Patient informed consent, ethical and legal considerations in the context of digital vulnerability with smart, cardiac implantable electronic devices.

Advancements in digitalisation with cardiac implantable electronic devices (CIEDs) allow patients opportunities for improved autonomy, quality of life, and a potential increase in life expectancy. However, with the digital and functional practicalities of CIEDs, there exists also cyber safety issues with transferring wireless information. If a digital network were to be hacked, a CIED patient could experience both the loss of sensitive data and the loss of functional control of the CIED due to an unwelcome party. Moreover, if a CIED patient were to become victim of a cyber attack, which resulted in a serious or lethal event, and if this information were to become public, the trust in healthcare would be impacted and legal consequences could result. A cyber attack therefore poses not only a direct threat to the patient's health but also the confidentiality, integrity, and availability of the CIED, and these cyber threats could be considered "patient-targeted threats." Informed consent is a key component of ethical care, legally concordant practice, and promoting patient-as-partner therapeutic relationships [1]. To date, there are no standardised guidelines for listing cybersecurity risks within the informed consent or for discussing them during the consent process. Providers are responsible for adhering to the ethical principles of autonomy, beneficence, non-maleficence, and justice, both in medical practice generally and the informed consent process specifically. At present, the decision to include cybersecurity risks is mainly left to the provider's discretion, who may also have limited cyber risk information. Without effective and in-depth communication about all possible cybersecurity risks during the consent process, CIED patients can be left unaware of the privacy and physical risks they possess by carrying such a device. Therefore, cyber risk factors should be covered within the patients' informed consent and reviewed on an ongoing basis as new risk information becomes available. By including cyber risk information in the informed consent process, patients are given the autonomy to make the best-informed decision.

The Role of Trait and State Mindfulness in Cognitive Performance of Male Adolescents.

Purpose: The number of mindfulness intervention projects is continually increasing. Within the educational environment, mindfulness has purported links to well-being, positive behaviour, educational and cognitive performance. Trait mindfulness is related to rational thinking and better performance in cognitive tests, suggesting that innate mindfulness ability contributes to self-regulation ability and thus the efficacy of mindfulness interventions. The current study investigates whether mindfulness is a moderating factor. It examines correlations between cognitive performance and trait mindfulness. The study investigates the influence of trait mindfulness on the ability of students to enter state mindfulness in an attempt to understand the role both types of mindfulness may have on cognitive performance. Participants and Method: Two-hundred and five male students aged fifteen and sixteen completed the adolescent version of the Mindfulness Awareness Scale, the Cognitive Reflection Test, and the Toronto Mindfulness Scale. Results: Hierarchical regression analysis found that state mindfulness was a predictor of cognitive reflection ability. ANOVA also found that having either trait or state mindfulness predicted higher cognitive reflection scores, but only state mindfulness had a significant effect on cognitive reflection. Trait mindfulness was not a moderating factor. Conclusion: Both state and trait aspects of mindfulness ability influence cognitive performance. Those with higher trait mindfulness ability are better able to enter state mindfulness and thus had better cognitive reflection scores. However, where it is possible to induce state mindfulness into those with low trait mindfulness, CRT scores were also higher although not significantly so.

The Role of Emotion Regulation for General Self-Efficacy in Adolescents Assessed Through Both Neurophysiological and Self-Reported Measures.

Background: Self-efficacy, the belief in one's ability and capacity to organize and execute actions required to achieve desired results, is associated with adolescent academic achievement and reduced risk for psychopathology. Adolescent emotion regulation represents an important component in the relationship between self-efficacy and developmental outcomes, but the underlying neurophysiological mechanisms are poorly understood. It is unclear how emotion regulation strategies, which change with experience, and emotion regulation capacity, which is largely determined by genetics, contribute to the development of self-efficacy. Aim: The present study aims to explore the relationship between emotion regulation and self-efficacy in adolescents. We hypothesize that neurophysiological emotion regulation capacity moderates the relationship between emotion regulation strategies and self-efficacy. Methods: The present study applied a cross-sectional design. A sample of high-school students (N = 45, nfemale = 31, age = 17-18) provided answers on the General Self-Efficacy Questionnaire and the Emotion Regulation Questionnaire. Vagal tone was used as an indicator for emotion regulation capacity. Results: In the initial correlational analysis, reappraisal, but not expressive suppression nor vagal tone was associated with self-efficacy. Vagal tone was not associated with any self-report measures of emotion regulation or self-efficacy. Contrary to our hypothesis, vagal tone did not moderate the relationship between emotion regulation and self-efficacy. Conclusion: This is the first study assessing the relationship between neurophysiological indicators of emotion regulation and self-efficacy. Our results do not indicate that vagal tone moderates the relationship between emotion regulation strategies and general self-efficacy. Future studies should also assess the possible influence of metacognition and interoception on relationships.

