Catastrophizing: a predictor of persistent pain among women with endometriosis at 1 year.

BACKGROUND: Endometriosis is the most common gynecological diagnosis among women with chronic pelvic pain, but the underlying mechanisms of endometriosis-associated chronic pelvic pain remain unclear. Therefore, the objective of this study was to determine the biopsychosocial predictors of pain improvement among women with endometriosis. METHODS: One hundred and fifteen women who presented for treatment of endometriosis-associated chronic pelvic pain at a tertiary referral center at a university-based hospital participated in this prospective observational study of clinical practice. Participants completed questionnaires assessing pain, mental health and catastrophizing at entry and 1 year follow-up. The main outcome measure assessed was the interval change in pain report using the McGill pain 1uestionnaire. RESULT(S): On average, participants experienced a 37.4% reduction in interval pain (P < 0.001). Adjusted for baseline pain, nulliparity (P = 0.002) and catastrophizing (P = 0.04) were associated with decreased probability of interval improvement in pain. Those referred for physical therapy had less interval pain improvement (P = 0.04). However, undergoing hysterectomy was a strong predictor of improvement in pain (P = 0.008). CONCLUSION(S): Our study suggests that chronic pain in endometriosis may be more akin to other idiopathic pain disorders. Specifically, biopsychosocial variables, such as catastrophizing, play an important role in reported severity. Further research on biopsychosocial correlates of chronic pelvic pain in endometriosis is warranted.

The development and validation of a new coeliac disease quality of life survey (CD-QOL).

BACKGROUND: Previous studies on coeliac disease (CD)-related quality of life (QOL) have been limited by their use of a 'generic' rather than coeliac disease-specific assessment instruments. AIM: To develop and psychometrically validate a new coeliac disease-specific instrument, the CD-QOL. METHODS: Through a series of focus groups, we elicited items from patients that related to the specific nature of their disease and its impact on their basic needs. Through expert review, cognitive debriefing with patients and pilot testing, a scale was developed, refined and administered to 387 patients on a gluten-free diet from both community-based support groups and a tertiary care referral centre. Finally, a formal validation study was conducted to assess the psychometric properties of the CD-QOL. RESULTS: The final CD-QOL has 20 items across four clinically relevant subscales (Limitations, Dysphoria, Health Concerns, and Inadequate Treatment). The CD-QOL has high internal consistency, reliability, and psychometric validation indicates both convergent and discriminate validity. CONCLUSIONS: The CD-QOL is a reliable and valid measure of coeliac disease related QOL. As a new disease-specific instrument, it is likely to be a useful tool for evaluating patients with this disorder.

Trauma, stressful life events and depression predict HIV-related fatigue.

Despite the fact that fatigue is a common and debilitating symptom among HIV-infected persons, we know little about the predictors of fatigue in this population. The goal of this cross-sectional study was to examine the effects of early childhood trauma, recent stressful life events and depression on intensity and impairment of fatigue in HIV, over and above demographic factors and clinical characteristics. We studied 128 HIV-infected men and women from one southern state. The median number of childhood traumatic events was two and participants tended to have at least one moderate recent stressful event. Multiple regression findings showed that patients with less income, more childhood trauma, more recent stressful events and more depressive symptoms had greater fatigue intensity and fatigue-related impairment in daily functioning. Recent stresses were a more powerful predictor of fatigue than childhood trauma. None of the disease-related measures (e.g. CD4, viral load, antiretroviral medication) predicted fatigue. Although stress and trauma have been related to fatigue in other populations, this is the first study to examine the effects of traumatic and recent stressful life events on fatigue in an HIV-infected sample.

Measuring fatigue in people living with HIV/AIDS: psychometric characteristics of the HIV-related fatigue scale.

