MRI Shows that Exhaustion Syndrome Due to Chronic Occupational Stress is Associated with Partially Reversible Cerebral Changes.

The present study investigates the cerebral effects of chronic occupational stress and its possible reversibility. Forty-eight patients with occupational exhaustion syndrome (29 women) and 80 controls (47 women) underwent structural magnetic resonance imaging (MRI) and neuropsychological testing. Forty-four participants (25 patients, 19 controls) also completed a second MRI scan after 1-2 years. Only patients received cognitive therapy. The stressed group at intake had reduced thickness in the right prefrontal cortex (PFC) and left superior temporal gyrus (STG), enlarged amygdala volumes, and reduced caudate volumes. Except for the caudate volume, these abnormalities were more pronounced in females. They were all related to perceived stress, which was similar for both genders. Thickness of the PFC also correlated with an impaired ability to down-modulate negative emotions. Thinning of PFC and reduction of caudate volume normalized in the follow-up. The amygdala enlargement and the left STG thinning remained. Longitudinal changes were not detected among controls. Chronic occupational stress was associated with partially reversible structural abnormalities in key regions for stress processing. These changes were dynamically correlated with the degree of perceived stress, highlighting a possible causal link. They seem more pronounced in women, and could be a substrate for an increased cerebral vulnerability to stress-related psychiatric disorders.

Chronic stress is linked to 5-HT(1A) receptor changes and functional disintegration of the limbic networks.

There are increasing reports about stress related cognitive and psychic declines in subjects who have no psychiatric premorbidity, depression, or major life trauma. Yet, little is known about the underlying neurobiology. Based on the typical symptomatology, fMRI data suggesting that stress activates the limbic circuits, and animal data showing a major involvement of the 5-HT(1A) receptor in stress regulation, we hypothesized that enduring daily stress causes widespread limbic dysfunctions, and specific changes of the 5-HT(1A) receptor. To test these hypotheses combined PET studies were carried out in 16 chronically stressed, and 16 non-stressed subjects. Limbic function was tested by measuring cerebral blood flow during rest, and when using an odor activation paradigm. 5-HT(1A) receptor binding potential (BP) was assessed with [(11)C]WAY100635. All subjects went through a battery of neuropsychological tests. Stressed subjects showed a functional disconnection between the amygdala and ACC/medial prefrontal cortex (mPFC), and an impaired odor activation of the ACC. They also displayed a reduced 5-HT(1A) receptor BP in the anterior cingulate (ACC), the insular-cortex, and the hippocampus. Their performance in attention-, odor discrimination-, and semantic memory tasks was impaired, and correlated with the BP-values in the respective region. The degree of reported stress was inversely correlated with activation of ACC, and the 5-HT(1A) receptor BP in the amygdala and hippocampus. Enduring every day psychosocial stress seems to be associated with a limbic reduction of 5-HT(1A) receptor binding and functional disintegration of ACC/mPFC. These changes support the notion of an impaired top-down regulation of stress stimuli, and identify potential targets for early treatment.

Associations between financial strain and the diurnal salivary cortisol secretion of long-term unemployed individuals.

OBJECTIVE: The study investigated the associations between self-rated financial strain and overall diurnal salivary cortisol levels, as well as secretory patterns among long-term unemployed individuals. METHODS: Psychosocial and life-style variables were assessed by means of questionnaires among 85 participants (mean age 42+/-9 years; 56% females). Salivary cortisol was sampled on four occasions during a 24-hour period and data was analysed separately for men and women. RESULTS: Among females, high financial strain was related to higher overall cortisol levels, and to elevated levels in the evening. These associations did not reach significance among men. Multivariate analyses showed that evening levels of cortisol were positively associated with financial strain, but largely unrelated to life-style variables and psychological distress. CONCLUSIONS: The results suggest that high financial strain influences the diurnal cortisol secretion of unemployed individuals in terms of elevated cortisol levels in the evening. The mediating mechanisms are in need of further investigation.

Intensive rehabilitation of emotionally distressed patients after coronary by-pass grafting.

OBJECTIVES: To evaluate whether the status of emotionally distressed post coronary by-pass surgery patients can be improved by a comprehensive, in-patient rehabilitation programme. DESIGN: Cross-sectional. SETTING: Rehabilitation hospital. SUBJECTS: One hundred and fifty-two post coronary by-pass surgery patients referred to an intensive rehabilitation programme. The study group was divided into two subgroups, according to the level of emotional distress. Forty-three (30%) out of 142 patients who completed the Nottingham Health Profile were considered to be distressed. INTERVENTIONS: The comprehensive 4-week inpatient rehabilitation programme consisted of daily physical exercise, lectures about coronary disease and risk factors, psychological support and nutrition counselling. MAIN OUTCOME MEASURES: Physical fitness, blood lipids and quality of life questionnaires. RESULTS: The two-way analysis of variance showed that emotionally distressed patients achieved equally good results as those obtained by nondistressed patients in performance regarding the maximal exercise stress test, maximum rate pressure product achieved, or the level of resting heart rate. Significant improvement in psychological well-being as assessed by a seven-point rating scale was observed in both groups. Both groups of patients were also equally successful in weight reduction and lowering of total cholesterol and triglycerides. Of all the patients who were employed at admission, twice the number of patients in the distressed group were in receipt of a permanent disability pension and half the number of patients was employed, compared to the initially nondistressed group, at 1-year follow-up. CONCLUSIONS: Distressed patients were very successful in improving their functional status and reducing risk factors when offered an intensive rehabilitation programme but they were much less successful in returning to work. Secondly, patients who were emotionally distressed after surgery did not differ in regard to disease status or physical capacity from nondistressed patients. They did, however, experience more angina pectoris both in daily life and when exposed to a maximal exercise stress test. Finally, the presence of emotional distress was easily detected by any measure of psychological status.

