Modulation of cellular immunity in medical students

The Effects of a Single Relaxation Hypnosis Session on Mental Stress in Chronically Stressed Individuals

Abstract. Background: Chronically stressed people often suffer from anxiety and depressive mood. Hypnosis is a technique that can induce a relaxation response and reduce negative stress symptoms. Objective: This explorative study investigated the impact of a single relaxation hypnosis session on stress-related psychological symptoms. Method: 47 suggestible, stressed individuals (87 % female) were randomized to a hypnosis group ( n = 23, 20-minute hypnosis) or a control group ( n = 24, 20-minute scientific documentary). Before and after the intervention, we assessed perceived stress, negative affect, anxiety, and depressive mood. Results: After the hypnosis intervention, depressive mood ( d = 0.36) and state anxiety ( d = 1.00) decreased, while negative affect remained stable ( d = 0.04). Perceived stress was reduced in both groups. Conclusion: A single relaxation hypnosis session decreased stress-related symptoms in chronically stressed individuals. Our results substantiated the stress-alleviating effects of hypnosis.

Immunotoxicity studies of sulfolane following developmental exposure in Hsd:Sprague Dawley SD rats and adult exposure in B6C3F1/N mice

Sulfolane is a solvent used in the petrochemical industry and a groundwater contaminant in areas near refineries. The current studies were conducted to assess the impact of oral exposure to sulfolane on the immune system using two models: (1) a perinatal drinking water exposure to 0, 30, 100, 300, or 1000 mg/L from gestation day (GD) 6 until ∼13 weeks-of-age in Harlan Sprague Dawley rats; and, (2) a 90-day gavage exposure of adult female B6C3F1/N mice to 0, 1, 10, 30, 100, or 300 mg/kg/day. Immune parameters evaluated included measurement of antibody production against sheep red blood cells (SRBC) and keyhole limpet hemocyanin (KLH), ex vivo measurements of natural killer (NK) cell activity, cytotoxic T-cell (CTL) activity, and T-cell proliferation, as well as measures of splenic immune cell populations, hematological parameters, and histopathology of immune tissues. A decrease in ex vivo NK cell activity was observed in cells from female - but not male - F1 rats following developmental exposure. In adult female mice, splenic NK cell number was lower than the vehicle controls at doses ≥ 100 mg/kg; however, ex vivo NK cell activity was not affected by sulfolane treatment. In female mice, a decrease in the number of large unstained cells at doses ≥ 30 mg/kg was observed. In F1 rats, effects on white blood cells (WBC) were limited to a decreasing trend in leukocytes in females; no effects were observed in males. Under the conditions of this study, a no-observed-effect level (NOEL) of 3 mg/kg/day was identified based on reduced NK cell activity in female F1 rats. Overall, these findings suggest that oral exposure to sulfolane in rodents had minimal effects on the immune system.

Die Wirkung von Hypnose auf Parameter des Immunsystems

Zusammenfassung. Theoretischer Hintergrund: Mit Hypnose können positive immunmodulierende und therapeutische Effekte bei psychischen sowie somatischen stress-assoziierten Erkrankungen erzielt werden. Fragestellung: Diese Arbeit beschäftigt sich mit immunologischen Veränderungen durch Hypnose und zeigt potentielle zukünftige Forschungsfelder zu biomolekularen Wirkfaktoren von Hypnose auf. Methode: Es werden empirische Befunde zur Wirkung von Hypnose auf Parameter des Immunsystems zusammengefasst. Ergebnisse: Hypnose führt zu einer Anpassungsreaktion des Immunsystems in Form von Veränderungen in der Anzahl von Immunzellen und Zytokinen. Schlussfolgerung: Ein spannendes neues Forschungsfeld liegt in der Untersuchung der Wirkmechanismen von Hypnose auf das Immunsystem sowie dessen Interaktion mit dem Stresssystem und dem Energiemetabolismus.

Group hypnosis for stress reduction and improved stress coping: a multicenter randomized controlled trial

Background

The aim of the trial was to investigate the effect of a hypnotherapeutic group program in healthy persons with increased levels of perceived stress.

Methods

In a randomized controlled multicenter trial participants with a self-assessed subjective stress level ≥ 40 mm on a visual analogue scale (0–100 mm; VAS) for the previous week and a stable state of health were randomized to either 5 weekly sessions of 120-min duration of a hypnotherapeutic group program for stress reduction and improved stress coping plus 5 hypnosis audiorecords for individual practice at home plus an educational booklet for stress coping (hypnosis group) versus an educational booklet only (control group). The primary outcome parameter was the VAS stress level for the previous week after 5 weeks. Secondary outcome parameters included the VAS stress level after 12 weeks, perceived stress (CPSS), depression (ADS-K), self efficacy (SWE) and quality of life (SF 36) after 5 weeks and 12 weeks. Analysis of covariance with a significance level of 5% using the full analysis set was used for analysis; the model included treatment (fixed effect), VAS baseline value (fixed covariate), and center (random effect).

Results

A total of 95 participants were randomized; 47 (40 female, 45 ± 13.4 years of age) were allocated to the hypnosis group, and 48 (41 female, 46.9 ± 14.3 years) were allocated to the control group. Regarding VAS stress level after 5 weeks, the adjusted VAS mean in the hypnosis group was 41.8 mm [95% confidence interval (CI): 35.2; 48.4] compared to 62.9 mm [56.2; 69.7] in the control group, and the group difference was − 21.2 mm [− 30.1; − 12.2] (P < 0.001). After 12 weeks, the stress intensity on the VAS showed a between-group difference of − 14.7 mm [− 25.1; − 4.4] (P = 0.006), and the adjusted means were 41.1 mm [33.4; 48.8] in the hypnosis group and 55.9 mm [48.4; 63.5] in the control group. Improvements were also reported for CPSS, SF-36, SWE and ADS-K after 5 and 12 weeks.

Conclusion

Compared to the control group, the hypnosis group showed reduced perceived stress after 5 and 12 weeks.

Trial registration

ClinicalTrials.gov NCT03525093; date of registration: May 15, 2018.