In the era of life-prolonging antiretroviral therapy, chronic fatigue is one of the most prevalent and disabling symptoms of people living with HIV/AIDS, yet its measurement remains challenging. No instruments have been developed specifically to describe HIV-related fatigue. We assessed the reliability and construct validity of the HIV-Related Fatigue Scale (HRFS), a 56-item self-report instrument developed through formative qualitative research and designed to measure the intensity and consequences of fatigue as well as the circumstances surrounding fatigue in people living with HIV. The HRFS has three main scales, which measure fatigue intensity, the responsiveness of fatigue to circumstances and fatigue-related impairment of functioning. The functioning scale can be further divided into subscales measuring impairment of activities of daily living, impairment of mental functioning and impairment of social functioning. Each scale demonstrated high internal consistency (Cronbach's alpha=0.93, 0.91 and 0.97 for the intensity, responsiveness and functioning scales, respectively). The HRFS scales also demonstrated satisfactory convergent validity when compared to other fatigue measures. HIV-Related Fatigue Scales were moderately correlated with quality of nighttime sleep (rho=0.46, 0.47 and 0.35) but showed only weak correlations with daytime sleepiness (rho=0.20, 0.33 and 0.18). The scales were also moderately correlated with general mental and physical health as measured by the SF-36 Health Survey (rho ranged from 0.30 to 0.68 across the 8 SF-36 subscales with most >0.40). The HRFS is a promising tool to help facilitate research on the prevalence, etiology and consequences of fatigue in people living with HIV.

Childhood abuse and initial presentation for HIV care: an opportunity for early intervention.

An alarmingly high prevalence of childhood sexual and physical abuse has been observed in HIV-infected men and women, with rates several times higher than observed in the general population. Childhood abuse history has been associated with worse antiretroviral adherence and negative health behaviours in HIV-infected patients. This study evaluates the relationship between childhood abuse and the timing of presentation for HIV care. Participants in a multi-center prospective cohort study, who established initial HIV care after January 1996 and had a CD4 count available within six months of initial presentation, were included in this analysis. Bivariate contingency tables and multivariate logistic regression were used to evaluate the association of childhood abuse with early presentation for HIV care (initial CD4 count > or =200/mm3). Among the 186 subjects included in this analysis, 33% had childhood abuse histories and 58% had an initial CD4 count > or =200/mm3. Participants with a history of childhood abuse were more likely to present early for HIV care (AOR=2.12; p=0.03), perhaps because survivors of abuse tend to have higher utilization of health services. Because HIV-infected patients with childhood abuse histories have worse antiretroviral medication adherence and are more likely to engage in high-risk sexual and injection drug use behaviours, early presentation affords clinicians the opportunity for timely institution of interventions that may improve patient outcomes and prevent secondary HIV infections.

Progression to AIDS, a clinical AIDS condition and mortality: psychosocial and physiological predictors.

BACKGROUND: The primary aim of this study is to examine prospectively the association of stressful life events, social support, depressive symptoms, anger, serum cortisol and lymphocyte subsets with changes in multiple measures of human immunodeficiency virus (HIV) disease progression. METHODS: Ninety-six HIV-infected gay men without symptoms or anti-retroviral medication use at baseline were studied every 6 months for up to 9 years. Disease progression was defined in three ways using the Centers for Disease Control (CDC) classifications (e.g. AIDS, clinical AIDS condition and mortality). Cox regression models with time-dependent covariates were used, adjusting for control variables (e.g. race, age, baseline, CD4 T cells and viral load, number of anti-retroviral medications). RESULTS: Higher cumulative average stressful life events and lower cumulative average social support predicted faster progression to both the CDC AIDS classification and a clinical AIDS condition. Higher anger scores and CD8 T cells were associated with faster progression to AIDS, and depressive symptoms were associated with faster development of an AIDS clinical condition. Higher levels of serum cortisol predicted all three measures of disease progression. CONCLUSIONS: These results suggest that stressful life events, dysphoric mood and limited social support are associated with more rapid clinical progression in HIV infection, with serum cortisol also exerting an independent effect on disease progression.

Elevated substance P levels in HIV-infected men.

