NADA Ear Acupuncture and Medical Acupuncture for Pain- and Health-Related Quality of Life among Older Patients with Chronic Nonspecific Low Back Pain: A Prospective Clinical Trial.

BACKGROUND: The purpose of this study was to investigate the efficacy and safety of the NADA (National Acupuncture Detoxification Association)-standardized ear acupuncture protocol in comparison to medical acupuncture (MA) in the treatment of chronic nonspecific low back pain (LBP) in older adults. METHODS: This was a prospective, clinical, single center, open label, comparative study. A total of 60 older patients with chronic nonspecific LBP were enrolled in the study. The patients were divided into two groups. The MA group received treatment with medical acupuncture (MA), while the NADA group received NADA ear acupuncture once a day for 20 min, for a total of 10 sessions. The co-primary outcome measures were the reduction in pain intensity evaluated by the Numeric Rating Scale (NRS) compared to baseline and improvement in patients' quality of life (QOL) assessed in the SF-36 questionnaire before and after treatment; this was compared between the two groups. RESULTS: After two weeks of treatment, a significant reduction compared to baseline was observed in the NRS scores following treatment with medical acupuncture as well as after the utilization of NADA ear acupuncture protocol: NRS score for average pain experienced by the patients over the previous week (NRSa) MA: p = 0.002; NADA: p < 0.001, maximum NRS score in the past week (NRSm) MA: p < 0.001; NADA: p < 0.001, and NRS score at the time of examination (NRSe) MA: p = 0.001; NADA: p < 0.001. Reduction of the NRSa score compared to baseline was significantly greater in the NADA group (p = 0.034). Significant improvements in the QOL of patients according to the SF-36 questionnaire compared to baseline were observed in the MA group in the following domains: PF (p = 0.003), RP (p = 0.002), SF (p = 0.041), RE (p = 0.005), MH (p = 0.043), HT (p = 0.013), PCS (p = 0.004), and MCS (p = 0.025); and in the NADA group, in the following domains: PF (p = 0.004), RP (p = 0.048), BP (p = 0.001), VT (p = 0.035), RE (p = 0.006), MH (p < 0.001), HT (p = 0.003), PCS (p < 0.001), and MCS (p < 0.001). There were minor complications observed in 35% of patients (total of 20 participants); 31% (9 patients) in the MA group and 39% (11 patients) in the NADA group. These were minor and quickly resolved, including insertion point pain, minor bleeding after needle removal, and one instance of fainting. No patients in either group reported worsening of LBP. These complications occurred in 4.14% of MA sessions (12 times/290 sessions) and in 6.07% of NADA acupuncture sessions (16 times/280 sessions). CONCLUSION: The outcomes of this study suggest that both MA and NADA ear acupuncture could be a valuable and personalized component of a comprehensive approach to managing chronic nonspecific LBP in older patients. Incorporation of MA and NADA ear acupuncture into the clinical management of chronic nonspecific LBP in elderly patients has the potential to reduce pain intensity and improve the overall quality of life of affected individuals. However, further studies are needed to confirm our findings.

Randomized Controlled Trial of Acupressure for Perception of Stress and Health-Related Quality of Life Among Health Care Providers During the COVID-19 Pandemic: The Self-Acupressure for Stress (SAS) Trial.

Background: The efficacy of providing self-acupressure educational materials in reducing stress and improving health-related quality of life (HRQOL) is uncertain. Evidence-based data to recommend for or against self-acupressure as an intervention for reducing stress and improving HRQOL is needed. Objective: The Self-Acupressure for Stress (SAS) trial evaluates whether providing self-acupressure educational materials would reduce stress and improve HRQOL among health care providers (HCPs). Design: Randomized behavioral clinical trial. Setting: The entire study took place remotely. Participants: One hundred fifty-nine adult HCPs with no prior experience or training in acupressure. Intervention: The intervention group received self-acupressure educational materials. Measurements: Primary outcomes were perception of stress measured by the Perceived Stress Scale (PSS), as well as scores on the physical and mental components of the 12-item Short Form Health Survey version 2 (SF-12v2). Results: From the baseline to midpoint evaluations, the intervention group significantly reduced their PSS score (P ≤ .001) and increased their SF-12v2 Mental score (P = .002) but not their SF-12v2 Physical score (P = .55). These findings persisted at the final follow-up (both PSS and SF-12v2 Mental changes from baseline P < .001). However the control group also significantly improved their SF-12v2 Mental from baseline to midpoint (P = .01) which was maintained at final follow-up (P = .02), whereas PSS and SF-12v2 Physical did not significantly change from baseline at either mid or final. Finally, the intervention group improved by significantly more than the control group from baseline to final follow-up for both PSS (P = .007) and SF-12v2 Mental (P = .02) HRQOL measures. Limitation: The trial was not blinded. Conclusion: Among HCPs during the coronavirus disease 2019 (COVID-19) pandemic, the provision of self-acupressure educational materials safely improved self-reported assessments of perception of stress and mental health. Self-acupressure represents a promising intervention for other populations. The study findings support the use of self-acupressure to reduce stress and improve HRQOL. Trial Registration: ClinicalTrials.gov: NCT04472559.

