An Emotionally Inexpressive (Type C) Coping Style Influences HIV Disease Progression at Six and Twelve Month Follow-ups

Positive and negative emotional expression measured from a single written essay about trauma predicts survival 17 years later in people living with HIV

OBJECTIVE

To determine whether expression of positive and negative emotions measured within a single written trauma essay predicts survival over 17 years in people living with HIV.

METHODS

This is a longitudinal, observational study of a volunteer sample of HIV-seropositive individuals at the mid-range of disease (150-500 CD4-cells/mm3 with no prior AIDS-defining symptoms). Exclusion criteria included substance dependence, dementia, and/or psychosis. Baseline assessments occurred between 1997 and 1999 and survival data was collected in 2014 (17 year follow up). At baseline, participants wrote an essay about the most traumatic event in their life. Emotional expression was measured by the number of positive and negative emotional words in the essay. The primary study outcome measure was survival from baseline. Biomedical covariates included CD4 count, viral load, age, and antiretroviral medications. Sociodemographic covariates included gender, race, and education.

RESULTS

The sample was diverse in terms of age (M [SD] 37.60 [9.07]), sex (70.7% male), sexual orientation (55.5% gay or bisexual), and race/ethnicity (37.2% African American, 30.5% white, 28.0% Hispanic, and 4.3% other). Positive, negative, and total emotional expression predicted greater survival (ps < 0.015). Those in the top third of total emotional expression had 3.83 times the survival rate (95% CI: 1.62, 9.02) of those in the bottom third. Odds ratios were 1.85 for positive emotion expression and 2.18 for negative emotion expression.

CONCLUSIONS

Both positive and negative emotions expressed in a written trauma essay predict survival over 17 years in people living with HIV. Expressing emotions may have benefits for health.

Inhibition of emotional needs and emotional wellbeing predict disease progression of chronic hepatitis C patients: an 8-year prospective study

Background

The role of psycosocial factors in the disease progression of chronic hepatitis C (CHC) patients remains unclear. The aim of the present study was to prospectively evaluate the prognostic value of behavioral patterns and the quality of life (QOL) of patients with CHC.

Methods

Two hundred and forty Japanese CHC patients (mean age 62.4 years) were assessed for behavioral patterns (Stress Inventory), QOL (Functional Assessment of Chronic Illness Therapy-Spiritual), and known prognostic factors at baseline then followed for a maximum of 8 years for disease progression, defined as either the first diagnosis of hepatocellular carcinoma (HCC) or hepatitis-related death.

Results

Forty-nine events occurred during the study period (46 newly diagnosed HCC cases, three hepatitis-related deaths). In a Cox proportional hazard model including known prognostic factors and treatment-related factors as time-dependent variables, behavioral patterns associated with inhibition of emotional needs (hazard ratio (HR): 1.35; 95 % confidence interval (CI): 1.02–1.77; p = 0.036) and QOL, representing emotional wellbeing (HR 0.60; 95 % CI 0.37–0.98; p = 0.041), were each associated with the risk of disease progression.

Conclusion

Psychosocial factors such as behavioral patterns relevant to the inhibition of emotional needs and emotional wellbeing independently affect the clinical course of patients with CHC.

Electronic supplementary material

The online version of this article (doi:10.1186/s13030-016-0075-3) contains supplementary material, which is available to authorized users.

Alexithymia, Assertiveness and Psychosocial Functioning in HIV: Implications for Medication Adherence and Disease Severity

Psychosocial function and adherence to antiretroviral regimen are key factors in human immunodeficiency virus (HIV) disease management. Alexithymia (AL) is a trait deficit in the ability to identify and describe feelings, emotions and bodily sensations. A structural equation model was used to test whether high levels of AL indirectly relate to greater non-adherent behavior and HIV disease severity via psychosocial dysfunction. Blood draws for HIV-1 viral load and CD4 T-lymphocyte, along with psychosocial surveys were collected from 439 HIV positive adults aged 18-73 years. The structural model supports significant paths from: (1) AL to non-active patient involvement, psychological distress, and lower social support, (2) psychological distress and non-active involvement to non-adherent behavior, and (3) non-adherence to greater HIV disease severity (CFI = .97, RMSEA = .04, SRMR = .05). A second model confirmed the intermediary effect of greater patient assertiveness on the path from AL to social support and non-active patient involvement (CFI = .94, RMSEA = .04, SRMR = .05). Altogether, AL is indirectly linked with HIV disease management through it's association with poor psychosocial function, however greater patient assertiveness buffers the negative impact of AL on relationship quality with healthcare providers and members of one's social support network.