Group Hypnosis for Stress Reduction - A Feasibility Study

The aim of this study was to develop a standardized hypnotherapeutic group program for stress reduction, test its feasibility, and measure its preliminary pre- to postintervention effects. In this prospective, single-arm feasibility study, healthy adult participants with self-assessed increased stress levels received 5 weekly group hypnosis sessions plus audio recordings. Twelve persons (10 females, mean (SD) age 48.9 (11.8) years participated. The mean (SD) intensity of perceived stress on a 0-to-100 mm VAS was reduced from 75.5 (11.5) mm at baseline to 33.9 (18.8) mm after 5 weeks. Cohen's perceived stress scale was reduced from 20.8 (5.7) to 13.8 (5.4). Focus group interviews showed that the study intervention was feasible and well accepted. Confirmatory testing of the intervention in a randomized controlled trial is necessary.

Suppression of the innate cancer-killing activity in human granulocytes by stress reaction as a possible mechanism for affecting cancer development

Psychological stress may be linked to cancer incidence; however, more direct evidence is required to support this viewpoint. In this study, we investigated the effects of stress on immunosurveillance against cancer cells using a previously established examination stress model. We showed that the cancer killing activity (CKA) of granulocytes (also known as polymorphic nuclear cells, PMNs) is sharply reduced during examination stress stimulation in some donors who are psychologically sensitive to examination stress, with the concentration of plasma stress hormones (cortisone, epinephrine, and norepinephrine) increasing accordingly. The effects of stress hormones on immune cell CKA were also investigated under two in vitro co-incubation conditions, with all three hormones found to exert inhibitory effects on the CKA of PMNs and mononuclear cells. We showed that stress triggered the release of stress hormones which had profound inhibitory effects on the innate anticancer functions of PMNs. These results provide a possible explanation for the relationship between psychological stress and cancer incidence.

Effectiveness of Stress-Reducing Interventions on the Response to Challenges to the Immune System: A Meta-Analytic Review

BACKGROUND

There is consistent evidence showing an interplay between psychological processes and immune function in health and disease processes.

OBJECTIVES

The present systematic review and meta-analysis aims to provide a concise overview of the effectiveness of stress-reducing psychological interventions on the activation of immune responses in both healthy subjects and patients.

METHODS

Included are 3 types of challenges: in vivo, in vitro, and psychophysiological. Such challenges are designed to mimic naturally occurring immune-related threats.

RESULTS

A systematic literature search was conducted using PubMed, EMBASE, and PsychInfo, resulting in 75 eligible studies. The risk of bias was assessed with the Cochrane risk-of-bias tool. Across all studies, a small-to-medium effect size was found for the effects of psychological interventions on optimization of the immune function (g = 0.33; 95% CI 0.22-0.43). While the largest effects were found for in vivo immune-related challenges (g = 0.61; 95% CI 0.34-0.88; especially on studies that incorporated skin tests and wound healing), studies incorporating psychophysiological challenges and in vitro immune-related stimulations similarly suggest more optimal immune responses among those receiving stress-reducing interventions (g = 0.28; 95% CI 0.15-0.42).

CONCLUSION

These findings showed substantial heterogeneity depending on the type of challenge, the study populations, and the intervention types. These data demonstrate support for the effectiveness of stress-reducing psychological interventions in improving immunity in studies that tested immune function by means of incorporating an in vivo,in vitro, or psychophysiological challenge. Future research should more consistently incorporate challenges into the study design to gather more insights in the mechanisms underlying the optimized immune function following a psychological intervention. This is also relevant for clinical practice, as psychological interventions can possibly supplement, or at least partially replace, current drug treatments in various somatic conditions to reduce side effects.

Between the Error Bars: How Modern Theory, Design, and Methodology Enrich the Personality-Health Tradition

The study of relationships between personality traits and health has a long history in psychosomatic research. However, personality science has evolved from an understanding of personality as fixed traits to one that acknowledges that personality is dynamic. Dynamic approaches to conceptualizing and measuring personality and individual differences can enrich personality-health research. In this Presidential Address (American Psychosomatic Society, 2018), I consider how different formulations of personality-stable traits, stable signals in a noisy or variable measure, within-person changes, and intraindividual variability-can be implemented to better understand how personality is related to health and particularly to immune function. These approaches recognize and, in some cases, capitalize on the fact that personality factors can display variability as well as stability over time. They also require repeated measurement and therefore greater methodological sophistication that considers reliability and generalizability, Simpson's paradox, and the difference between variability and flexibility. Dynamic qualities of personality and individual differences potentially influence health, and designs and methodology that incorporate them can illuminate the important processes that occur inside the error bars.

Stress, depression, diet, and the gut microbiota: human-bacteria interactions at the core of psychoneuroimmunology and nutrition

Humans and their gut bacteria have evolved multiple ways to communicate with and regulate one another. Psychological stress and depression can promote consumption of highly palatable foods, influencing which gut bacteria thrive. Additionally, stress and depression can reshape the gut bacteria's composition through stress hormones, inflammation, and autonomic alterations. In turn, the gut bacteria release metabolites, toxins, and neurohormones that can alter eating behavior and mood. Some bacterial species may encourage dysregulated eating. The gut bacteria may also upregulate stress responsiveness and heighten the risk for depression, which probiotic supplementation may attenuate. This review focuses on human studies to address the bidirectional links among diet, stress, and the gut bacteria, and their impact on immune function and health.

Infant cortisol stress-response is associated with thymic function and vaccine response

Stress can impair T cell-mediated immunity. To determine if infants with high stress responses had deficits in T-cell mediated immunity, we examined the association of pain-induced cortisol responsiveness with thymic function and vaccine responses in infants. This study was performed among 306 (male = 153 and female = 153) participants of a randomized, controlled trial examining the effect of neonatal vitamin A supplementation on immune function in Bangladesh (NCT01583972). Salivary cortisol was measured before and 20 min after a needle stick (vaccination) at 6 weeks of age. The thymic index (TI) was determined by ultrasonography at 1, 6, 10 and 15 weeks. T-cell receptor excision circle and blood T-cell concentrations were measured at 6 and 15 weeks. Responses to Bacillus Calmette-Guérin (BCG), tetanus toxoid, hepatitis B virus and oral poliovirus vaccination were assayed at 6 and 15 weeks. Cortisol responsiveness was negatively associated with TI at all ages (p < .01) in boys only, was negatively associated with naïve helper T-cell concentrations in both sexes at both 6 (p = .0035) and 15 weeks (p = .0083), and was negatively associated with the delayed-type hypersensitivity (DTH) skin test response to BCG vaccination at 15 weeks (p = .034) in both sexes. Infants with a higher cortisol response to pain have differences in the T-cell compartment and a lower DTH response to vaccination. Sex differences in the immune system were seen as early as 6 weeks of age in these healthy infants.