A 3D mixed reality visualization of network topology and activity results in better dyadic cyber team communication and cyber situational awareness.

Background: Cyber defense decision-making during cyber threat situations is based on human-to-human communication aiming to establish a shared cyber situational awareness. Previous studies suggested that communication inefficiencies were among the biggest problems facing security operation center teams. There is a need for tools that allow for more efficient communication of cyber threat information between individuals both in education and during cyber threat situations. Methods: In the present study, we compared how the visual representation of network topology and traffic in 3D mixed reality vs. 2D affected team performance in a sample of cyber cadets (N = 22) cooperating in dyads. Performance outcomes included network topology recognition, cyber situational awareness, confidence in judgements, experienced communication demands, observed verbal communication, and forced choice decision-making. The study utilized network data from the NATO CCDCOE 2022 Locked Shields cyber defense exercise. Results: We found that participants using the 3D mixed reality visualization had better cyber situational awareness than participants in the 2D group. The 3D mixed reality group was generally more confident in their judgments except when performing worse than the 2D group on the topology recognition task (which favored the 2D condition). Participants in the 3D mixed reality group experienced less communication demands, and performed more verbal communication aimed at establishing a shared mental model and less communications discussing task resolution. Better communication was associated with better cyber situational awareness. There were no differences in decision-making between the groups. This could be due to cohort effects such as formal training or the modest sample size. Conclusion: This is the first study comparing the effect of 3D mixed reality and 2D visualizations of network topology on dyadic cyber team communication and cyber situational awareness. Using 3D mixed reality visualizations resulted in better cyber situational awareness and team communication. The experiment should be repeated in a larger and more diverse sample to determine its potential effect on decision-making.

Working from home during lockdown: the association between rest breaks and well-being.

One of the challenges with working from home (WFH) is the question of its effect on health and well-being. The impact of home working on health has so far not been studied extensively. We address this gap by investigating the association between internal recovery, operationalised as rest break frequency (low, medium, and high) during the working day, on self-reported musculoskeletal pain, and post-work recovery symptoms in WFH knowledge workers (n = 382). The analysis showed that failing to take frequent breaks was associated with a dose-response increased risk of reporting headaches. For post-work recovery symptoms, failing to take rest breaks throughout the day was associated with an increased risk of reporting psychological fatigue, physical fatigue, and sleep problems, and a decreased risk of psychologically detaching from work and experiencing adequate rest. Our findings emphasise the importance of remote workers taking recovery breaks from work demands in the maintenance of health and well-being.Practitioner Summary: For the foreseeable future, many knowledge workers will be obliged to work from home for at least, some days of the week. It is therefore important for workers to learn to regulate their behaviour, and workers need to be educated about the value of taking regular rest breaks throughout the working day.Abbreviations: ICT: Information and communications technology; MSDs: musculoskeletal disorders; MSPs: Musculoskeletal pain symptoms; OR: Odds ratio; WFH: Working from home; WRRQ: Work-Related Rumination Questionnaire Questionnaire.

Guided Internet-Delivered Treatment for Depression: Scoping Review.

BACKGROUND: Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder. OBJECTIVE: The aim of this study was to provide an overview of this research area and identify potential gaps in the research. METHODS: In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition. RESULTS: A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion. CONCLUSIONS: This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

The cortisol awakening response at admission to hospital predicts depression severity after discharge in major depressive disorder patients-A replication study.