Promoting whole person health: Exploring the role of traditional Chinese medicine in Polish healthcare.

Poland has a unique history of traditional Chinese medicine (TCM) dating back to the 17th century when Polish missionary Michael (Michal) Boym was a pioneer in the field. In the 20th century, his successor, Professor Zbigniew Garnuszewski, reintroduced acupuncture to medical practice in Poland. However, other methods of TCM and its holistic approach to patient care have not found their place in modern medicine in Poland. At present, the legal status of TCM in Poland remains unregulated, with TCM included in the broad spectrum of complementary and alternative medicine (CAM) practices. Few reports are available on the use of TCM methods among the Polish population. Integrative medicine combines conventional medicine with evidence-based CAM interventions and considers all aspects of a patient's health, including physical, emotional, mental, social, and environmental factors. An integrative healthcare model that incorporates TCM modalities and lifestyle recommendations as well as a whole person approach may provide a more sustainable solution for the constantly underfinanced Polish healthcare system, which faces challenges of multimorbidity in an aging society and limited access to care. The coronavirus disease 2019 pandemic, war in Ukraine, and ongoing climate crisis have underscored the need to strengthen the resilience of the Polish healthcare system and search for new solutions. A model of care that blends the best of biomedicine and TCM healing approaches may be a better option for both patients and the healthcare system in Poland. Please cite this article as: Rybicka M, Zhao J, Piotrowicz K, Ptasnik S, Mitka K, Kocot-Kepska M, Hui KK. Promoting whole person health: Exploring the role of traditional Chinese medicine in Polish healthcare. J Integr Med. 2023; 21(6): 509-517.

Menstrual cycle characteristics as an indicator of fertility outcomes: evidence from prospective birth cohort study in China.

OBJECTIVE: To evidently assess the applicability of regulate menstrual cycle (MC) characteristics in Traditional Chinese Medicine (TCM) as an indicator for fertility. METHODS: A community-based prospective cohort study was conducted in China. Between January 2010 and December 2012, women who were willing to conceive within 2 years were enrolled in the study. Other than the MC length pattern, a well-adopted MC characteristic, menstrual blood color and clots were specifically concerned for women enrolled. All participants were followed up in 2 years by trained nurses. Pregnancy rate, fecundability odds ratio () and risk of miscarriage were assessed as fertility outcomes. RESULTS: A total of 2109 women were effectively included in this cohort for analysis. Results show that women with irregular MC length were less likely to achieve conception (= 0.59; 95% = 0.45-0.77, < 0.001). Menstrual blood in bright red color was also associated with decline in likelihood of conception ( = 0.79; 95% = 0.63-0.98, = 0.04). Women with menstrual blood in light red were at higher risk of miscarriage ( = 2.39; 95% = 0.91-6.28, = 0.08). No significant impact was found between menstrual blood clots and fertility outcomes ( = 1.02, 95% = 0.83-1.25, = 0.88; = 1.26 95% = 0.77-2.07, = 0.35). CONCLUSIONS: MC characteristics can be an effective and simple indicator for women's fertility. Increasing the knowledge of MC characteristics for women in reproductive ages would bring great benefits to their preconception health conditions.

Acupuncture for cancer pain: an evidence-based clinical practice guideline.