The neuropeptide, substance P, is a potent modulator of neuroimmunoregulation. Substance P and its receptor modulate HIV infection. HIV-seropositive men had significantly higher plasma substance P levels compared with uninfected controls, which were associated with decreased CD16 and CD56 natural killer (NK) cell populations. The changes in plasma substance P levels and decreases in NK subsets did not correlate with CD4 cell levels, but a diurnal pattern was suggested for substance P. The balance between substance P expression and functions of immune cells may be important in the immunopathogenesis of HIV infection.

Psychosocial-immune relationships in HIV disease.

Human immunodeficiency virus (HIV) is now commonly viewed as a chronic disease, which often consists of a wide array of recurrent and sometimes severe psychosocial stressors. An individual's response to these multiple challenges over time may impact their health. In this article, we review research examining the relationship of psychologic factors (eg, depression, stressful life events, coping, social support) with immune system function and disease course. We also explore some of the potential physiologic pathways that may underlie these types of psychosocial-immune relationships, as well as the effects of psychologic interventions, particularly cognitive-behavioral stress management (CBSM), on the psychosocial, neuroendocrine, and immune functioning of people living with HIV. We conclude by suggesting some areas for future research, particularly the study of HIV-positive women.

The effects of depression, stressful life events, social support, and coping on the progression of HIV infection.

This article reviews recent findings concerning the role of psychosocial factors on the progression of HIV. Specifically, we examine the role of depression, stressful life events, social support, and coping on changes in CD4 T-lymphocytes and other indicators of HIV disease progression. Studies have yielded important evidence that depression, stressful life events, low social support, and denial coping may have a detrimental impact on HIV disease course. Delineating the role of psychosocial factors on HIV disease progression may aid in the development of new interventions for this devastating disease.

Impact of stressful life events, depression, social support, coping, and cortisol on progression to AIDS.

OBJECTIVE: This study examined prospectively the effects of stressful events, depressive symptoms, social support, coping methods, and cortisol levels on progression of HIV-1 infection. METHOD: Eighty-two homosexual men with HIV type-1 infection without AIDS or symptoms at baseline were studied every 6 months for up to 7. 5 years. Men were recruited from rural and urban areas in North Carolina, and none was using antiretroviral medications at entry. Disease progression was defined as CD4(+) lymphocyte count <200/microl or the presence of an AIDS indicator condition. RESULTS: Cox regression models with time-dependent covariates were used adjusting for race, baseline CD4(+) count and viral load, and cumulative average antiretroviral medications. Faster progression to AIDS was associated with higher cumulative average stressful life events, coping by means of denial, and higher serum cortisol as well as with lower cumulative average satisfaction with social support. Other background (e.g., age, education) and health habit variables (e.g., tobacco use, risky sexual behavior) did not significantly predict disease progression. The risk of AIDS was approximately doubled for every 1.5-unit decrease in cumulative average support satisfaction and for every cumulative average increase of one severe stressor, one unit of denial, and 5 mg/dl of cortisol. CONCLUSIONS: Further research is needed to determine if treatments based on these findings might alter the clinical course of HIV-1 infection.

Effects of coping on health outcome among women with gastrointestinal disorders.

BACKGROUND: Studies have shown that the nature and quality of coping may positively or negatively affect health outcome; however, this relationship has not been well studied among patients with gastrointestinal (GI) disorders. OBJECTIVES: The primary objective was to study the effect of different coping strategies on the health outcome of women with GI disorders and how these coping strategies may modify the effects of education, GI disease type, neuroticism, and abuse severity on health outcome. METHODS: We followed 174 patients in a referral GI clinic for 12 months to assess their health status as a derived variable of daily pain, bed disability days, psychological distress, daily dysfunction, number of visits to physicians, and number of surgeries and procedures. We obtained at baseline their GI diagnosis (functional vs. organic), neuroticism score (NEO Personality Inventory), sexual and/or physical abuse history, and scores on two coping questionnaires. Regressions analyses were used to determine the relative effect of the coping measures on health outcome and their modifying effects on education, GI disease type, neuroticism, and abuse severity. RESULTS: A higher score on the Catastrophizing scale and a lower score on the Self-Perceived Ability to Decrease Symptoms scale (Coping Strategies Questionnaire) predicted poor health outcome. Less education, a functional GI diagnosis, a higher neuroticism score, and greater abuse severity also contributed to poor health status. However, the effect of GI disease type and neuroticism on health outcome was significantly reduced by the coping measures. CONCLUSIONS: Maladaptive coping (eg, catastrophizing) and decreased self-perceived ability to decrease symptoms may adversely affect health outcome and may modify the effect of GI disease type and neuroticism on health outcome.