Immunostimulatory effect of kumquat (Fortunella crassifolia) and its constituents, β-cryptoxanthin andR-limonene

The active constituents of kumquat in NK cell activation and anti-stress effects are β-cryptoxanthin andR-limonene.

Group interventions to promote mental health in health professional education: a systematic review and meta-analysis of randomised controlled trials

Effects of interventions for improving mental health of health professional students has not been established. This review analysed interventions to support mental health of health professional students and their effects. The full holdings of Medline, PsycINFO, EBM Reviews, Cinahl Plus, ERIC and EMBASE were searched until 15th April 2016. Inclusion criteria were randomised controlled trials of undergraduate and post graduate health professional students, group interventions to support mental health compared to alternative education, usual curriculum or no intervention; and post-intervention measurements for intervention and control participants of mindfulness, anxiety, depression, stress/distress or burnout. Studies were limited to English and short term effects. Studies were appraised using the PEDro scale. Data were synthesised using meta-analysis. Four comparisons were identified: psychoeducation or cognitive-behavioural interventions compared to alternative education, and mindfulness or relaxation compared to control conditions. Cognitive-behavioural interventions reduced anxiety (-0.26; -0.5 to -0.02), depression (-0.29; -0.52 to -0.05) and stress (0.37; -0.61 to -0.13). Mindfulness strategies reduced stress (-0.60; -0.97 to -0.22) but not anxiety (95% CI -0.21 to 0.18), depression (95% CI -0.36 to 0.03) or burnout (95% CI -0.36 to 0.10). Relaxation strategies reduced anxiety (SMD -0.80; 95% CI -1.03 to -0.58), depression (-0.49; -0.88 to -0.11) and stress (-0.34; -0.67 to -0.01). Method quality was generally poor. Evidence suggests that cognitive-behavioural, relaxation and mindfulness interventions may support health professional student mental health. Further high quality research is warranted.

Effects of transportation, relocation, and acclimation on phenotypes and functional characteristics of peripheral blood lymphocytes in rhesus monkeys (Macaca mulatta)

Nonhuman primates from domestic sources constitute a small, but critical, proportion of animals studied in research laboratories. Many of these nonhuman primates are raised at one facility and subsequently transported/relocated to another facility for research purposes. We examined the effects of transport, relocation, and acclimation on the phenotype and function of peripheral blood mononuclear cells (PBMCs) in a group of rhesus monkeys that were transported by road for approximately 21 hours from one facility to another. Using a panel of human antibodies and a set of standardized human immune assays, we evaluated the phenotype of lymphocyte subsets by flow, mitogen-specific immune responses of PBMCs in vitro, and levels of circulating cytokines and cortisol in plasma at various time points including immediately before transport, immediately upon arrival, and after approximately 30 days of acclimation. Analyses of blood samples revealed that CD3+ T-cell and CD20+ B-cell populations had decreased significantly immediately after relocation but had recovered within 30 days after arrival at the new facility. Similarly, circulating cortisol and cytokine levels in plasma were significantly higher immediately after relocation; and by the 30-day time point, these differences were no longer significant. However, immune assays of PBMCs indicated that mitogen-specific responses for proliferation, interferon γ (IFN-γ), and perforin were significantly higher after relocation and 30 days of acclimation. These findings have implications on the research participation of transported and relocated nonhuman primates in immunologic research studies, suggesting that 30 days is not sufficient to ensure return to baseline immune homeostasis. These data should be considered when planning research studies in order to minimize potential confounding factors associated with relocation and to maximize study validity.

Impact of chronic and acute academic stress on lymphocyte subsets and monocyte function

This study investigated the effects of a temporally confined naturalistic stressor (academic stress) on immune functions. Furthermore, moderating influences of a number of psychological variables were assessed. Five blood samples were obtained from 20 students during an observation period of 8 weeks, starting 4.5 weeks before an exam period up to 1 week following the last exam. The analysis of 45 immune parameters revealed several time-dependent changes attributable to examination stress. We observed a reduction in the absolute numbers of natural killer (NK) cells and monocytes in peripheral blood and a shift towards more immature and naïve cells within NK and T cell populations. In addition, IL-6 and TNF-α production by LPS-stimulated monocytes was increased. Psychological variables were grouped by means of factor analyses into two factors. One factor, which was interpreted as an indication of chronic stress, moderated the relationships between academic stress and percentages of mature CD57+ NK cells. This chronic stress factor was also associated with an increase in memory and a decrease in naïve CD8 T cells and increased serum levels of IL-17. The present study identifies important potential psychological mediators of stress-induced changes in specific immunological parameters.

Hypnosis in patients with perceived stress - a systematic review

BACKGROUND

Although hypnosis and hypnotherapy have become more popular in recent years, the evidence for hypnosis to influence perceived stress is unclear. In this systematic review we searched and evaluated randomized clinical studies investigating the effect of hypnosis on perceived stress reduction and coping.

METHODS

The Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Review of Effects, EMBASE, Medline, PsycINFO, PSYNDEX and PubMed were systematically screened from their inception until December 2015 for randomized controlled trials (RCTs) reporting about hypnosis or hypnotherapy for stress reduction in healthy participants. Risk of Bias was assessed according the Cochrane Collaboration recommendations.