BACKGROUND: This study aims to develop an evidence-based clinical practice guideline of acupuncture in the treatment of patients with moderate and severe cancer pain. METHODS: The development of this guideline was triggered by a systematic review published in JAMA Oncology in 2020. We searched databases and websites for evidence on patient preferences and values, and other resources of using acupuncture for treatment of cancer pain. Recommendations were developed through a Delphi consensus of an international multidisciplinary panel including 13 western medicine oncologists, Chinese medicine/acupuncture clinical practitioners, and two patient representatives. The certainty of evidence, patient preferences and values, resources, and other factors were fully considered in formulating the recommendations. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was employed to rate the certainty of evidence and the strength of recommendations. RESULTS: The guideline proposed three recommendations: (1) a strong recommendation for the treatment of acupuncture rather than no treatment to relieve pain in patients with moderate to severe cancer pain; (2) a weak recommendation for the combination treatments with acupuncture/acupressure to reduce pain intensity, decrease the opioid dose, and alleviate opioid-related side effects in moderate to severe cancer pain patients who are using analgesics; and (3) a strong recommendation for acupuncture in breast cancer patients to relieve their aromatase inhibitor-induced arthralgia. CONCLUSION: This proposed guideline provides recommendations for the management of patients with cancer pain. The small sample sizes of evidence limit the strength of the recommendations and highlights the need for additional research.

Reframing Palliative Care: An East-West Integrative Palliative Care Model.

Convergence of principles of palliative care and integrative medicine has led to the introduction of the new practice of integrative palliative care in which integrative therapies (including mind-body modalities, traditional Chinese medicine, Ayurveda, and dietary supplements) are used to provide symptom management for patients who are dying or experiencing the sequelae of serious illness and its treatment. We propose an East-West Integrative palliative care model using non-drug therapies, such as acupuncture, diet, exercise, and stress management that shift the paradigm from suppressing the symptoms of illness to addressing both the root cause of the symptoms and the imbalance and declining homeostatic reserve that perpetuate these symptoms. This whole-person model expands the reach of palliative care, prolonging a better quality of life and allowing the patient to maintain as many activities as possible by preventing symptoms and improving function. Through this approach we reframe the dialogue such that patients are "living better" rather than "dying better" when faced with serious illness or death. In this article, we provide an overview of the principles of palliative care, integrative medicine, and the novel area of integrative palliative care, and propose an East-West integrative palliative care model that incorporates and broadens the scope of these existing approaches.

Chinese herbal medicine might be associated with a lower rate of joint replacement in patients with osteoarthritis: A 12-year population-based matched cohort analysis.

ETHNOPHARMACOLOGICAL RELEVANCE: To determine whether adjuvant Chinese herbal medicine (CHM) treatment is associated with the risk of joint replacement in osteoarthritis (OA) patients. MATERIALS AND METHODS: This retrospective study used a population-based national health insurance (NHI) database from 2000 to 2012 in Taiwan. A total of 125,023 newly diagnosed OA patients were selected from one million beneficiaries of longitudinal health insurance database. Based on applying ten selected frequently used CHM formulas for OA, patients were divided into CHM user and non-CHM user. One-CHM to four-non-CHM user were propensity score matched with age, gender, monthly income, urbanization, comorbidities, Nonsteroidal anti-inflammatory drugs (NSAIDs) and index year were adjusted to reduce selection bias and confounding. Cox regression model was used for comparing the hazard ratios (HR) for the risk of joint replacement and Kaplan-Meier curve for the proportion of joint replacement. RESULTS: OA patients who were female, younger (20-60 years), higher income and lived in urbanization location were found to preferred using CHM. Younger CHM users had a lower adjusted HR (0.63) of the risk of joint replacement (95% confidence interval (CI) = 0.42-0.94). Compared to non-CHM user, HR among CHM users (≥225 days annually) is 0.48 (95% CI = 0.31-0.76). The proportion of joint replacement in younger non-CHM user began to rise notably with time (log-rank test, p = 0.026). However, this benefit by CHM did not apply to older (over 60 years) OA patients. CONCLUSION: This study suggested that adjuvant CHM might be associated with a lower rate of joint replacement in OA patients. CHM therapy might be considered in OA patients to reduce the need of joint replacement.

A Patient-Centered Integrative Approach Improves Visual Field Defect: A Case Report.