Characterizing and dating the onset of symptoms in psychotic illness: the Symptom Onset in Schizophrenia (SOS) inventory.

Prodromal symptoms, including disturbances of perceptions, beliefs, cognition, affect, and behavior, are often the first symptoms of schizophrenia. Little is understood about the initial, prodromal stage of schizophrenia, despite the compelling research and clinical need. The development and psychometric properties of a new, time-efficient instrument to characterize and date the initial symptoms of a psychotic illnesses, the Symptom Onset in Schizophrenia (SOS) scale, is described in this paper. The SOS rates the presence and dates the onset of 16 general prodromal, positive, negative, and disorganizational symptoms, as well as a clinician, family, and patient global rating of onset of illness. Inter-rater reliability for the presence of each symptom in 35 patients with schizophrenia, schizoaffective, or schizophreniform disorder was good to excellent, with kappa coefficient >0.7 for 12 items, and >0. 5 for all items. Agreement on symptom duration was good to excellent for individual items (ICC=0.7-1.0) and for global rating of duration of illness (ICC=0.97). Our data indicate that the SOS is a reliable, valid, time-efficient tool useful to retrospectively assess the onset of schizophrenia and related psychotic disorders. Further study is underway to evaluate other psychometric properties of the SOS, including test-retest reliability and predictive validity.

High versus low basal cortisol secretion in asymptomatic, medication-free HIV-infected men: differential effects of severe life stress on parameters of immune status.

The authors hypothesized that HIV-infected men with high basal cortisol secretion would exhibit greater stress-related reductions in the ratio of Th1/Th2 cell-derived cytokines and numbers of CD8+ T and NK lymphocytes than low basal cortisol secretors. A semistructured interview was used to assess life stress during the preceding 6 months of 94 HIV-infected men classified as high and low cortisol secretors (n = 47/group). Increased levels of severe life stress were highly correlated with lower numbers of CD8+ T cells, CD16+ and CD56+ NK cells, CD57+ cells, and higher DHEA-S concentrations in the high cortisol group. Conversely, no significant correlations were found in the low cortisol group. No correlations were found between stress and CD4+ T helper/inducer cell counts, cytokine production, or testosterone levels in either participating group. These data suggest that severe stress in combination with high glucocorticoid activity may modify select parameters of immune status in HIV-infected men.

Progression to AIDS: the effects of stress, depressive symptoms, and social support.

OBJECTIVE: We examined the effects of stress, depressive symptoms, and social support on the progression of HIV infection. METHODS: Eighty-two HIV-infected gay men without symptoms or AIDS at baseline were followed up every 6 months for up to 5.5 years. Men were recruited from rural and urban areas in North Carolina as part of the Coping in Health and Illness Project. Disease progression was defined using criteria for AIDS (CD4+ lymphocyte count of <200/microl and/or an AIDS-indicator condition). RESULTS: We used Cox regression models with time-dependent covariates, adjusting for age, education, race, baseline CD4+ count, tobacco use, and number of antiretroviral medications. Faster progression to AIDS was associated with more cumulative stressful life events (p = .002), more cumulative depressive symptoms (p = .008), and less cumulative social support (p = .0002). When all three variables were analyzed together, stress and social support remained significant in the model. At 5.5 years, the probability of getting AIDS was about two to three times as high among those above the median on stress or below the median on social support compared with those below the median on stress or above the median on support, respectively. CONCLUSIONS: These data are among the first to demonstrate that more stress and less social support may accelerate the course of HIV disease progression. Additional study will be necessary to elucidate the mechanisms that underlie these relationships and to determine whether interventions that address stress and social support can alter the course of HIV infection.