The cortisol awakening response (CAR) is a non-invasive biomarker for hypothalamic-pituitary-adrenal axis (HPA) dysregulation, reflecting accumulated stress over time. In a previous study we reported that a blunted CAR before an inpatient treatment predicted self-reported depressive symptoms six weeks and six months after discharge [Eikeseth, F. F., Denninghaus, S., Cropley, M., Witthöft, M., Pawelzik, M., & Sütterlin, S. (2019). The cortisol awakening response at admission to hospital predicts depression severity after discharge in major depressive disorder (MDD) patients. Journal of Psychiatric Research, 111, 44-50)]. This replication study adopted an improved overall methodology with more stringent assessment protocols and monitoring. The longitudinal design included 122 inpatients from a psychosomatic hospital with a diagnosis of MDD displaying symptoms of moderate to severe major depression (n = 80 females). The CAR was measured at intake. Depression severity was assessed as Beck Depression Inventory II scores at intake, discharge, 6 weeks and 6 months following discharge. Results from the original study were replicated in terms of effect size but did not reach statistical significance (correlation between BDI-II 6 months after discharge and AUCg: r = -0.213; p = 0.054). The replication study yielded nearly identical correlation coefficients as in the original study (BDI-II 6 months and CAR, r = -0.223, p < 0.05). The replication of previously reported effect sizes with a concurrent lack of statistical significance in the more restrictive, larger and better controlled replication study may well inform research on psycho-endocrinological predictors for treatment success, but suggests a rather limited practical relevance for cortisol awakening response measures in this clinical context.

The Effect of Heart Rate Variability Biofeedback Training on Vagal Tone in Athletically Talented Secondary School Students.

This study examines whether twelve sessions of heart rate variability biofeedback training would improve vagally mediated heart rate variability. If so, it would go some way in explaining why breathing-based interventions reduce clinical symptoms and improve non-clinical performance outcomes. METHODS: Thirty participants (N = 30, Nfemale = 13) aged 14-13-year-old, all talented athletes, from a sport specialist school in SE London UK, were randomly divided into three groups, a control group, a psychology skills training combined with heart rate variability biofeedback training group, and a heart rate variability biofeedback only group. For the combined group, a variety of typical psychological skill training techniques were also used. RESULTS: Paired participant t-test and the Wilcoxon Signed Rank test found non-significant differences between pre- and post-intervention measurements of heart rate variability. Non-significant results remained even after pooling the biofeedback training groups (n = 19). CONCLUSIONS: Our results do not indicate that beneficial effects associated with focused breathing training can be attributed to improved vagal tone. Further investigation into the underlying mechanisms of the benefits of focused breathing techniques is necessary to maximize clinical and non-clinical outcomes.

Emotions and emotion up-regulation during the COVID-19 pandemic in Germany.

In stressful situations such as the COVID-19-pandemic, unpleasant emotions are expected to increase while pleasant emotions will likely decrease. Little is known about the role cognitive appraisals, information management, and upregulating pleasant emotions can play to support emotion regulation in a pandemic. In an online survey (N = 1682), we investigated predictors of changes in pleasant and unpleasant emotions in a German sample (aged 18-88 years) shortly after the first restrictions were imposed. Crisis self-efficacy and felt restriction were predictors of changes in unpleasant emotions and joy alike. The application of emotion up-regulation strategies was weakly associated with changes in joy. Among the different upregulation strategies, only "savouring the moment" predicted changes in joy. Our study informs future research perspectives assessing the role of upregulating pleasant emotions under challenging circumstances.

Prefrontally modulated vagal neuroimmunomodulation is associated with telomere length.

Background: Accumulated senescent cells are proposed to be one of the main drivers of age-related pathology such as dementia and cancer through disruption of tissue structure and function. We recently proposed the Neuro-Immuno-Senescence Integrative Model (NISIM), which relates prefrontally modulated vagal tone and subsequent balance between vagal and sympathetic input to the spleen to inflammatory responses leading to generation of reactive oxygen species and oxidative telomere damage. Aim: In this study, we assess inflammation as a mediator in the relationship between prefrontally modulated vagal tone and leukocyte telomere length (LTL). We also assess the relationship between a recently proposed index of vagal neuroimmunomodulation (vagal tone/inflammation ratio; NIM index) and telomere length. Methods: This study uses participant data from a large nationally representative longitudinal study since 1974 with a total of 45,000 Norwegian residents so far. A sub-sample of 131 participants from which ultrashort recordings (30 s) of vagal tone, c reactive protein, and LTL could be obtained were included in the study. Relationships were analyzed with Pearson's correlations and hierarchical multiple linear regression using either vagal tone and CRP or the NIM index to predict telomere length. Results: Vagal tone was a significant positive predictor of telomere length but this was not mediated by c reactive protein, even after controlling for confounders. The NIM index was a significant positive predictor of telomere length, also when controlling for confounders. In a follow-up analysis simultaneously comparing telomere length between groups with high and low values of vagal tone, and between groups with high and low NIM index values, telomere length was only significantly different between NIM index groups. Conclusion: This is the first study suggesting that prefrontally modulated vagal neuroimmunomodulation is associated with telomere length thus supporting the NISIM. Results indicate that the NIM index is a more sensitive indicator of vagal neuroimmunomodulation than vagal tone and CRP in isolation.