We present a case involving a patient with a complicated visual field defect preventing her from renewing her driver license. It highlights the underappreciated role of chronic stress in the genesis and perpetuation of ill health and the potential of Chinese medicine (CM) to complement biomedicine in the treatment of an intractable visual disorder. The patient experienced impaired vision from age 15, and ophthalmologists considered various diagnoses including optic neuritis and acute zonal occult outer retinopathy (AZOOR)-complex disorder with acute macular neuroretinopathy. She was treated with an integrative East-West medical approach incorporating acupuncture, cupping, trigger point injections, guidance on self-care and lifestyle modification. Although the eye disorder was not cured, there was visual improvement as demonstrated by various objective ophthalmologic tests, and the patient was able to renew her driver license. Visual improvement remained stable upon follow-up examination three years after the treatment intervention. Other concomitant health issues reported by the patient also improved including amelioration of neck pain, a more regular menstrual cycle, and decreased anxiety. This case demonstrates how a patient with an intractable complex eye disorder can have objective visual improvement when treated with an integrative patient-centered approach.

Women's preconception health patterns in traditional Chinese medicine as a predictor of fertility outcomes.

OBJECTIVE: To examine the association between traditional Chinese medicine (TCM), preconception health patterns and fertility outcomes. METHODS: A community-based prospective cohort study was conducted in China. A total of 3012 newly married women who were willing to conceive within 2 years were enrolled in the study and took National Free Prepregnancy Checkups (NFPC). A reliably structured self-rating scale was used to measure the TCM preconception health patterns of the enrolled women. A 3-year follow-up was conducted to obtain the fertility outcomes, including pregnancy rate, time to pregnancy, spontaneous miscarriage and newborn status. Statistical analyses were conducted using Chi-square or Fisher's exact tests, logistic regression models, general linear models and the Cox proportional hazard model. RESULTS: The fertility outcomes showed no statistic correlations to the terms of NFPC in this population. Approximately a half of the women (46.66%) had unhealthy patterns. Women with qi & blood-deficiency (odds ratio [OR] = 35.19, 95% confidence interval [CI] = 1.55-801.15) or qi-stagnation (OR = 4.55, 95% CI = 0.90-23.06) pattern took a longer time to get pregnant, and those with qi-stagnation (OR = 2.05, 95% CI = 1.1-3.82) or yang-deficiency (OR = 1.91, 95% CI = 1.12-3.25) pattern had a higher risk of spontaneous miscarriage. CONCLUSION: Three unhealthy TCM patterns during the preconception period might be risk factors for low fecundity or poor pregnancy outcomes. The TCM preconception pattern identification may provide a convenient and effective way to screen for potential pregnancy risks beyond the NFPC. Further, appropriate interventions based on the TCM preconception health patterns are needed to improve quality in women's fecundability and birth outcomes.

Supportive Care in Lung Cancer: Improving Value in the Era of Modern Therapies.

Driven by a discipline-wide imperative to maximize patient centeredness and value, supportive care services have experienced remarkable growth and acceptance in oncology care. Two such services with a growing evidence base and examples of routine integration into usual oncology care are palliative care and integrative medicine. Both focus on the patient experience with cancer during and after cancer-directed treatments occur, from diagnosis through survivorship or end-of-life care. With a frame of increasing value for all in the oncology care ecosystem, we highlight the evidence for how these two disciplines can improve the experience of patients with cancer and their loved ones. We further highlight how additional focus in palliative care and integrative medicine can continue to build toward a shared vision of high-value, high-quality cancer care.

Change in Health-Related Quality-of-Life at Group and Individual Levels Over Time in Patients Treated for Chronic Myofascial Neck Pain.

BACKGROUND: This study evaluated change in health-related quality of life at the group and individual levels in a consecutive series of patients with chronic myofascial neck pain. METHODS: Fifty patients with chronic neck pain self-administered the Short Form-36 Version 2 (SF-36 v2) before treatment and 6 weeks later. Internal consistency reliability was estimated for the 8 scale scores and Mosier's formula was used to estimate reliability of the physical and mental health composite scores. Significance of group-level change was estimated using within-group t statistics. Significance of individual change was evaluated by reliable change index. RESULTS: Statistically significant ( P < .05) group mean improvement over time was found for all SF-36 scores. At the individual level, 20% of the possible changes were statistically significant (17% improvement, 3% decline). CONCLUSIONS: Estimating the significance of individual change in health-related quality of life adds important information in comparing different treatment modalities for chronic myofascial neck pain.