Illness perception in systemic lupus erythematosus patients: The roles of alexithymia and depression

OBJECTIVE

Alexithymia and depressive mood have been described as important dimensions of several medical diseases. Systemic lupus erythematosus is a chronic condition characterized by unpredictable clinical manifestations. The relationships between alexithymia, depression, and illness perception were examined in systemic lupus erythematosus patients. The interrelationships between psychological factors, such as alexithymia and depressive mood, were explored in systemic lupus erythematosus patients, and associations between these factors and illness perception in SLE were examined. We hypothesized that alexithymia and negative perceptions of illness would be associated in SLE patients, and depression would mediate this relationship.

METHODS

Subjects were 100 consecutive systemic lupus erythematosus patients attending the outpatient clinic at the University of Pisa rheumatology unit. They completed the Toronto Alexithymia Scale, Beck Depression Inventory, and Revised Illness Perceptions Questionnaire. Clinical variables were measured, disease activity was evaluated using the European Consensus Lupus Activity Measure, and damage was assessed using the Systemic Lupus International Collaborative Clinics/American College of Rheumatology Damage Index.

RESULTS

There were no associations between clinical variables, alexithymia, and depression. The results highlight the existence of significant links between alexithymia and illness perception for systemic lupus erythematosus patients. Moreover, our data suggest that some of these links are mediated by depression, which is the direct predictor of different aspects of perceived health.

CONCLUSION

Our findings suggest that studying the role of psychological factors, such as alexithymia and depression, may contribute to a more comprehensive perspective of systemic lupus erythematosus, including their impact on patients' beliefs about treatment effectiveness and emotional adaptation to chronic disease.

Antiretroviral treatment adherence as a mediating factor between psychosocial variables and HIV viral load

Psychosocial factors may directly impact HIV health measures such as viral load (VL) whether or not patients are taking antiretroviral treatment (ART) consistently. Structural equation modeling plus Baron and Kenny's (1986) four-step approach were used to test a mediated model predicting VL among 246 HIV-infected adults who were on ART. Exogenous variables were social support, barriers to adherence, and stress. Moderators were alcohol use, marijuana use, and neurocognitive impairment. A small positive association between marijuana use and ART adherence approached significance. Only barriers to adherence predicted a decrease in adherence rates and an increase in VL. No other factors were significantly associated with either VL or adherence, and no interaction effects between exogenous variables and moderators were identified. The association between barriers to adherence and VL was partially mediated by ART adherence. Findings provide modest support for a direct link between psychosocial variables and a virologic response to ART.

Emotional Regulation and Depression: A Potential Mediator between Heart and Mind

A narrative review of the major evidence concerning the relationship between emotional regulation and depression was conducted. The literature demonstrates a mediating role of emotional regulation in the development of depression and physical illness. Literature suggests in fact that the employment of adaptive emotional regulation strategies (e.g., reappraisal) causes a reduction of stress-elicited emotions leading to physical disorders. Conversely, dysfunctional emotional regulation strategies and, in particular, rumination and emotion suppression appear to be influential in the pathogenesis of depression and physiological disease. More specifically, the evidence suggests that depression and rumination affect both cognitive (e.g., impaired ability to process negative information) and neurobiological mechanisms (e.g., hypothalamic pituitary adrenal axis overactivation and higher rates of cortisol production). Understanding the factors that govern the variety of health outcomes that different people experience following exposure to stress has important implications for the development of effective emotion-regulation interventional approaches (e.g., mindfulness-based therapy, emotion-focused therapy, and emotion regulation therapy).

Adverse psychosocial factors predict poorer prognosis in HIV disease: a meta-analytic review of prospective investigations

There is a growing epidemiological literature focusing on the association between psychosocial stress and human immunodeficiency virus (HIV) disease progression or acquired immunodeficiency syndrome (AIDS), but inconsistent findings have been published. We aimed to quantify the association between adverse psychosocial factors and HIV disease progression. We searched Medline; PsycINFO; Web of Science; PubMed up to 19 January 2009, and included population studies with a prospective design that investigated associations between adverse psychosocial factors and HIV disease progression or AIDS. Two reviewers independently extracted data on study characteristics, quality, and estimates of associations. The overall meta-analysis examined 36 articles including 100 psychosocial and disease related relationships. It exhibited a small, but robust positive association between adverse psychosocial factors and HIV progression (correlation coefficient as combined size effect 0.059, 95% confidence interval 0.043-0.074, p<0.001). Notably, sensitivity analyses showed that personality types or coping styles and psychological distress were more strongly associated with greater HIV disease progression than stress stimuli per se, and that all of the immunological and clinical outcome indicators (acquired immunodeficiency syndrome stage, CD4+ T-cell decline, acquired immunodeficiency syndrome diagnosis, acquired immunodeficiency syndrome mortality, and human immunodeficiency virus disease or acquired immunodeficiency syndrome symptoms) except for viral load exhibited detrimental effects by adverse psychosocial factors. In conclusion, the current review reveals a robust relationship between adverse psychosocial factors and HIV disease progression. Furthermore, there would appear to be some evidence for particular psychosocial factors to be most strongly associated with HIV disease progression.