Virtual and Augmented Reality in Social Skills Interventions for Individuals with Autism Spectrum Disorder: A Scoping Review.

In the last decade, there has been an increase in publications on technology-based interventions for autism spectrum disorder (ASD). Virtual reality based assessments and intervention tools are promising and have shown to be acceptable amongst individuals with ASD. This scoping review reports on 49 studies utilizing virtual reality and augmented reality technology in social skills interventions for individuals with ASD. The included studies mostly targeted children and adolescents, but few targeted very young children or adults. Our findings show that the mode number of participants with ASD is low, and that female participants are underrepresented. Our review suggests that there is need for studies that apply virtual and augmented realty with more rigorous designs involving established and evidenced-based intervention strategies.

Neurophysiological and emotional influences on team communication and metacognitive cyber situational awareness during a cyber engineering exercise.

Background: Cyber operations unfold at superhuman speeds where cyber defense decisions are based on human-to-human communication aiming to achieve a shared cyber situational awareness. The recently proposed Orient, Locate, Bridge (OLB) model suggests a three-phase metacognitive approach for successful communication of cyber situational awareness for good cyber defense decision-making. Successful OLB execution implies applying cognitive control to coordinate self-referential and externally directed cognitive processes. In the brain, this is dependent on the frontoparietal control network and its connectivity to the default mode network. Emotional reactions may increase default mode network activity and reduce attention allocation to analytical processes resulting in sub-optimal decision-making. Vagal tone is an indicator of activity in the dorsolateral prefrontal node of the frontoparietal control network and is associated with functional connectivity between the frontoparietal control network and the default mode network. Aim: The aim of the present study was to assess whether indicators of neural activity relevant to the processes outlined by the OLB model were related to outcomes hypothesized by the model. Methods: Cyber cadets (N = 36) enrolled in a 3-day cyber engineering exercise organized by the Norwegian Defense Cyber Academy participated in the study. Differences in prospective metacognitive judgments of cyber situational awareness, communication demands, and mood were compared between cyber cadets with high and low vagal tone. Vagal tone was measured at rest prior to the exercise. Affective states, communication demands, cyber situational awareness, and metacognitive accuracy were measured on each day of the exercise. Results: We found that cyber cadets with higher vagal tone had better metacognitive judgments of cyber situational awareness, imposed fewer communication demands on their teams, and had more neutral moods compared to cyber cadets with lower vagal tone. Conclusion: These findings provide neuroergonomic support for the OLB model and suggest that it may be useful in education and training. Future studies should assess the effect of OLB-ing as an intervention on communication and performance.

Impact of Initial Emotional States and Self-Efficacy Changes on Nursing Students' Practical Skills Performance in Simulation-Based Education.

Training through simulation has shown to increase relevant and specific skills sets across a wide range of areas in nursing and related professions. Increasing skills has a reciprocal relation to the development of self-efficacy. A study was conducted to assess changes in the development of self-efficacy in simulation training for 2nd year nursing students. Initial emotional states, pre and post self-efficacy, and expert ratings of simulation performance were assessed. Results show that students who displayed an increase in self-efficacy as a result of simulation training were also judged to perform better by expert ratings. The effect of simulation on self-efficacy could be influenced by initial states of physiological activation and over control. Results also showed that initial emotional states did not moderate self-efficacy development on outcome measures. These findings improve our understanding on the relationship between students' self-efficacy and performance of practical skills and inform pedagogical designs and targeted interventions in relation to feedback and supervision in nursing education.

CyberGenomics: Application of Behavioral Genetics in Cybersecurity.

Cybersecurity (CS) is a contemporary field for research and applied study of a range of aspects from across multiple disciplines. A cybersecurity expert has an in-depth knowledge of technology but is often also recognized for the ability to view technology in a non-standard way. This paper explores how CS specialists are both a combination of professional computing-based skills and genetically encoded traits. Almost every human behavioral trait is a result of many genome variants in action altogether with environmental factors. The review focuses on contextualizing the behavior genetics aspects in the application of cybersecurity. It reconsiders methods that help to identify aspects of human behavior from the genetic information. And stress is an illustrative factor to start the discussion within the community on what methodology should be used in an ethical way to approach those questions. CS positions are considered stressful due to the complexity of the domain and the social impact it can have in cases of failure. An individual risk profile could be created combining known genome variants linked to a trait of particular behavior using a special biostatistical approach such as a polygenic score. These revised advancements bring challenging possibilities in the applications of human behavior genetics and CS.