RESULTS

Nine RCTs with a total of 365 participants met the inclusion criteria and were included in this review. Most included participants were medical students, predominantly female (n = 211). Mean age of participants ranged in most studies between 20 and 25 years, in three studies the mean ages were between 30 and 42 years. Perceived stress was measured by a wide range of psychological questionnaires including Face Valid Stress Test, Stress Thermometer, and immunological data was collected. All nine included studies used explorative designs and showed a high risk of bias. Six out of nine studies reported significant positive effects of hypnosis for stress reduction in the main outcome parameter compared to control groups (3 active controls, 3 no therapy controls). Immunological outcomes were assessed in six studies, the results were inconclusive.

CONCLUSIONS

Due to exploratory designs and high risk of bias, the effectiveness of hypnosis or hypnotherapy in stress reduction remains still unclear. More high quality clinical research is urgently needed.

Job stress and major coronary events: results from the Job Stress, Absenteeism and Coronary Heart Disease in Europe study

AIMS

The intention of this study is to investigate the relationship of the demands/control/strain model with hard coronary events in an epidemiological, prospective, multicenter, European study.

METHODS AND RESULTS

Six cohorts (Brussels, Ghent, Lille, Barcelona, Göteborg and Malmö) from four European countries (Belgium, France, Spain and Sweden) consisting of 21 111 middle-aged male subjects participated between 1993 and 1996 in the baseline survey of the Job Stress, Absenteeism and Coronary Heart Disease in Europe (JACE) study. The Karasek strain model of psychological demands (five items)/control (nine items) was used. During a mean follow-up of 40 months 185 acute coronary events or coronary deaths were observed. Age-adjusted hazard ratios (HRs) for developing an acute coronary event were 1.46 [CI 95% confidence interval (1.08-1.97)] for high against low psychological demands and 1.53 (95% CI 1.0-2.35) for strained (high demands plus low control) against relaxed (low demands plus high control) groups. After adjustment for standard cardiovascular risk factors the HR for developing a coronary event for those above or equal to the median against those below the median of psychological demands was 1.46 (95% CI 1.08-1.97) whereas the HR for strained against relaxed groups is 1.46 (95% CI 0.96-2.25). Sensitivity analyses confirmed the robustness of the results.

CONCLUSION

In this European, multicenter, prospective, epidemiological study the Karasek job strain model was an independent predictor of acute coronary events, with the psychological demands scale emerging as the important component.

Associations Between Attachment Representations and Health Behaviors in Late Adolescence

In this study, we tested the associations among attachment ratings and health behaviors by relationship status. For individuals in relationships, attachment security was associated positively with health promotion and quality sleep and negatively with risk behaviors; fearfulness was associated positively with risk behaviors. With the exception of sleep behaviors, associations with security and fearfulness were reversed for single participants. Associations between dismissingness and quality of sleep support the proposal that individuals who deny or dismiss their attachment needs may experience physical symptoms of distress that affect their health. Future work exploring the benefits of security when coping with illness or lifestyle change is discussed.

Anger Expression, Coping Styles, and Well-being

This study examined the role of anger expression in the experience of stress, coping with stress and psychological and physical well-being. Based on a sample of 268 Singaporeans, the results, using structural equation modelling, indicated that anger expression was significantly related to reported stress, mechanisms for coping with stress and psychological wellbeing. Higher levels of anger expression were associated with higher levels of stress as well as lower use of active coping. Active coping was in turn positively related to psychological well-being. In addition, higher levels of anger expression showed a direct negative relationship with psychological well-being as did higher levels of stress. In contrast, the only significant predictor of physical well-being was reported stress, with higher levels of stress related to lower levels of physical well-being. The implications of these results for understanding the role of anger expression in psychological and physical wellbeing are discussed.

Associating Changes in the Immune System with Clinical Diseases for Interpretation in Risk Assessment

This overview is an update of the unit originally published in 2004. While the basic tenets of immunotoxicity have not changed in the past 10 years, several publications have explored the application of immunotoxicological data to the risk assessment process. Therefore, the goal of this unit is still to highlight relationships between xenobiotic-induced immunosuppression and risk of clinical diseases progression. In immunotoxicology, this may require development of models to equate moderate changes in markers of immune functions to potential changes in incidence or severity of infectious diseases. For most xenobiotics, exposure levels and disease incidence data are rarely available, and safe exposure levels must be estimated based on observations from experimental models or human biomarker studies. Thus, it is important to establish a scientifically sound framework that allows accurate and quantitative interpretation of experimental or biomarker data in the risk assessment process.

A Meta-analysis of universal mental health prevention programs for higher education students

This meta-analysis investigated the effectiveness of universal mental health prevention programs for higher education students on a range of adjustment outcomes. A systematic literature search identified 103 controlled published and unpublished interventions involving college, graduate, or professional students. As hypothesized, skill-training programs that included a supervised practice component were significantly more effective overall (mean effect size = 0.45, confidence interval (CI) = 0.39 to 0.52) compared to skill-training programs without supervised practice (0.11, CI = -0.01 to 0.22) and psychoeducational (information-only) programs (0.13, CI = 0.06 to 0.21). When comparisons on specific outcomes were possible, skill-training programs including supervised practice were significantly more effective than the other two groups of programs in reducing symptoms of depression, anxiety, stress, and general psychological distress, and in improving social-emotional skills, self-perceptions, and academic behaviors and performance. The magnitude of effects achieved in several outcome areas is comparable to or higher than that reported in other reviews of universal programs, suggesting that skill-training programs for higher education students that incorporate supervised practice now join the ranks of other effective preventive mental health interventions. This review offers several recommendations to improve the experimental rigor of future research.

Bifidobacterium bifidum R0071 results in a greater proportion of healthy days and a lower percentage of academically stressed students reporting a day of cold/flu: a randomised, double-blind, placebo-controlled study

Acute psychological stress is positively associated with a cold/flu. The present randomised, double-blind, placebo-controlled study examined the effect of three potentially probiotic bacteria on the proportion of healthy days over a 6-week period in academically stressed undergraduate students (n 581) who received Lactobacillus helveticus R0052, Bifidobacterium longum ssp. infantis R0033, Bifidobacterium bifidum R0071 or placebo. On each day, participants recorded the intensity (scale: 0 = not experiencing to 3 = very intense) for nine cold/flu symptoms, and a sum of symptom intensity >6 was designated as a day of cold/flu. B. bifidum resulted in a greater proportion of healthy days than placebo (P≤ 0·05). The percentage of participants reporting ≥ 1 d of cold/flu during the 6-week intervention period was significantly lower with B. bifidum than with placebo (P< 0·05). There were no effects of B. infantis or L. helveticus compared with placebo on either outcome. A predictive model accounted for influential characteristics and their interactions on daily reporting of cold/flu episodes. The proportion of participants reporting a cold on any given day was lower at weeks 2 and 3 with B. bifidum and B. infantis than with placebo for the average level of stress and the most commonly reported number of hours of sleep. Daily intake of bifidobacteria provides benefit related to cold/flu outcomes during acute stress.

