Cortisol, Health, and Coping in Patients with Nonspecific Low Back Pain.

Subjective health complaints (SHC), including nonspecific low back pain (LBP) as the most common single complaint, are the main reasons for long-term sick leave in many western countries. These complaints are often attributed to "stress". Cortisol has frequently been considered a biomarker reflecting sustained physiological HPA-axis activity, and is characterized by a high cortisol awakening response (CAR) and low evening values. The aim of the study was to investigate whether LBP patients had a normal characteristic cortisol profile, and whether possible deviations were related to coping and health. 305 patients on long-term sick leave for LBP participated in the study, and saliva cortisol profiles were compared to a reference population consisting of Danish workers. Cortisol was measured upon awakening, after 30 min, and in the evening. Additionally, patients answered questionnaires about SHC, fatigue, pain, coping, and social support. The patients showed a seemingly normal cortisol profile. However, CAR was larger among patients compared to the reference population. Patients with low cortisol reactivity had more SHC, pain, and fatigue, and those with higher evening cortisol reported higher scores on coping. The results are discussed in terms of theory, practical considerations, and possible mechanisms for the association between cortisol, health, and coping.

Multidisciplinary Intervention in Patients with Musculoskeletal Pain: a Randomized Clinical Trial.

BACKGROUND: Musculoskeletal pain is associated with comorbidity, extensive use of health services, long-term disability and reduced quality of life. The scientific literature on effects of treatment for musculoskeletal pain is inconclusive. PURPOSE: The purpose of this study is to compare a multidisciplinary intervention (MI), including use of the novel Interdisciplinary Structured Interview with a Visual Educational Tool (ISIVET), with a brief intervention (BI), on effects on mental and physical symptoms, functioning ability, use of health services and coping in patients sick-listed due to musculoskeletal pain. METHOD: Two hundred eighty-four adults aged 18-60, referred to a specialist clinic in physical rehabilitation, were randomized to MI or BI. Patients received a medical examination at baseline and completed a comprehensive questionnaire at baseline, 3 months and 12 months. RESULTS: Both groups reported improvements in mental and physical symptoms, including pain, and improved functioning ability at 3 and 12 months, but the MI group improved faster than the BI group except from reports of pain, which had a similar course. Significant interactions between group and time were found on mental symptoms (anxiety (p < 0.05), depression (p < 0.01), somatization (p < 0.01)) and functioning ability (p < 0.01) due to stronger effects in the MI group at 3 months. At 3 and 12 months, the MI group reported significantly less use of health services (general practitioner (p < 0.05)). At 12 months, the MI group reported better self-evaluated capability of coping with complaints (p < 0.001) and they took better care of their own health (p < 0.001), compared to the BI group. CONCLUSION: The results indicate that the MI may represent an important supplement in the treatment of musculoskeletal pain.

Brain sensitization to external and internal stimuli.

Sensitization is defined as a non-associative learning process occurring when repeated administrations of a stimulus result in a progressive amplification of a response (Shettleworth, 2010). The purpose of this review paper is to discuss whether brain sensitization is helpful in common health problems in man. The paper reviews data on brain sensitization covering increased behavioral, physiological, cognitive, and emotional responses in man and animals. The paper concludes that brain sensitization may be a helpful concept to understand subjective and "unexplained" health complaints (nonspecific muscle pain, mood changes, fatigue, and gastrointestinal complaints), and, therefore, relevant for evidence based treatment and prevention of these common health problems.

Sick-leave decisions for patients with severe subjective health complaints presenting in primary care: a cross-sectional study in Norway, Sweden, and Denmark.

OBJECTIVES: The primary objective of this study was to explore whether general practitioners (GPs) in Norway, Sweden, and Denmark make similar or different decisions regarding sick leave for patients with severe subjective health complaints (SHC). The secondary objective was to investigate if patient diagnoses, the reasons attributed for patient complaints, and GP demographics could explain variations in sick leave decisions. DESIGN: A cross-sectional study. METHOD: Video vignettes of GP consultations with nine different patients. SUBJECTS: 126 GPs in Norway, Sweden, and Denmark. SETTING: Primary care in Norway, Sweden, and Denmark. MAIN OUTCOME MEASURE: Sick leave decisions made by GPs. RESULTS: "Psychological" diagnoses in Sweden were related to lower odds ratio (OR) of granting sick leave than in Norway (OR = 0.07; 95% CI = 0.01-0.83) Assessments of patient health, the risk of deterioration, and their ability to work predicted sick leave decisions. Specialists in general medicine grant significantly fewer sick leaves than non-specialists. CONCLUSION: Sick-leave decisions made by GPs in the three countries were relatively similar. However, Swedish GPs were more reluctant to grant sick leave for patients with "psychological" diagnoses. Assessments regarding health-related factors were more important than diagnoses in sick-leave decisions. Specialist training may be of importance for sick-leave decisions.