Psychological Burden During the COVID-19 Pandemic in Germany.

After the first COVID-19 case was diagnosed in Germany, various measures limiting contact between people were introduced across the country. The implementation of these measures varied between jurisdictions and potentially had a negative impact on the psychological well-being of many people. However, the prevalence, severity, and type of symptoms of psychological burden has not been documented in detail. In the current study, we analysed various self-reported symptoms of psychological burden in a German sample. The dataset was collected between April 8th and June 1st, 2020, through an online survey measuring psychological burden using the ICD-10-symptom rating scale. More than 2,000 individuals responded to the survey, with a total of 1,459 complete datasets. Data was then sampled to compare (1) the new data to an existing demographically comparable reference dataset including a total of 2,512 participants who did not undergo any kind of contact restrictions or other pandemic measurements, and (2) psychological burden in two different German states. In line with recent observations from Germany, Italy, China, Austria and Turkey, we found a high prevalence of depressive symptoms in comparison to the reference sample. Furthermore, we found a high prevalence of eating disorder and compulsion symptoms. Especially younger adults and women reported a higher symptom severity compared to other groups during our measurement period. However, no difference between the two states in psychological burden was found.

Reduction of depressive symptoms during inpatient treatment is not associated with changes in heart rate variability.

Vagally mediated heart rate variability (HRV) is a psychophysiological indicator of mental and physical health. Limited research suggests there is reduced vagal activity and resulting lower HRV in patients with Major Depressive Disorder (MDD); however little is actually known about the association between HRV and symptoms of depression and whether the association mirrors symptom improvement following psychotherapy. The aim of this study was to investigate the association between antidepressant therapy, symptom change and HRV in 50 inpatients (68% females; 17-68 years) with a diagnosis of MDD. Severity of depressive symptoms was assessed by self-report (Beck Depression Inventory II) and the Hamilton Rating Scale of Depression. Measures of vagally mediated HRV (root mean square of successive differences and high-frequency) were assessed at multiple measurement points before and after inpatient psychotherapeutic and psychiatric treatment. Results showed an expected negative correlation between HRV and depressive symptoms at intake. Depressive symptoms improved (d = 0.84) without corresponding change in HRV, demonstrating a de-coupling between this psychophysiological indicator and symptom severity. To our knowledge, this study is the first to examine an association between HRV and depressive symptoms before and after psychotherapy. The observed de-coupling of depression and HRV, and its methodological implications for future research are discussed.

Virtual reality and naturalistic developmental behavioral interventions for children with autism spectrum disorder.

BACKGROUND: Naturalistic Developmental Behavioral Interventions (NDBI) have been evaluated as the most promising interventions for children with autism spectrum disorder. In recent years, a growing body of literature suggests that technological advancements such as Virtual Reality (VR) are promising intervention tools. However, to the best of our knowledge no studies have combined evidence-based practice with such tools. AIM: This article aims to review the current literature combining NDBI and VR, and provide suggestions on merging NDBI-approaches with VR. METHODS: This article is divided into two parts, where we first conduct a review mapping the research applying NDBI-approaches in VR. In the second part we argue how to apply the common features of NDBI into VR-technology. RESULTS: Our findings show that no VR-studies explicitly rely on NDBI-approaches, but some utilize elements in their interventions that are considered to be common features to NDBI. CONCLUSIONS AND IMPLICATIONS: As the results show, to date, no VR-based studies have utilized NDBI in their intervention. We therefore, in the second part of this article, suggests ways to merge VR and NDBI and introduce the term Virtual Naturalistic Developmental Behavioral Interventions (VNDBI). VNDBI is an innovative way of implementing NDBI which will contribute in making interventions more accessible in central as well as remote locations, while reducing unwanted variation between service sites. VNDBI will advance the possibilities of individually tailoring and widen the area of interventions. In addition, VNDBI can provide the field with new knowledge on effective components enhancing the accuracy in the intervention packages and thus move forward the research field and clinical practice.

Altered regulation of negative affect in patients with fibromyalgia: A diary study.