Dysregulation of cardiovascular and neuroendocrine responses to stress in premenstrual dysphoric disorder.

Twelve women with prospectively confirmed premenstrual dysphoric disorder (PMDD or PDD) were compared with 12 healthy control subjects for cardiovascular and neuroendocrine responses to speech and mental arithmetic (Paced Auditory Serial Addition Task) stressors during both the follicular and luteal phases of the menstrual cycle. Structured clinical interview was used to assess psychiatric and abuse histories, and standardized questionnaires were administered to assess current life stress. Results revealed that PMDD women had significantly lower stroke volume, cardiac output and cortisol levels but significantly elevated norepinephrine and total peripheral resistance at rest and also during mental stressors compared with control subjects. These effects were evident in both cycle phases. Significantly more women with PMDD had histories of sexual abuse, and they also reported greater current life stress than control subjects. Consistent with a history of trauma, the PMDD women exhibited significantly greater ratios of norepinephrine to cortisol at rest and during stress. These results are interpreted as reflecting dysregulation of the stress response and may be related to histories of severe and/or chronic exposure to stress for a subgroup of PMDD women.

Selected symptoms associated with sexual and physical abuse history among female patients with gastrointestinal disorders: the impact on subsequent health care visits.

BACKGROUND: Despite a growing literature pointing to the deleterious health effects of sexual and physical abuse history, few studies provide evidence about which medical symptoms are most affected. The aim of this paper is to determine the impact of sexual and physical abuse history on a selected set of medical symptoms, and to test how such abuse, medical symptoms and functional disability may affect subsequent health care visits. METHODS: We studied 239 women from a referral-based gastroenterology clinic; follow-up data were available on 196 of these women. All women were interviewed about sexual and physical abuse history. RESULTS: Women with abuse history, particularly those with severe abuse, were much more likely to report somatic symptoms related to panic (e.g. palpitations, numbness, shortness of breath), depression (e.g. difficulty sleeping, loss of appetite), musculoskeletal disorders (e.g. headaches, muscle aches), genito-urinary disorders (e.g. vaginal discharge, pelvic pain, painful intercourse), skin disturbance (e.g. rash) and respiratory illness (e.g. stuffy nose). Furthermore, we found that the severity of abuse history, somatic symptoms and functional disability predicted 30% of the variance in health care visits during the subsequent year, and that the effect of abuse severity on visits was explained by abused women having more somatic symptoms and functional disability. CONCLUSIONS: Patients' reports of abuse history, somatic symptoms and functional disability appear to be important factors in explaining the number of health care visits among a clinic sample of women with gastrointestinal disorders.

How multiple types of stressors impact on health.

OBJECTIVE: Although many studies have focused on the relationship between stress and health, few have examined the impact of multiple types of stressors. The current study investigated the health impact of four stressors: sexual and physical abuse history, lifetime losses and traumas, turmoil in childhood family, and recent stressful life events. METHOD: The sample included 239 female patients from a referral-based gastroenterology clinic. RESULTS: We found that the four stressors (abuse history, lifetime traumas, turmoil in childhood family, and recent stressful life events) were related to poor health status (eg, more pain, symptoms, bed disability days, physician visits, functional disability, and psychological distress); together, these stressors accounted for 32% of the variance in overall current health. Furthermore, women who scored high on one type of stressor also tended to have experienced other types. Unlike many previous studies, we did not find that social support buffered the effects of stress. CONCLUSIONS: This study provides evidence that many different types of stressors independently contribute to poor health outcome. Such findings suggest that health practitioners and researchers should question patients about histories of traumatic events, in addition to the examination of the biological aspects of illness, inasmuch as both may have notable effects on health status.

Severe life stress as a predictor of early disease progression in HIV infection.