Parenting Style and Behavior as Longitudinal Predictors of Adolescent Alcohol Use.

OBJECTIVE: Adolescent alcohol use is a serious problem in Australia and other nations. Longitudinal data on family predictors are valuable to guide parental education efforts. The present study tested Baumrind's proposal that parenting styles are direct predictors of adolescent alcohol use. METHOD: Latent class modeling was used to investigate adolescent perceptions of parenting styles and multivariate regression to examine their predictive effect on the development of adolescent alcohol use. The data set comprised 2,081 secondary school students (55.9% female) from metropolitan Melbourne, Australia, who completed three waves of annual longitudinal data starting in 2004. RESULTS: Baumrind's parenting styles were significant predictors in unadjusted analyses, but these effects were not maintained in multivariate models that also included parenting behavior dimensions. CONCLUSIONS: Family influences on the development of adolescent alcohol use appear to operate more directly through specific family management behaviors rather than through more global parenting styles.

[Clinical practice of integrative medicine in the United States and its development in primary care].

The field of integrative medicine (IM) has grown tremendously in the United States over last two decades, in terms of clinical practice, research, and education. Its growing popularity among patients has led to increased need for physicians with appropriate counseling skills and a knowledge base of the efficacy and safety of complementary and alternative medicine (CAM) therapies. Family medicine is the first specialty as a whole to embrace IM, which encounters similar ailing conditions and emphasizes similar core values-person centered, evidence based, proactive, and continuous in nature. As integrative family medicine emerges, family medicine educators have developed suggested curriculum guidelines and approved measurable competencies to implement the best of evidence-based CAM and principles of IM. There are currently over 40 family medicine residencies that officially advertise CAM/IM in their programs. Meanwhile, IM centers have also been developing their own primary care programs based on their unique characteristics. This physician-led IM workforce is similar to that of China's IM in the early 1960s. As the Chinese government embarks on repeating its efforts to educate more Western medicine trained physicians in Chinese medicine in primary care training programs, the process and insights related to implementation of their practice in the United States would provide useful food for thought.

A cross-sectional study of provider and patient characteristics associated with outpatient disclosures of dietary supplement use.

OBJECTIVE: Explore patterns in patients' disclosures of supplement use and identify provider and patient characteristics associated with disclosures. METHODS: Cross-sectional study of 61 outpatient primary care, integrative medicine, and complementary medicine providers, and 603 of their patients. Primary outcomes were supplement disclosures (based on audio recorded office visits, post-visit patient surveys and medical record abstractions for the day of the visits). RESULTS: Seventy-nine percent of 603 patients reported on a post-visit survey that they took a total of 2107 dietary supplements. Of those taking supplements, 232 patients (48.6%) discussed at least one supplement with their provider on the day of their office visit. However, patients disclosed only 714 (33.9%) of the 2107 supplements they were taking. Patients more frequently disclosed supplement use when they saw providers who attributed greater importance to asking about supplements. Patient characteristics such as patient activation, number of medical conditions, and use of prescription medications were not associated with disclosure of supplement use. CONCLUSIONS: Provider rating of the importance of asking about supplements is a major factor prompting patients' disclosures of supplement use. PRACTICE IMPLICATIONS: Provider-targeted interventions to encourage provider awareness about potential supplement-drug interactions are needed to increase disclosures about dietary supplement use.

Factors Affecting Definitions of and Approaches to Integrative Medicine: A Mixed Methods Study Examining China's Integrative Medicine Development.

Aim. This study identifies existing definitions and approaches among China's integrative medicine (IM) experts and examines relationships with key characteristics distinguishing individual experts. Methods. Snowball sampling was used to select 73 IM experts for semistructured interviews. In this mixed methods study, we first identified definitions and approaches through analyzing core statements. Four key factors, including age, education, practice type, and working environment, were then chosen to evaluate the associations with the definitions. Results. Four unique definitions were identified, including IM as a "new medicine" (D1), as a combination of western medicine (WM) and Chinese medicine (CM) (D2), as a modernization of CM (D3), and as a westernization of CM (D4). D4 was mostly supported by those working in WM organizations, while D3 was more prominent from individuals working in CM organizations (P = 0.00004). More than 64% clinicians had D2 while only 1 (5.9%) nonclinician had D2. Only 1 clinician (1.8%) had D4 while almost 30% nonclinicians had D4 (P = 0.0001). Among nonclinicians working in WM organizations, 83.3% of them had D4 (P = 0.001). Conclusion. Findings indicate that institutional structure and practice type are factors affecting IM approaches. These results carry implications for the ways in which western countries move forward with the definition and implementation of IM.