Psychological distress, killer lymphocytes and disease severity in HIV/AIDS

Immunocellular mechanisms that account for the association between psychosocial risk factors and increased susceptibility to faster progression of HIV/AIDS are largely unknown. This study used structural equation modeling to test the hypothesis that enumerative and functional alterations in killer lymphocytes mediate the relationship between higher levels of psychological distress (defined by perceived stress, anxiety and depressive symptoms) and greater HIV disease severity (defined by HIV-1 viral load and T-helper (CD4(+)) cell count), independent of standard demographic and various HIV-related covariates. Participants were 200 HIV-1 seropositive adults on combination antiretroviral therapy (ages 20-55 years; 67% men; 62% black; 84% AIDS). The data fit a psychoimmune model in which the significant relationship between higher distress levels and greater disease severity was mediated by diminished natural killer (NK) cell count and cytotoxic function, as well as increased cytotoxic (CD8(+)) T-cell activation. Overall the findings indicated that the psychoimmune model accounted for 67% of the variation in HIV disease severity. In contrast, the data did not support a reverse directionality mediation model, where greater HIV disease severity predicted greater distress as a function of killer lymphocyte status. In sum, the psychoimmune associations of the final model are physiologically consistent and suggest that distress-related alterations in killer lymphocyte immunity may play a role in the biobehavioral mechanisms linked with HIV-1 pathogenesis.

Psychological adjustment to chronic disease

This Review discusses physiological, emotional, behavioural, and cognitive aspects of psychological adjustment to chronic illness. Reviewing the reports of the past decade, we identify four innovative and promising themes that are relevant for understanding and explaining psychological adjustment. In particular, the emphasis on the reasons why people fail to achieve a healthy adjustment has shifted to the identification of factors that help patients make that adjustment. To promote psychological adjustment, patients should remain as active as is reasonably possible, acknowledge and express their emotions in a way that allows them to take control of their lives, engage in self-management, and try to focus on potential positive outcomes of their illness. Patients who can use these strategies have the best chance of successfully adjusting to the challenges posed by a chronic illness.

Type C coping, alexithymia, and heart rate reactivity are associated independently and differentially with specific immune mechanisms linked to HIV progression

The maladaptive Type C coping style has been linked to disease progression in HIV and other immunologically mediated disorders. We hypothesized that strong Type C coping, higher levels of alexithymia, and greater cardiovascular (particularly heart rate) responses to, and prolonged recovery from stress would be associated with poorer functioning of immune parameters previously linked to HIV pathogenesis and progression: (1) antigen-stimulated production of the beta (beta)-chemokines MIP-1 alpha and MIP-1 beta, which bind to the HIV co-receptor CCR5 and block HIV entry into CD4(+) lymphocytes; and (2) antigen-stimulated production of the proinflammatory cytokine interleukin-6 (IL-6), which synergizes immune activation associated with HIV replication. We examined relations among psychological, cardiovascular, and immune variables in a baseline sample of 200 HIV-infected, predominantly African American outpatients attending an HIV primary care clinic in inner-city Baltimore. In regression analyses adjusted for CD4(+) count and age, strong Type C coping was associated with significantly higher IL-6 production, as predicted. The theoretically related construct of alexithymia was correlated with significantly lower stimulated production of HIV-inhibiting MIP-1 alpha. Independent of alexithymia, greater heart rate reactivity, and poorer heart rate recovery in response to experimental stressors were also significantly associated with lower production of MIP-1 alpha, adjusted for cardiovascular medications, methadone use, CD4(+) count, and age. These findings support our primary set of hypotheses that maladaptive Type C coping, alexithymia, and heart rate reactivity/recovery are associated with disturbances in two key immune parameters implicated in HIV pathogenesis. Our secondary hypothesis, that dysregulated heart rate reactivity may mediate the connections between Type C coping and/or alexithymia and IL-6/ MIP-1 alpha was not confirmed. The finding that Type C coping, alexithymia, and heart rate reactivity/recovery are associated independently and differentially with specific aspects of relevant immune functioning may reflect distinct biobehavioral pathways that contribute to HIV progression.