OBJECTIVE: Although there is evidence that stress is associated with alterations in immunity, the role of emotional factors in the onset and course of immune-based diseases such as cancer and AIDS has not been established. This prospective study was designed to test the hypothesis that stressful life events accelerate the course of HIV disease. METHOD: Ninety-three HIV-positive homosexual men who were without clinical symptoms at the time of entry into the study were studied for up to 42 months. Subjects received comprehensive medical, neurological, neuropsychological, and psychiatric assessments every 6 months, including assessment of stressful life events during the preceding 6-month interval. Several statistical approaches were used to assess the relation between stress and disease progression. RESULTS: The time of the first disease progression was analyzed with a proportional hazard survival method, which demonstrated that the more severe the life stress experienced, the greater the risk of early HIV disease progression. Specifically, for every one severe stress per 6-month study interval, the risk of early disease progression was doubled. Among a subset of 66 subjects who had been in the study for at least 24 months, logistic regression analyses showed that higher severe life stress increased the odds of developing HIV disease progression nearly fourfold. the degree of disease progression was also predicted by severe life stress when a proportional odds logistic regression model was used for analysis. CONCLUSIONS: This report presents the first evidence from a prospective research study that severe life event stress is associated with an increased rate of early HIV disease progression.

Severe stress, depressive symptoms, and changes in lymphocyte subsets in human immunodeficiency virus-infected men. A 2-year follow-up study.

BACKGROUND: This study examined how severe stress and depressive symptoms were related to changes in immune measures during a 2-year period in a sample of gay men with human immunodeficiency virus (HIV) infection. These analyses follow up our initial cross-sectional observations that severe stress was correlated with lower levels of natural killer (NK) cells and CD8+ T lymphocytes in these men. METHODS: Data were collected in North Carolina as part of an ongoing, longitudinal study, the Coping in Health and Illness Project. Sixty-six HIV-infected gay men, who were asymptomatic at baseline, were assessed systematically at 6-month intervals. RESULTS: Severe stress and depressive symptoms were independently related to decreases on immune measures from entry to 2-year follow-up, that is, declines in CD8+ T cells and CD56+ and CD16+ NK cell subsets. Subjects most likely to have decreases on these immune measures were those who scored above the median on both stress and depressive symptoms. CONCLUSIONS: Our findings are among the first prospective data showing that stress and depressive symptoms, especially when they occur jointly, are associated with decreased number of NK and CD8+ T lymphocytes in HIV-infected men. Since these immune cells may play a protective role in the progression of HIV infection, our data suggest that stress and depressive symptoms may have clinical implications for the course of this disease.

Impact of sexual and physical abuse dimensions on health status: development of an abuse severity measure.

OBJECTIVE: Despite the abundant literature showing a relationship of sexual and/or physical abuse history with poor health status, few studies provide evidence about which dimensions of abuse may have a worse impact on health. In female patients with gastrointestinal (GI) disorders, the present study aims to identify which dimensions of abuse history (eg, number of perpetrators, injury) might predict poor current health status, in order to develop an empirically based severity of abuse measure. METHODS: Of a sample of 239 female patients from a referral gastroenterology clinic, this paper primarily focuses on 121 women with a past history of contact sexual abuse (N = 99), and/or life threatening physical abuse (N = 68). RESULTS: Among those with a sexual abuse history, 24% of current health status was explained by serious injury during abuse (p = .0006), victimization by multiple perpetrators (p = .03), and being raped (p = .09). Among the physically abused, rape (in addition to life threat) (p = .0001), and multiple life-threatening incidents (p = .002) explained 39% of the variance in overall health. Among the women with a sexual and/or physical abuse history, the experience of rape, serious injury during sexual abuse, and multiple life-threatening incidents explained one fourth of the variance in current health status. Based on these three dimensions of abuse, we created an abuse severity measure which explained about one fourth of the variance in health status among the subgroup with abuse history, and among the entire clinic sample. CONCLUSIONS: Given the high prevalence of abuse in referral practice, and the potential health impact of previous abuse, it is important that history taking include details concerning the abuse experience. The severity of abuse measure developed in this paper should prove useful for both research and clinical practice.