Effect of perineal self-acupressure on constipation: a randomized controlled trial.

BACKGROUND: The efficacy of perineal self-acupressure in treating constipation is uncertain. OBJECTIVE: We aimed to evaluate whether perineal self-acupressure would improve patient reports of quality of life and bowel function at 4 weeks after training. DESIGN: A randomized, parallel group trial was conducted. SETTING: The study took place at the UCLA Department of Medicine. PATIENTS: One hundred adult patients who met Rome III criteria for functional constipation participated. INTERVENTION: The control group received information about standard constipation treatment options, while the treatment group received training in perineal self-acupressure plus standard treatment options. MEASUREMENTS: Primary outcome was the Patient Assessment of Constipation Quality of Life (PAC-QOL). Secondary outcomes included patient assessments of bowel function (as measured by a modified Bowel Function Index (BFI)), and health and well-being (as measured by the SF-12v2). RESULTS: The mean PAC-QOL was improved by 0.76 in the treatment group and by 0.17 in the control group (treatment-effect difference, 0.59 [95 % CI, 0.37 to 0.81]; p < 0.01). The mean modified BFI was improved by 18.1 in the treatment group and by 4.2 in the control group (treatment-effect difference, 13.8 [95 % CI, 5.1 to 22.5]; p < 0.01). The mean SF-12v2 Physical Component Score was improved by 2.69 in the treatment group and reduced by 0.36 in the control group (treatment-effect difference, 3.05, [95 % CI, 0.85 to 5.25]; p < 0.01); and the mean SF-12v2 Mental Component Score was improved by 3.12 in the treatment group and improved by 0.30 in the control group (treatment-effect difference, 2.82, [95 % CI, -0.10 to 5.74]; p < 0.07). LIMITATION: The trial was not blinded. CONCLUSION: Among patients with constipation, perineal self-acupressure improves self-reported assessments of quality of life, bowel function, and health and well-being relative to providing standard constipation treatment options alone.

Introducing considerations in the Translation of Chinese Medicine.

This article introduces the document, Considerations in the Translation of Chinese Medicine, published in PDF form online in both Chinese and English. This 20-page document includes several sections describing why the Considerations is necessary, the specificity of texts in Chinese medicine; the history of translation in Chinese medicine; who constitutes an ideal translator of Chinese medicine; what types of language exist in Chinese medicine; and specific issues in the translation of Chinese medicine, such as domestication versus foreignization, technical terminology, period-specific language, style, polysemy, and etymological translation. The final section offers a brief advisory for consumers, and concludes with a call to further discussion, and action, specifically in the development of international collaborative efforts towards the creation of more rigorous guidelines for the translation of Chinese medicine. The current article provides an overview of several of these sections, and includes links to the original document.

Stress reactivity in traditional Chinese medicine-based subgroups of patients with irritable bowel syndrome.

OBJECTIVES: This study aimed to examine differences in autonomic responses to stress, pain perception, and the role of negative affect in these responses in individuals with irritable bowel syndrome (IBS) according to Traditional Chinese Medicine (TCM) classifications. DESIGN: Fifty-nine female patients with IBS age 18-65 years diagnosed by TCM practitioners as showing primarily an excess (n=32) or an overlap (n=27) pattern (mixed excess and deficiency) were assessed for symptom differences, heart rate, and skin conductance responses to a psychosocial stressor and pain perception. SETTINGS/LOCATIONS: University of California in Los Angeles, California. RESULTS: Compared with the excess group, the overlap group showed significantly greater overall gastrointestinal symptom severity, abdominal pain, and negative affect. The excess group with higher levels of negative affect showed greater reactivity to stress, whereas the overlap group showed an opposite response pattern. The overlap group showed increased cold sensitivity. CONCLUSIONS: IBS patients with the overlap pattern have greater disease severity and comorbidity than those with excess alone. Those with excess showed a pattern of increased stress response with greater negative affect, whereas the overlap group with greater deficiency showed lower physiologic arousal with greater negative affect, consistent with depletion resulting from allostatic load.