Do positive psychosocial factors predict disease progression in HIV-1? A review of the evidence

Adding to a traditional stress perspective, behavioral medicine has been focusing increasingly on investigating the potential impact of positive psychosocial factors on disease course in HIV. Dispositional optimism, active coping, and spirituality show the most evidence for predicting slower disease progression, although the data are not entirely consistent. Findings for the role of social support are mixed, although indications are that it may be particularly helpful at later stages of illness. Many of the other constructs (positive affect, finding meaning, emotional expression/processing, openness, extraversion, conscientiousness, altruism, and self-efficacy) have only been examined in one or two studies; results are preliminary but suggestive of protective effects. Plausible behavioral and biological mechanisms are discussed (including health behaviors, neurohormones, and immune measures) as well as suggestions for clinicians, limitations, future directions, and a discussion of whether these constructs can be changed. In conclusion, investigating the importance and usefulness of positive psychosocial factors in predicting disease progression in HIV is in its beginning scientific stages and shows good initial evidence and future promise.

Behavioral mediation of the relationship between psychosocial factors and HIV disease progression

The psychological and physical demands of coping with medication side effects and comorbid illnesses can be overwhelming and may influence behaviors, such as medication adherence, substance use, sexual risk behavior, and exercise that, in turn, affect health outcomes. Cross-sectional and prospective studies among diverse populations of persons living with HIV suggest that these behavioral mechanisms may be associated with HIV disease progression. The motivation to change behavior is often highest in the immediate aftermath of a stressor. However, over time the motivation to continue a particular behavior change is often challenged by habits, environmental influences, and psychosocial factors. Furthermore, a number of studies suggest that behavioral mechanisms may mediate the relationship between psychosocial variables (e.g., stress, depression, coping, and social support) and disease progression in HIV. Thus, developing clinical interventions that address these psychosocial factors and enhance protective health behaviors and reduce behaviors that convey risk to health are likely to lessen overall morbidity and mortality among patients living with HIV/AIDS.

Coping as a multisystem construct associated with pathways mediating HIV-relevant immune function and disease progression

We review psychoneuroimmunological research linking coping with HIV disease progression and its indicators, as well as with viral and host factors that may mediate or contribute to HIV progression. Our perspective on coping broadly encompasses the attempts of multiple mental and biological systems to adapt to changing internal and environmental conditions and to reestablish homeostasis. Accordingly, we discuss studies within four dimensions of coping: cognitive (appraisals, expectancies, and explanatory style), emotional (the Type C coping pattern and related constructs), active-passive strategies and behavior patterns, and physiological (autonomic reactivity and recovery). Finally, we present a model that integrates key studies linking coping with HIV prognostic indicators and clinical disease progression. Based on empirical evidence, the model suggests plausible mechanisms by which coping may be connected to HIV progression/antiprogression factors and immunopathogenesis to affect HIV clinical progression.

Emotions and emotional approach and avoidance strategies in fibromyalgia

OBJECTIVE

Disturbances in emotional functioning may contribute to psychological and physical symptoms in patients with fibromyalgia. This study examined emotions and emotion-regulation strategies in women with fibromyalgia and in controls, and how these variables relate to symptoms of fibromyalgia.

METHODS

We compared 403 women with fibromyalgia to 196 control women using self-report questionnaires.

RESULTS

Negative emotions and the use of emotional-avoidance strategies were elevated, and positive emotions were reduced, in fibromyalgia patients; the alexithymia scale "difficulty identifying feelings" showed a large deviation from normal. Emotional-approach measures were not deviant. In the fibromyalgia sample, emotional-avoidance strategies were highly correlated with more mental distress and were modestly correlated with more pain and fatigue, while emotional-approach strategies were only minimally related to better functioning. We tested two interaction models. The intense experiencing of emotions was related to more pain only in patients who lack the ability to process or describe emotions. Although fibromyalgia patients showed deficits in the experiencing of positive affect, positive affect did not buffer the association between pain and negative affect.

CONCLUSION

This study demonstrates increased negative emotions and decreased positive emotions, as well as increased emotional-avoidance strategies, in women with fibromyalgia. Research should test whether interventions that reduce emotional avoidance lead to health improvements in women with fibromyalgia.