Expectancies, socioeconomic status, and self-rated health: use of the simplified TOMCATS Questionnaire.

BACKGROUND: Coping has traditionally been measured with inventories containing many items meant to identify specific coping strategies. An alternative is to develop a shorter inventory that focusses on coping expectancies which may determine the extent to which an individual attempts to cope actively. PURPOSE: This paper explores the usefulness and validity of a simplified seven-item questionnaire (Theoretically Originated Measure of the Cognitive Activation Theory of Stress, TOMCATS) for response outcome expectancies defined either as positive ("coping"), negative ("hopelessness"), or none ("helplessness"). The definitions are based on the Cognitive Activation Theory of Stress (CATS; Ursin and Eriksen, Psychoneuroendocrinology, 29(5):567­92, 2004). The questionnaire was tested in two different samples. First, the questionnaire was compared with a traditional test of coping and then tested for validity in relation to socioeconomic differences in self-reported health. METHODS: The first study was a comparison of the brief TOMCATS with a short version of the Utrecht Coping List (UCL; Eriksen et al., Scand J Psychol, 38(3):175­82, 1997). Both questionnaires were tested in a population of 1,704 Norwegian municipality workers. The second study was a cross-sectional analysis of TOMCATS, subjective and objective socioeconomic status, and health in a representative sample of the Swedish working population in 2003­2005 (N = 11,441). RESULTS: In the first study, the coping item in the TOMCATS questionnaire showed an expected significant positive correlation with the UCL factors of instrumental mastery-oriented coping and negative correlations with passive and depressive scores. There were also the expected correlations for the helplessness and hopelessness scores, but there was no clear distinction between helplessness and hopelessness in the way they correlated with the UCL. In the second study, the coping item in TOMCATS and the three-item helplessness scores showed clear and monotonous gradients over a subjective socioeconomic status (SES) ladder. Positive response outcome expectancy ("coping") was related to high subjective SES and no expectancy ("helplessness") to low subjective SES. In a model including age and sex, TOMCATS scores explained more variance (r 2 = 0.16) in self-reported health than both subjective (r 2 = 0.08) and objective SES (r 2 = 0.02). CONCLUSION: The brief TOMCATS questionnaire showed acceptable and significant correlations with a traditional coping questionnaire and is sensitive enough to register systematic differences in response outcome expectancies across the socioeconomic ladder. The results furthermore confirm that psychological and learning factors contribute to the socioeconomic gradient in health.

Saliva cortisol levels in construction workers in the Arctic (78°N).

OBJECTIVES: The aim was to investigate how working in an extreme and isolated environment in the Arctic affected the diurnal rhythm of saliva cortisol. STUDY DESIGN: Field study. METHODS: Twenty-five male tunnel workers were screened during 3 different working cycles with different light conditions during a 9-month construction period; April/May (24 hours [h] light), September/October (approximately 12 h light and 12 h darkness) and November/December (24 h darkness). The work schedule was 10 h on/14 h off, 21 days at work/21 days off work. The workers alternated between the day shift in 1 work period and the night shift in the next. Four saliva samples were collected on day 14 in all 3 periods; immediately after awakening, and then 30 minutes, 6 hours and 12 hours after awakening. RESULTS: Regardless of shift schedule, the workers' cortisol levels were significantly lower in the period with 24 hours of light per day compared to the period with "normal" light conditions. There were no differences in the cortisol levels of the workers on night shifts in the period with 24 hours of darkness compared to those in the period with "normal" light conditions, but the workers who were on day shifts in the period with 24 of hours darkness had a disturbed cortisol rhythm (lower peak after awakening and lack of the normal decrease during the day). CONCLUSIONS: External light conditions and shift schedule were important factors in regulating the workers' cortisol rhythm. It seems to be easier to adapt to a night rhythm than an early morning rhythm in an isolated and extreme environment.

Still healthy after extended work hours? Ten hours shift, twenty-one days working period for tunnel workers.