Mind-body skills groups for medical students: reducing stress, enhancing commitment, and promoting patient-centered care

BACKGROUND

For several decades, psychological stress has been observed to be a significant challenge for medical students. The techniques and approach of mind-body medicine and group support have repeatedly demonstrated their effectiveness at reducing stress and improving the quality of the education experience.

DISCUSSION

Mind-Body Skills Groups provide medical students with practical instruction in and scientific evidence for a variety of techniques that reduce stress, promote self-awareness and self-expression, facilitate imaginative solutions to personal and professional problems, foster mutual understanding among students, and enhance confidence in and optimism about future medical practice. The Center for Mind-Body Medicine, which developed this model 20 years ago, has trained medical school faculty who offer these supportive small groups to students at more than 15 US medical schools. This paper describes the model, surveys its use in medical schools, summarizes published research on it, and discusses obstacles to successful implementation as well as its benefits.

SUMMARY

Mind-Body Skills groups have demonstrated their effectiveness on reducing stress in medical students; in enhancing the students' experience of medical education; and in helping them look forward more confidently and hopefully to becoming physicians. The experience of these 15 institutions may encourage other medical schools to include mind-body skills groups in their curricula.

Gut-directed hypnotherapy significantly augments clinical remission in quiescent ulcerative colitis

BACKGROUND

Psychotherapy is not routinely recommended for in ulcerative colitis (UC). Gut-directed hypnotherapy (HYP) has been linked to improved function in the gastrointestinal tract and may operate through immune-mediated pathways in chronic diseases.

AIMS

To determine the feasibility and acceptability of HYP and estimate the impact of HYP on clinical remission status over a 1-year period in patients with an historical flare rate of 1.3 times per year.

METHODS

A total of 54 patients were randomised at a single site to seven sessions of gut-directed HYP (n = 26) or attention control (CON; n = 29) and followed for 1 year. The primary outcome was the proportion of participants in each condition that had remained clinically asymptomatic (clinical remission) through 52 weeks post treatment.

RESULTS

One-way analysis of variance comparing HYP and CON subjects on number of days to clinical relapse favoured the HYP condition [F = 4.8 (1, 48), P = 0.03] by 78 days. Chi-squared analysis comparing the groups on proportion maintaining remission at 1 year was also significant [χ²(1) = 3.9, P = 0.04], with 68% of HYP and 40% of CON patients maintaining remission for 1 year. There were no significant differences between groups over time in quality of life, medication adherence, perceived stress or psychological factors.

CONCLUSION

This is the first prospective study that has demonstrated a significant effect of a psychological intervention on prolonging clinical remission in patients with quiescent ulcerative colitis (Clinical Trial # NCT00798642).

An evaluative review of outcome research on universal mental health promotion and prevention programs for higher education students

OBJECTIVE

This review is the first large-scale attempt to evaluate the effectiveness of universal promotion and prevention programs for higher education students on a range of adjustment outcomes.

PARTICIPANTS/METHODS

The current review examined 83 controlled interventions involving college, graduate, and professional students, with a focus on 3 main outcomes: social and emotional skills, self-perceptions, and emotional distress.

RESULTS/CONCLUSIONS

Skill-oriented programs that included supervised practice demonstrated the strongest benefits, thus showing promise as a successful mental health promotion and preventive intervention. In comparing different intervention strategies, mindfulness training and cognitive-behavioral techniques appear to be the most effective. Furthermore, interventions conducted as a class appear to be effective, suggesting the potential for exposing higher education students to skill training through routine curricula offerings. This review offers recommendations for improving the experimental rigor of future research, and implications for enhancing campus services to optimize student success in psychosocial--and thus ultimately academic--domains.

Promoting psychosocial adjustment and stress management in first-year college students: the benefits of engagement in a psychosocial wellness seminar

OBJECTIVE/METHODS

This research evaluates the effectiveness of a psychosocial wellness seminar for first-year college students, from 2009 to 2011, using an 8-month prospective quasi-experimental design.

PARTICIPANTS/RESULTS

Compared with controls (n = 22) involved in an alternative seminar, intervention participants (n = 29) showed no differences at baseline, but reported significantly greater perceived improvements over the course of the intervention, in psychosocial adjustment and stress management. Furthermore, specific aspects of intervention engagement (attendance and student-rated skills practice, but not didactic mastery or facilitator-rated skills practice) differentially predicted beneficial outcomes: (1) psychosocial adjustment (increases in psychosocial well-being, decreases in psychological distress), after adjusting for baseline levels of these outcomes; (2) college-related stress management (lower college-related stress, greater adaptation to college); and (3) perceived improvements in psychosocial adjustment and stress management.

CONCLUSIONS

This research indicates promising avenues for programmatic efforts to promote psychosocial adjustment and stress management in college students, during this critical developmental juncture.

Galactooligosaccharide supplementation reduces stress-induced gastrointestinal dysfunction and days of cold or flu: a randomized, double-blind, controlled trial in healthy university students

BACKGROUND

Acute psychological stress induced by academic exams is associated with dysregulated gastrointestinal and immune function.

OBJECTIVE

We examined whether supplementation with galactooligosaccharides reduced gastrointestinal dysfunction and the percentage of days with cold or flu in academically stressed undergraduate students.

DESIGN

In a randomized, double-blind study, subjects (n = 427) received 0, 2.5, or 5.0 g galactooligosaccharides for 8 wk around the time of fall final exams. Levels of stress and cold or flu symptom intensity (SI; 0 = not experiencing to 3 = severe) were recorded daily. The SI from 9 cold or flu symptoms was summed with 1 d of cold or flu defined as a sum >6. The Gastrointestinal Symptom Response Scale was completed weekly.