BACKGROUND: Fibromyalgia is characterized by widespread musculoskeletal pain and often accompanied by cognitive and emotional problems. Adaptation to fibromyalgia may therefore also rely on one's ability to regulate emotional problems. In this study, we examined two indices of emotion regulation, that is, (a) affective instability, involving frequent large fluctuations in self-reported affect, and (b) resting heart rate variability (HRV). METHODS: Participants were 46 patients with fibromyalgia (Mage  = 45.4 years; 39 females) and 46 matched healthy controls (Mage  = 44.9 years; 37 females). Heart rate was monitored under resting conditions to derive HRV. Subsequently, participants completed an electronic end-of-day diary for 14 consecutive days assessing daily levels of pain, disability, negative affect (NA) and positive affect (PA). Affective instability was operationalized as the mean square of successive differences in daily mood. RESULTS: Results indicate increased levels of NA instability and reduced levels of HRV in patients with fibromyalgia in comparison with healthy controls. Furthermore, HRV and NA instability were inversely related. Finally, in patients, higher NA instability was related to increased pain disability. CONCLUSIONS: Current findings support the idea that patients with fibromyalgia are confronted with fluctuating emotions. These results may have important implications for treatment as they provide support for the use of emotion regulation skills training in patients with fibromyalgia to impact upon NA instability. SIGNIFICANCE: This study provides novel insight in the link between emotion regulation indices,that is, heart-rate variability and negative affective (NA) instability, in patients with fibromyalgia, and presents evidence for differences in both emotion regulation indices between patients with fibromyalgia and healthy people. Furthermore, results link increased NA instability with increased levels of daily disability in patients with fibromyalgia. Together, these findings offer support for a key role of emotion regulation in fibromyalgia outcomes, providing pathways for clinical practice.

The Test-Retest Reliability of Heart Rate Variability and Its Association With Personality Functioning.

Background: Heart rate variability (HRV) is a widely used non-invasive index of emotion regulation ability. The main aim of our study was to investigate the relationship between HRV and level of personality functioning in a clinical sample, most of whom had a personality disorder. Our secondary aim was to examine the test-retest reliability of HRV in our sample as there is a lack of knowledge regarding the test-retest reliability in psychiatric populations. We hypothesized that trait HRV would be negatively associated with impairments of personality functioning. Method: Thirty-two adults (23 females, mean age = 27) with threshold or subthreshold personality disorders were recruited from two psychiatric outpatient clinics in Norway. Impairment of personality functioning was assessed by the first module of the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders (SCID-5-AMPD-I); Level of Personality Functioning Scale (LPFS). HRV was assessed during resting conditions with spontaneous breathing over three separate days. Trait HRV was calculated by averaging all three HRV assessments. The test-retest reliability of HRV was assessed using intraclass correlations. Results: Contrary to expected, a positive association between trait HRV and the LPFS Self-direction domain emerged. This was driven by positive associations between the LPFS and HRV at time point 2. Overall, the test-retest reliability of HRV was comparable to previous studies on healthy subjects. However, the reliability coefficients for the first two time points were considerably lower relative to the second and third time points. Conclusions: We propose that impairment of personality functioning may have increased the proportion of variance in HRV attributed to state relative to trait. This could explain the lower test-retest reliability for the first two time points. The increased test-retest reliability for the last two time points could reflect a habituation to the testing situation and hence, less pronounced influences of state in the second and third time points.

Proposing a Framework for the Restorative Effects of Nature through Conditioning: Conditioned Restoration Theory.

Natural environments have been shown to trigger psychological and physiological restoration in humans. A new framework regarding natural environments restorative properties is proposed. Conditioned restoration theory builds on a classical conditioning paradigm, postulating the occurrence of four stages: (i) unconditioned restoration, unconditioned positive affective responses reliably occur in a given environment (such as in a natural setting); (ii) restorative conditioning, the positive affective responses become conditioned to the environment; (iii) conditioned restoration, subsequent exposure to the environment, in the absence of the unconditioned stimulus, retrieves the same positive affective responses; and (iv) stimulus generalization, subsequent exposure to associated environmental cues retrieves the same positive affective responses. The process, hypothetically not unique to natural environments, involve the well-documented phenomenon of conditioning, retrieval, and association and relies on evaluative conditioning, classical conditioning, core affect, and conscious expectancy. Empirical findings showing that restoration can occur in non-natural environments and through various sensory stimuli, as well as findings demonstrating that previous negative experience with nature can subsequently lower restorative effects, are also presented in support of the theory. In integration with other existing theories, the theory should prove to be a valuable framework for future research.