The aim of this study was to investigate self-reported health effects of extended work hours (10 h on/14 h off) for 21 d at work/21 d off, for 40 male tunnel workers in an Arctic area. A questionnaire obtaining information about demographics and subjective health complaints (SHC), including musculoskeletal, pseudoneurological, gastrointestinal, allergic, and flu-like complaints the last thirty days was distributed on day 14 of a work period. In addition questions on coping, psychological job demands, control, and social support were asked. The questionnaire was repeated three times during a nine months observation period. Twenty-six workers completed all three questionnaires. The prevalence of subjective health complaints did not change during the observation period. The prevalence of subjective health complaints was the same or lower than in a control group. There was a slight increase in self-reported job demands during the observation period. Coping, job control, and social support from colleagues and management were reported high and did not change. No association between this type of long work hours and changes in self-reported health was found in this study. However, this might have been a selected group of workers, and the same results may not be found in another population.

Cortisol, reaction time test and health among offshore shift workers.

OBJECTIVE: The stress hormone cortisol shows a pronounced endogenous diurnal rhythm, which is affected by the sleep/wake cycle, meals and activity. Shift work and especially night work disrupts the sleep/wake cycle and causes a desynchronization of the natural biological rhythms. Therefore, different shift schedules may have different impact on performance at work and health. AIM: The purpose was to study if health, reaction time, and the cortisol rhythm were negatively affected when a group of shift workers changed their work schedule from ordinary day-night shift (fixed shift) to "swing shift". METHODS AND SETTINGS: 19 healthy workers on a Norwegian oil rig participated in the study. They worked 2 weeks offshore followed by 4 weeks off work. The ordinary schedule consisted of 12-h day shift and 12-h night shift every other work period (14 days or nights=fixed shift). "Swing shift" involved 1 week of night shift, followed by 1 week of day shift during the work period. All participants worked ordinary day-night shift when baseline data were collected (questionnaires, saliva cortisol, and reaction time during work). After collection of baseline data the workers changed their work schedule to "swing shift", for every working period, and 9 months later the same data were collected. RESULTS: "Swing shift" did not give any negative health effects or any negative changes in reaction time during the day they shifted from night work to day work. Personnel adapted to night shift within a week regardless of schedule, but recovery from night shift took longer time. During swing shift the cortisol rhythm went back towards a normal rhythm in the second week, but it was not returned completely to normal values when they returned home for the 4 weeks off period. However, the cortisol rhythms were readapted to normal values after 1 week at home. For personnel returning home directly from 14 consecutive night shifts, cortisol adaptation was not complete after 1 week at home. CONCLUSION: We found no increase in health complaints from swing shift or reaction time in the shift from night to day work. Recovery from night shift takes longer time.

Cognitive activation theory of stress (CATS).

The cognitive activation theory of stress (CATS) is based on a long series of experiments on animals and on humans, in the laboratory, and in real life situations. From the common sense coping concept formulated by Seymour Levine; coping is when my "tommy" does not hurt, we have advanced to a systematic theory for what is behind the relaxed and happy coping rat (and cat). We also cover the translational leap to humans, starting with the now classic parachutist study. The bridge is based on formal and symbolic definitions, a theoretical short cut that Levine actually never really accepted. The essential pathophysiological concept is the potential pathological effects of sustained activation, which may occur in the absence of coping (positive response outcome expectancy). We review the current status of CATS in Behavioural Medicine by discussing its potential explanatory power in epidemiology, prevention and treatment of "subjective health complaints".

The development of a Cognitive Activation Theory of Stress: from limbic structures to behavioral medicine.

This paper attempts to argue for a consistent trend in a research spanning more than fifty years, starting in the exciting neuroscience environment in the Anatomical Institute at the University of Oslo, and presently to be found as an active behavioral medicine unit in Bergen. The most comprehensive theoretical result is a systematic and formalized theory of stress, referred to as the Cognitive Activation Theory of Stress, CATS for short (Ursin & Eriksen, 2004). There are many roots, many related issues, and many scientists involved. There is no way to produce a complete story. However, one aspect is beyond discussion, the story started in the Neurophysiology laboratory in Oslo.

Shift work disorder among oil rig workers in the North Sea.