Gender Differences in Emotion Regulation and Relationships with Perceived Health in Patients with Rheumatoid Arthritis

Emotion regulation has been associated with perceived health in rheumatoid arthritis, which is diagnosed three times more often in women than men. Our aim was to examine gender differences in styles of emotion regulation (ambiguity, control, orientation, and expression) and gender-specificity of the associations between emotion regulation and perceived health (psychological well-being, social functioning, physical functioning, and disease activity) in 244 female and 91 male patients with rheumatoid arthritis. Women reported more emotional orientation than men, but did not differ from men with regard to ambiguity, control, and expression. Structural equation modelling showed that relationships between emotion regulation and perceived health were more frequent and stronger for women than men. This held especially for the affective dimension of health, while associations were similar for both women and men with regard to social and physical functioning. Only for women, the association between ambiguity and disease activity was significant, which appeared to be mediated by affective functioning. The observations that women are more emotionally oriented than men and that emotion regulation is more interwoven with psychological health in women than men, support the usefulness of a gender-sensitive approach in research and health care of patients with rheumatoid arthritis.

Styles of emotion regulation and their associations with perceived health in patients with rheumatoid arthritis

BACKGROUND

Patients with rheumatoid arthritis face the challenge of adjusting to adverse health consequences and accompanying emotions. Styles of emotion regulation may affect health.

PURPOSE

The objective is to examine associations between styles of emotion regulation and perceived health, consisting of psychological well-being, social functioning, physical functioning, and disease activity.

METHODS

Principal component analysis was used to summarize styles of emotion regulation of 335 patients with rheumatoid arthritis. Relationships between emotion regulation and perceived health were examined with structural equation modeling.

RESULTS

Four styles of emotion regulation were identified: ambiguity, control, orientation, and expression. Ambiguity and control were mutually correlated, as were orientation and expression. Styles of emotion regulation were not uniquely related to perceived physical functioning and disease activity. Emotional ambiguity and orientation were related to poorer, whereas expression and control were related to more favorable psychological well-being and social functioning.

CONCLUSIONS

Our cross-sectional study suggests that emotion regulation is not of direct importance for perceived somatic health of patients with rheumatoid arthritis, but it may be of importance for psychological well-being and social functioning, and perhaps through this route for somatic health. The more conscious and controlled aspects of control and expression are positively related to psychosocial health, and the more unconscious automatic aspects of ambiguity and orientation are negatively related. Changing emotion regulation will potentially affect psychosocial health. It would be worthwhile to verify this possibility in prospective research.

How psychological therapy may prolong survival in cancer patients: new evidence and a simple theory

This article presents new data and attempts to draw together converging lines of evidence on the mental attributes that may favor prolonged survival in the face of metastatic cancer. The authors interviewed 10 individuals with medically incurable cancers who had outlived their prognoses by from 2.2 to 12.5 years (and have all survived, a further 2 more years in most cases, between interview and publication). The authors derived, by qualitative analysis, a number of themes common to most or all of them. Three major qualities emerged: "authenticity," or a clear understanding of what was important in one's life; "autonomy," the perceived freedom to shape life around what was valued; and "acceptance," a perceived change in mental state to enhanced self-esteem, greater tolerance for and emotional closeness to others, and an affective experience described as more peaceful and joyous. Previous descriptions of "remarkable survivors" have suffered from a serious limitation: the research to date has not clarified to what extent they differed psychologically from their many peers who did not survive. The authors attempted to address this question in 2 ways. Six of the subjects were part of a protocol (the Healing Journey study) in which patients belonged to a larger group, all of whom were medically assessed prospectively, by an expert panel. A prediction of the likely duration of survival was made for each of the patients in this study, and it could be shown that those who subsequently survived were not a random sample of the whole but displayed a much higher degree of early involvement in their psychological self-help than did most of their nonsurviving peers. They also compared long survivors with 2 other groups: 6 individuals with similar diseases who had not yet received psychological help and 6 individuals from the Healing Journey study whose survival duration was at the lower end of the whole group. The patients in these comparison groups also lacked many of the most salient qualities identified among the long survivors. Many of the attributes found in the long survivors were, however, also noted in the earlier reports of remarkable survivors in the literature, which suggests that the observations may be generalizable. Putting these joint findings together with the early work of Temoshok on "type C" adaptation as a risk factor for cancer, one can see that there is a mirrored symmetry between the psychological patterns possibly promoting disease and the changed adaptations that may lead to longer survival in some cases. The authors arrive at a commonsense hypothesis: to the extent that the progression of cancer, or other chronic disease, is favored by a distorted psychological adaptation such as type C, healing may be assisted by a reversal of that adaptation--in the case of cancer, toward greater authenticity of thought and action.