RESULTS

Stress was positively related to diarrhea, indigestion, and reflux syndromes and with abdominal pain, average daily cold or flu SI score, and the percentage of days with cold or flu. Gastrointestinal symptom scores for diarrhea (P = 0.0298), constipation (P = 0.0342), abdominal pain (P = 0.0058), and indigestion (P = 0.0003) syndromes were lower after galactooligosaccharide supplementation. The cold or flu SI score was affected by galactooligosaccharides and stress (P < 0.0001); 2.5 g was associated with a lower SI score across all levels of stress, but 5.0 g was protective only at lower levels of stress. The percentage of days with cold or flu was associated with galactooligosaccharides within different body mass index categories (P = 0.0002), wherein a 40% reduction in the percentage of days with cold or flu was observed in normal-weight individuals with 5.0 g galactooligosaccharides. This effect was not observed in overweight or obese individuals.

CONCLUSIONS

Acute psychological stress was directly related to symptoms of gastrointestinal dysfunction and cold or flu. Galactooligosaccharide supplementation reduced these symptoms and the number of days with cold or flu. This trial was registered at clinicaltrials.gov as NCT01137760.

Use of saliva for assessment of stress and its effect on the immune system prior to gross anatomy practical examinations

The objective of this study was to determine the longitudinal effects of a series of stressful gross anatomy tests on the immune system. Thirty-six freshman occupational therapy students completed a written stress evaluation survey, and saliva samples were obtained at baseline and prior to each of three timed-practical gross anatomy tests. Cortisol, secretory IgA (sIgA), and IL-12 concentrations were measured within the salivary samples by enzyme-linked immunosorbent assay. The total scores from the stress surveys were used as markers for environmental stress. Data were compiled for each student at baseline and prior to each examination and were compared by repeated-measures MANOVA and Pearson's correlation test. Following normalization for protein concentration and flow rate, the concentrations of IL-2, IL-6, IL-12, and sIgA progressively increased from baseline to the third test. Cortisol concentrations, following normalization for flow rate, were highest prior to the first test and became significantly reduced prior to second and third test. Prior to second and third test, salivary concentrations of IL-6, IL-2, IL-12, and sIgA were significantly correlated (P < 0.05). In contrast, prior to third test, there was a negative correlation between salivary concentrations of cortisol and IL-12 (P < 0.05). Progressive increases in salivary sIgA, IL-6, IL-2, and IL-12 concentrations from the first to the third test coincident to decreased salivary cortisol suggest that the initial examination stressors precede significant effects on the immune system. These data suggest that there may be latent effects of examination stress on the immune system and that saliva can be used to predict these effects.

Efficacy of hypnosis in the treatment of human papillomavirus (HPV) in women: rural and urban samples

This article investigates the effect of hypnosis on immunity and whether this is the key mechanism in the hypnotic treatment of the genital infection caused by human papillomavirus (HPV). HPV is the most common sexually transmitted disease and can lead to cervical and other cancers. Current medical treatments are aimed at tissue assault (acids, freezing, surgery). Medical wart clearance rates are only 30% to 70% and recurrence is common. Our research contrasted hypnosis-only with medical-only therapies, using both urban hospital and rural community samples. Both hypnosis and medical therapy resulted in a statistically significant (p < .04) reduction in areas and numbers of lesions. Yet, at the 12-week follow-up, complete clearance rates were 5 to 1 in favor of hypnosis.

Immune Measures in Behavioral Medicine Research: Procedures and Implications

Immune system activity is heavily influenced by the central nervous system. These interactions provide us the means to study mind–body interactions and how they affect health. In general, measures of immune system activity can be divided into two categories: those that are evident in the circulation and those that need to be elicited. For example, leukocytes can be collected from the circulation, counted, and their function accessed in cell culture. To test the ability of the immune system to respond to an experimental challenge more directly, studies involving wound healing, or involving the response to an infectious agent, can be performed. The purpose of this chapter is briefly to describe immune assays that are commonly employed in behavioral medicine research, including a rationale for their use as well as a brief description of the methodology. This chapter also describes previous studies in which circulatory and elicited immune measures have been studied in human subjects experiencing different psychological stressors, with an emphasis on studies involving medical students experiencing academic stress and caregivers of a spouse with Alzheimer’s disease. Finally, the chapter discusses the important role that the employment of animal models can play in studies of stress and health and in defining how nervous system activity can influence the immune response.

Biomarkers in the Study of Families of Individuals with Developmental Disabilities

Research during the past 20 years on families of children with developmental disabilities has yielded a rich body of knowledge about the stress of parenting a child with DD, and the risk and protective factors that result in profiles of family resilience vs. vulnerability at various stages of the family life course. Virtually all of this research has been based on data collected from self-report measures, and has focused on family interactions and relationships, and the psychosocial well-being of individual family members. The present chapter focuses on different sources of data, namely biomarkers, which have the potential to extend our understanding of the biological mechanisms by which the stress of parenting a child with developmental disabilities can take its toll on parents' physical and mental health. We focus on two examples: (1) variations in the FMR1 gene, FMRP, and FMR1 messenger RNA in mothers of children with fragile X syndrome and the association of these measures with maternal depression and anxiety; and (2) profiles of cortisol expression in mothers of children with disabilities and the association of cortisol with daily measures of caregiving stress.

Mind-Body Medicine and Immune System Outcomes: A Systematic Review

This study is a systematic review of mind-body interventions that used immune outcomes in order to: 1) characterize mind-body medicine studies that assessed immune outcomes, 2) evaluate the quality of mind-body medicine studies measuring immune system effects, and 3) systematically evaluate the evidence for mind-body interventions effect on immune system outcomes using existing formal tools. 111 studies with 4,777 subjects were reviewed. The three largest intervention type categories were Relaxation Training (n=25), Cognitive Based Stress Management (n=22), and Hypnosis (n=21). Half the studies were conducted with healthy subjects (n=51). HIV (n=18), cancer (n=13) and allergies (n=7) were the most prominent conditions examined in the studies comprising of non-healthy subjects. Natural killer cell and CD4 T lymphocyte measures were the most commonly studied outcomes. Most outcome and modality categories had limited or inconclusive evidence. Relaxation training had the strongest scientific evidence of a mind-body medicine affecting immune outcomes. Immunoglobulin A had the strongest scientific evidence for positive effects from mind-body medicine. Issues for mind-body medicine studies with immune outcomes are discussed and recommendations are made to help improve future clinical trials.