STUDY OBJECTIVES: Shift work disorder (SWD) is a circadian rhythm sleep disorder caused by work hours during the usual sleep period. The main symptoms are excessive sleepiness and insomnia temporally associated with the working schedule. The aim of the present study was to examine SWD among shift workers in the North Sea. DESIGN AND PARTICIPANTS: A total of 103 shift workers (2 weeks on 7 nights/7days, 12-h shifts, 4 weeks off), mean age 39.8 years, working at an oil rig in the North Sea responded to a questionnaire about SWD. They also completed the Pittsburgh Sleep Quality Index, Bergen Insomnia Scale, Epworth Sleepiness Scale, Composite Morningness Questionnaire, Subjective Health Complaint Inventory, Demand/Control, and Instrumental Mastery Oriented Coping (based on the Utrecht Coping list). Most of these instruments were administered during the first day of the 2-week working period, thus reflecting symptoms and complaints during the 4-week non-work period. The shift workers were also compared to day workers at the oil rig. RESULTS: Twenty-four individuals were classified as suffering from SWD, yielding a prevalence for SWD of 23.3%. During the 4-week non-work period, individuals with SWD reported significantly poorer sleep quality, as measured by the Pittsburgh Sleep Quality Index, and more subjective health complaints than individuals not having SWD. There were no differences between the 2 groups in sleepiness, insomnia, circadian preference, psychological demands, or control. Individuals with SWD reported significantly lower scores on coping. The reports of shift workers without SWD were similar to those of day workers regarding sleep, sleepiness, subjective health complaints, and coping. CONCLUSIONS: The prevalence of SWD was relatively high among these shift workers. Individuals with SWD reported poorer sleep quality and more subjective health complaints in the non-work period than shift workers not having SWD.

A multi-state model for sick-leave data applied to a randomized control trial study of low back pain.

AIMS: Analysing and presenting data on different outcomes after sick-leave is challenging. The use of extended statistical methods supplies additional information and allows further exploitation of data. METHODS: Four hundred and fifty-seven patients, sick-listed for 8-12 weeks for low back pain, were randomized to intervention (n=237) or control (n=220). Outcome was measured as: "sick-listed'', "returned to work'', or "disability pension''. The individuals shifted between the three states between one and 22 times (mean 6.4 times). In a multi-state model, shifting between the states was set up in a transition intensity matrix. The probability of being in any of the states was calculated as a transition probability matrix. The effects of the intervention were modelled using a non-parametric model. RESULTS: There was an effect of the intervention for leaving the state sick-listed and shifting to returned to work (relative risk (RR)=1.27, 95% confidence interval (CI) 1.09- 1.47). The nonparametric estimates showed an effect of the intervention for leaving sick-listed and shifting to returned to work in the first 6 months. We found a protective effect of the intervention for shifting back to sick-listed between 6 and 18 months. The analyses showed that the probability of staying in the state returned to work was not different between the intervention and control groups at the end of the follow-up (3 years). CONCLUSIONS: We demonstrate that these alternative analyses give additional results and increase the strength of the analyses. The simple intervention did not decrease the probability of being on sick-leave in the long term; however, it decreased the time that individuals were on sick-leave.

Cognitive-behavioural therapy v. mirtazapine for chronic fatigue and neurasthenia: randomised placebo-controlled trial.

BACKGROUND: Single interventions in chronic fatigue syndrome have shown only limited effectiveness, with few studies of comprehensive treatment programmes. AIMS: To examine the effect of a comprehensive cognitive-behavioural treatment (CCBT) programme compared with placebo-controlled mirtazapine medication in patients with chronic fatigue, and to study the effect of combined medication and CCBT. METHOD: A three-armed randomised clinical trial of mirtazapine, placebo and a CCBT programme was conducted to investigate treatment effect in a patient group (n=72) with chronic fatigue referred to a specialist clinic. The CCBT programme was compared with mirtazapine or placebo therapy for 12 weeks, followed by 12 weeks treatment with a mixed crossover-combination design. Assessments were done at 12 weeks and 24 weeks. RESULTS: By 12 weeks the treatment effect was significantly better in the group initially receiving CCBT, as assessed with the Fatigue Scale (P=0.014) and the Clinical Global Impression Scale (P=0.001). By 24 weeks the treatment group initially receiving CCBT for 12 weeks followed by mirtazapine for 12 weeks showed significant improvement compared with the other treatment groups on the Fatigue Scale (P<0.001) and the Clinical Global Impression Scale (P=0.002). Secondary outcome measures showed overall improvement with no significant difference between treatment groups. CONCLUSIONS: Multimodal interventions may have positive treatment effects in chronic fatigue syndrome. Sequence of interventions seem to be of importance.

Subjective health complaints are more prevalent in Maasais than in Norwegians.

The aim of this observational, population-based study was to compare subjective health complaints (SHC) in Norwegians, living in a Western welfare society, and Maasai people, living in rural Kenya under primitive conditions. An interview-based version of SHC inventory was used. Data from 320 Maasais were compared to data from 1243 Norwegians. The Maasais had significantly higher score than the Norwegians on 23 of 28 items, involving musculoskeletal, "pseudo-neurological" and gastrointestinal complaints. The Maasais, living under primitive conditions, close to nature, seems to have more SHC than Norwegians, living in a modern, highly developed and industrialized country.

Psychological selection of Antarctic personnel: the "SOAP" instrument.

