively low-cost treatment modality, has the potential to improve important health outcomes in FM.

Measurement of psychological and heart rate reactivity to stress in the real world.

The purpose of the present investigation was to develop and test an innovative methodology to assess stress reactivity in the real world. A portable microcomputer was programmed to administer two questionnaires eight times per day for 3 days in the field. Heart rate was measured simultaneously using a reliable and valid ambulatory monitor (Sport Tester PE-3000). Data were analyzed in terms of stress versus no stress, based on subjects' perceptions of the 24 events. It was found that heart rate was significantly higher in the stress condition and that physical stressors contributed significantly to heart rate variability, as did cigarette smoking. Three emotional responses were evident when subjects were stressed: anxiety, hostility and depression; the former two emotions also contributed to heart rate variability. The heart rate data were compared to a number of other studies conducted in the field and found to be strikingly similar. It was concluded that the new technologies currently available allow for the measurement of stress reactivity in the field.

Determining baseline and adaptation periods in stress research.

Investigations pertaining to psychophysiological stress responses typically employ a preexperimental 'baseline' period. The appropriateness of this methodology was examined in two studies using heart rate (HR) measures. In study 1, HR decreased significantly from the beginning to the end of a 15-min adaptation period, suggesting that the optimal length for a prestress adaptation period must be at least 15 min for HR when a stressor is anticipated. Study 2 compared the customary prestress 'baseline' measure to four other possible candidates: two recovery periods between stressor presentations, a postexperimental time period, and a recording taken on a different day when no stressors were presented. The prestress measure was significantly higher than recovery and postexperimental measures. The postexperimental measure was retained as the best option for the computation of a baseline score. These studies highlight the factors pertinent to the selection of a suitable time frame for a baseline measure.