Psychosocial and biological markers of daily lives of midlife parents of children with disabilities

Using daily telephone interviews, 82 midlife parents (mean age = 57.4) of children with disabilities (mean age = 29.9) were compared with a closely matched sample of unaffected parents (N = 82) to elucidate the daily experience of nonnormative parenting. In addition, salivary cortisol samples were obtained to examine whether parents of children with disabilities had dysregulated diurnal rhythms and the extent to which the amount of time spent with children was associated with divergent patterns of cortisol expression. We found that parents of children with disabilities had similar patterns of daily time use and similar likelihood of positive daily events as the comparison group, but they had elevated levels of stress, negative affect, and physical symptoms, all reported on a daily basis. In addition, their diurnal rhythm of cortisol expression differed significantly from the comparison group, a pattern that was strongest for parents of children with disabilities on days when they spent more time with their children.

Immuno-modulatory effects of relaxation training and guided imagery in women with locally advanced breast cancer undergoing multimodality therapy: a randomised controlled trial

Eighty women undergoing multimodality treatment for large (>4cm) or locally advanced (T3, T4, Tx, N2), breast cancers participated in a randomised controlled trial (RCT) to evaluate the immuno-modulatory effects of relaxation training and guided imagery. Patients underwent chemotherapy followed by surgery, radiotherapy, and hormone therapy. Those in the intervention group were taught relaxation and guided imagery. Patients kept diaries of the frequency of relaxation practice and imagery vividness. On 10 occasions during the 37 weeks following the diagnosis, blood was taken for immunological assays CD phenotyping: T cell subsets (helper, cytotoxic), natural killer (NK) and lymphokine activated killer (LAK) cells, B lymphocytes and monocytes; cytotoxicity: NK and LAK cell activities; cytokines interleukin 1 beta (1beta), 2, 4 and 6 and tumour necrosis factor alpha. Significant between-group differences were found in the number of CD25+ (activated T cells) and CD56+ (LAK cell) subsets. The number of CD3+ (mature) T cells was significantly higher following chemotherapy and radiotherapy, in patients randomised to relaxation and guided imagery. Using a median split, women who rated their imagery ratings highly had elevated levels of NK cell activity at the end of chemotherapy and at follow-up. Significant correlations were obtained between imagery ratings and baseline corrected values for NK and LAK cell activity, and IL1beta. Relaxation frequency correlated with the number of CD4+ (T helper) cells, the CD4+:8+ (helper:cytotoxic) ratio, and IL1beta levels. Relaxation training and guided imagery beneficially altered putative anti-cancer host defences during and after multimodality therapy. Such changes, to the best of our knowledge, have not been previously documented in a RCT.

Knowledge and use of music therapy among pediatric practitioners in Michigan

OBJECTIVE

Increasingly, music therapy is being used, in combination with conventional treatment modalities, as part of the health care treatment plan. The objective of our study was to determine the awareness, knowledge and use of music therapy by members of the Michigan chapter of the American Academy of Pediatrics (Michigan AAP) in their health care practice.

METHODS

Members of the Michigan AAP were asked to participate in a survey designed to assess their knowledge and use of music therapy in their health care practice.

RESULTS

Although the majority of respondents were aware of the use of music therapy in health care settings, very few had referred their own patients for music therapy services.

CONCLUSION

Music therapy is an inexpensive and noninvasive treatment modality being used increasingly, especially to alleviate pain, stress, and anxiety among patients in a variety of conditions. Pediatric practitioners in Michigan, who responded to our survey, expressed a strong interest in learning more about music therapy and learning about ways to incorporate music therapy into their health care practice.

Stress hormones and immune function

Over the past 20 years we have demonstrated both in animal models and in human studies that stress increases neuroendocrine hormones, particularly glucocorticoids and catecholamines but to some extent also prolactin, growth hormone and nerve growth factor. We have also shown that stress, through the action of these stress hormones, has detrimental effects on immune function, including reduced NK cell activity, lymphocyte populations, lymphocyte proliferation, antibody production and reactivation of latent viral infections. Such effects on the immune system have severe consequences on health which include, but are not limited to, delayed wound healing, impaired responses to vaccination and development and progression of cancer. These data provide scientific evidence of the effects of stress on immune function and implications for health.

Mid-life stress is associated with both up- and down-regulation of markers of humoral and cellular immunity

Perception of stress with consequent activation of a neuroendocrine cascade causes changes in immune function that may be bi-directional, with alterations in basal levels of biological parameters outside the optimal range. In this cross-sectional study of 302 healthy persons (males 56.3%, females 43.7%) aged 41-46 years, higher stress levels, as assessed by questionnaire measures of recurrent and recent perceived stress, were associated with a 4-fold greater risk of having a high compared to mid-range serum neopterin concentration, indicating activation of cellular immune mechanisms [adjusted odds ratio, OR; (95% confidence intervals, CI): Low stress=1.00 (reference group); Medium stress=4.13 (1.51, 11.29); High stress=4.63, (1.35, 15.83), p for trend=0.01]. Higher stress levels were associated with a 3-fold greater risk of having signs of humoral immune activation, as indicated by salivary IgA concentration [high compared to mid-range salivary IgA: Low stress=1.00 (reference group); Medium stress=1.06 (0.48, 2.34); High stress=3.62 (1.26, 10.39), p for trend=0.02], but also a 4-fold greater risk of humoral immune depression [low compared to mid-range IgA: Low stress=1.00 (reference group); Medium stress=1.72 (0.74, 3.99); High stress=4.38 (1.47, 13.00), p for trend=0.02]. In conclusion, in this cross-sectional study, higher stress levels were associated with higher serum neopterin and both elevated and depressed salivary IgA levels. These findings emphasise the importance of considering that stress may have bi-directional effects on immune mechanisms, and are consistent with an activational effect of chronic, perceived stress on cellular immunity, and a bi-directional effect on IgA levels, one aspect of humoral immunity.