INTRODUCTION: The potential advantage of including a psychological test battery in the selection process for service in the Antarctic was examined in 348 applicants for employment in Antarctica with the British Antarctic Survey (BAS). METHODS: Applicants were screened with the Selection of Antarctic Personnel battery (SOAP) consisting of nine well-known psychological instruments. The SOAP scores were not revealed to the BAS selection panel members, who based the selection on operational criteria, interview, and a general medical examination. The SOAP scores of those selected (n = 177) were further compared with station commanders' reports of winter adaptation (n = 140), and subjective health complaints (SHC) (n = 86). RESULTS: There were no significant agreements between SOAP scores (n = 348) and those actually selected by the BAS panel (121 accepted, 227 not accepted) (Cohen's Kappas for inter-rater agreement < 0.20). Participants characterized as exceptionally well adapted by the station commanders had higher scores on Openness on the NEO-FFI (the "Big Five" personality inventory) [Odds Ratio (OR) = 5.2], and higher levels of Emotion-Focused Coping (OR = 2.7) and fewer SHC (OR = 0.3). Participants rated by station commanders as "poor" had higher levels of Defensive Hostility (OR = 4.2), and lower levels of Emotion-Focused Coping (OR = 0.3). Women had higher rates of success in service than men, but were less likely to be selected. DISCUSSION AND CONCLUSION: Adding a psychological test battery would improve the odds of selecting good performers, and reduce the odds of selecting poor performers.

Cognitive activation theory of stress, sensitization, and common health complaints.

According to the cognitive activation theory of stress (CATS), a formal system of systematic definitions, the term "stress" is used for stress stimuli, the stress experience, the nonspecific, general stress response, and the experience of the stress response. The stress response is normal, healthy, and necessary alarm. If sustained there may be a risk of illness and disease. The level and duration of the alarm depend on the expectancy of the outcome of stimuli and the specific responses available for coping. The most common health complaints are subjective health complaints like muscle pain, tiredness and mood changes. These are normal aches of short duration and low intensity for most people. For some the pains and complaints are substantial and longlasting with serious implications for functioning. There are no sharp or obvious limits in the distribution of health complaints, separating "normal" and endurable pain and complaints, and intolerable complaints that need professional help. These conditions are most often unspecific, and are the most common reason for encounters with health professionals, and the most frequent reason for sick leave and disability. There is a striking comorbidity for all these conditions. This may be explained by psychobiological sensitization within neural loops, maintained by sustained activation, which has been suggested as a mechanism for these conditions.

Health complaints and satisfied with the job? A cross-sectional study on work environment, job satisfaction, and subjective health complaints.

OBJECTIVE: The aim of this study was to examine the prevalence of subjective health complaints (SHCs) among satisfied and dissatisfied workers. The second aim was to evaluate whether any SHC differences were attributable directly to the work environment or mediated by the individual perception of the environment (satisfactory or not). METHOD: In a cross-sectional study of 458 employees (56% women) in 5 different organizations, work environment, job satisfaction, and SHC were measured. RESULTS: Satisfied workers reported an average of five to six subjective health complaints that correspond to the prevalence found in a Norwegian general population. Work environment explained 43% of the variance for job satisfaction and 9% of the variance in SHCs. CONCLUSION: SHCs are common among satisfied workers. Work environment has only a limited influence on this validated health indicator.

Coffee, stress and cortisol in nursing staff.

According to cognitive activation theory, long-lasting work demands without rest or lack of coping may lead to sustained activation and pathology. Cortisol is one of the most important stress hormones in humans and increased basal levels of cortisol are considered a valid marker for sustained activation. In order to investigate this association further, we investigate the relationships between salivary cortisol profiles, job stress, work load (effort/reward, demand/control) and health (subjective health complaints and health-related quality of life) in a population of health care workers. Forty-four women filled in a questionnaire and collected five saliva samples on two consecutive working days (1: wake-up time, 2: wake-up time+30 min, 3: wake-up time+45 min, 4: 1500 h and 5: 2200 h). There was no relationship between psychosocial factors at work and cortisol levels in the morning (cortisol level at wake-up time and awakening cortisol response (ACR)). Only the confounding variable tobacco reached a significant level in the hierarchical regressions analyses. Our significant findings are limited to the afternoon decline and the evening values. The decrease during the day relates to decision authority, physical functioning, general health, and vitality in the single, unadjusted regression analyses. The decrease also relates to coffee intake, which we included originally as a confounding variable. In the final hierarchical regression of the evening values, only decision authority and coffee were significantly related to cortisol levels in the evening.