Music therapy in pediatrics

The soothing effects of music have been well described over the centuries and across cultures. In more recent times, studies have shown the beneficial effects of music in alleviating symptoms in a wide variety of clinical and psychologic conditions. Music therapy has been primarily used as an intervention to control emotional states, in pain management, cognitive processing, and stress management. Stress is associated with increased production of the stress hormone cortisol, which is known to suppress immune responses. Several studies in the past few decades have demonstrated a positive effect of music therapy on reducing stress or increasing immune responses, or both. Music therapy should therefore be considered as a valuable addition to standard pharmacologic therapeutic modalities in enhancing the immune response and lowering stress levels in such conditions. This article reviews the role of music as a therapeutic modality and the future for music therapy, particularly in pediatrics.

Lymphocyte subsets, cardiovascular measures and anxiety state before and after a professional examination

Controversies exist regarding the impact of psychological stress on the functioning of the immune system in humans. The aim of the present study, therefore, was to evaluate whether the condition of a pre-exam stress may or not modify resting lymphocyte subsets, as well as blood pressure and heart rate. About 22 medical residents of both sexes not suffering from any medical or psychiatric disorder were included in the study. Anxiety levels were measured by means of the Hamilton rating scale for anxiety (HRSA) and anxiety traits by means of the panic-agoraphobic spectrum self-report (PAS-SR) version and the obsessive-compulsive spectrum self-report (OBS-SR) version. The results showed that systolic blood pressure and heart rate increased significantly just before sitting an examination (t(1)) in all subjects, as compared with a calm situation (t(2)), in parallel with the increase in the HRSA total score, while no significant difference was observed in lymphocyte subsets at the two assessment times. However, men had a higher number of CD4+ cells than women at t(1) and t(2), while women showed a higher heart rate at t(1). In addition, significant correlations between CD4+ lymphocyte count and heart rate at t(1) or HRSA at t(2) were detected. These findings indicate that the acute stress determined by sitting for examination provokes changes in autonomic nervous system parameters, such as blood pressure and heart rate, as well as in the subjective feeling of anxiety, as shown by the increased HRSA total scores, which were not paralleled by modifications of lymphocyte subsets. However, individual differences, related to both sex and personality traits yet to be identified, seem to have an impact in shaping the stress response.

Psychologic stress, reduced NK cell activity, and cytokine dysregulation in women experiencing diagnostic breast biopsy

The purpose of this study was to evaluate a woman's psychological and immunological response to breast biopsy before and after the procedure. Women were enrolled into the study when notified of the need for breast biopsy. Psychological and immunological assessments were made at enrollment, on the day of breast biopsy, as well as 1 month and 4 months after notification of biopsy results. Psychological assessments demonstrated that perceived stress, anxiety, and mood disturbance were heightened before biopsy and remained elevated after biopsy regardless of the diagnosis. Immunologically, the women exhibited reduced natural killer cell activity and INF gamma production before biopsy with reductions significant 1 month after the procedure. In contrast, IL-4, IL-6, and IL-10 production were increased before and after the procedure with most significant increases prior to the procedure and continuing 1 month after the procedure. These results demonstrate that undergoing biopsy of the breast for cancer diagnosis is an emotional experience, characterized by increased perceived stress, anxiety, and mood disturbance. This emotional distress is accompanied by reduced NK cell activity and cytokine dysregulation. The psychological and immunological impact of breast biopsy is not transient, but persists well beyond the actual experience of the biopsy procedure. Noteworthy is the observation that women with benign or malignant biopsy results experienced similar psycho-immune consequences. Hence, these observations are of relevance not only to women diagnosed with malignancy, who face the challenges of cancer treatment and adaptation to illness, but also to women with benign biopsy findings.

Chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is thought to have a worldwide prevalence of 0.4-1% with approximately 240,000 patients in the UK. Diagnosis is based on clinical criteria and critically depends on exclusion of other physical and psychiatric diseases. Studies of pathogenesis have revealed immune system abnormalities and chronic immune activation, dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis, brain abnormalities, evidence of emotional stress (comprising host aspects) and evidence of exogenous insults, for example, various microbial infections (Epstein-Barr virus, enteroviruses, parvovirus B19, Coxiella burnetii and Chlamydia pneumoniae), vaccinations and exposure to organophosphate chemicals and other toxins (comprising environmental aspects). Emotional stress appears to be very important as it reduces the ability of the immune system to clear infections, it's presence has been shown to determine whether or not an individual develops symptoms upon virus infection, and it leads to activation of the HPA axis. But, emotional stress is distinct from depression, the presence of which precludes a diagnosis of CFS. There is no specific treatment for CFS other than the much underutilised approach of specific treatment of virus infections. Current priorities are to understand the molecular pathogenesis of disease in terms of human and virus gene expression, to develop a diagnostic test based on protein biomarkers, and to develop specific curative treatments.

[Psychological stress, immune function and disease development. The psychoneuroimmunologic perspective]

Interdisciplinary psychoneuroimmunological (PNI) research increasingly demonstrates clinically relevant interrelations between psychological stressors and the onset or progression of chronic diseases. Disturbances of the bi-directional interaction between the nervous system, the immune system and the endocrine system have been hypothesized to be implicated in several diseases. Here, we review evidence from psychoneuroimmunology within the theoretical framework of allostatic load to conceptualize some of these associations. Interdisciplinary PNI research investigating the importance of psychological stress for the higher incidence of infections, decreased responses to vaccinations and delayed wound healing is reviewed. Furthermore, the literature supporting similar associations with regard to progression of oncological diseases and autoimmune disorders is reviewed with a focus on breast cancer and multiple sclerosis. The accumulating evidence regarding the importance of neuroendocrine-immune interaction in these diseases may thus lead to novel insights into pathogenetic mechanisms and could contribute to the development of novel preventive and therapeutic strategies.