Patient-perceived quality of life after coronary bypass surgery. Experienced problems and reactions to supportive care one year after the operation.

In an interview conducted one year after coronary bypass surgery (CABG), 115 patients (92 males, 23 females) were asked to discuss their present quality of life, problems related to the operation and their reactions to the supportive care following the operation. The main purpose of this study was to assess whether the patients' own presentation of these questions revealed information not elucidated through a standard questionnaire which included the Nottingham Health Profile and other questions on physical, emotional and social well-being. About one quarter of the interviewed patients expressed dissatisfaction concerning their present quality of life, information which corresponded well with the findings in the questionnaires. Reported limitation in physical activity did not, however, match exercise test findings. The interviews alone revealed additional information concerning well-being. Most important were problems with wound healing and difficulties describing and interpreting pain and other discomfort in the thoracic area. Several patients also expressed dissatisfaction with the postoperative supportive care. We conclude that there is a need for a complementary approach to estimate quality of life, and that this could be included in an extended nursing care program designed to meet the varying needs of patients after CABG.

Psychosocial factors and heart rate variability in healthy women.

OBJECTIVE: This study was conducted to investigate associations between psychosocial risk factors, including social isolation, anger and depressive symptoms, and heart rate variability in healthy women. METHODS: The study group consisted of 300 healthy women (median age 57.5 years) who were representative of women living in the greater Stockholm area. For the measurement of social isolation, a condensed version of the Interpersonal Support Evaluation List was used and household size assessed. Anger was measured by the anger scales previously used in the Framingham study and depressive symptoms by a questionnaire derived from Pearlin. Health behaviors were measured by means of standard questionnaires. From 24-hour ambulatory electrocardiographic monitoring, both time and frequency domain measures were obtained: SDNN index (mean of the SDs of all normal to normal intervals for all 5-minute segments of the entire recording), VLF power (very low frequency power), LF power (low frequency power), HF power (high frequency power), and the LF/HF ratio (low frequency by high frequency ratio) were computed. RESULTS: Social isolation and inability to relieve anger by talking to others were associated with decreased heart rate variability. Depressive symptoms were related only to the LF/HF ratio. Adjusting for age, menopausal status, exercise and smoking habits, history of hypertension, and BMI did not substantially change the results. CONCLUSIONS: These findings suggest heart rate variability to be a mediating mechanism that could explain at least part of the reported associations between social isolation, suppressed anger, and health outcomes.

Emotional distress before coronary bypass grafting limits the benefits of surgery.

BACKGROUND: The inclusion of large, heterogeneous groups of patients for coronary bypass grafting (CABG) surgery has resulted in a more mixed treatment outcome. Thus it becomes important to identify patients who are less likely to benefit from surgery or who may require additional support to improve treatment outcome. The aim of the present study was to examine whether psychological status measured before CABG can contribute to prediction of short- and long-term outcomes of the surgery. METHODS AND RESULTS: One hundred seventy-one consecutive patients from two large university hospitals in Stockholm completed a psychosocial questionnaire before being scheduled for surgery. One year after CABG, patients again completed the questionnaire. Follow-up of medical charts was conducted during the first 3 years after surgery. All major cardiac events (cardiac death, definite myocardial infarction, revascularization, and unstable angina verified by angiography or myocardial scintigraphy) were recorded. Although the overall effect of surgery was excellent in the majority of cases, the patients exhibiting a high degree of distress (anxiety, depression, and tiredness) before surgery assessed their status as being much worse both before the operation and at the 1-year follow-up. Equally important was the fact that patients considered distressed before surgery had significantly higher rates of cardiac events (16%) in the 3-year follow-up period compared with nondistressed patients (5%) (chi-square=5.11, degrees of freedom=1, p < 0.02). CONCLUSIONS: Systematic evaluation and treatment of emotional distress in the candidates for coronary revascularization may be expected to result in more optimal subjective results and a reduction in the number of serious cardiac events after surgery.

State anxiety predicts poor psychosocial outcome after coronary bypass surgery.

A prospective study was conducted to identify predictors of poor psychosocial adjustment 1 year after coronary bypass graft (CABG) surgery. Fifty-two of 61 consecutive patients (mean age = 66 +/- 9, 3 years, 76% men) were studied before and 1 year after surgery. Psychological, social, and surgical data were assessed. The roles of State and Trait anxiety, emotional reactions, and different coping modes were evaluated. At baseline the patients were divided into 3 groups according to their level of anxiety as assessed by Spielberger's State Anxiety Inventory (STAI). The 3 groups did not differ in any of the basic parameters, except for their subjective experience of symptoms of dyspnoea (p < .01), and quality of life (p < .0001) for the whole patient group 1 year after surgery. However, patients belonging to the moderate-anxiety and high-anxiety groups remained more psychologically distressed (p < .0001) and perceived a higher degree of residual angina pectoris (p < .0001) than did patients who did not display anxiety preoperatively. Dividing the patients into groups according to their answers to the other measures of psychological distress or negative coping strategies yielded similar results. The results indicate that the SATI is a valuable instrument for identifying risk patients for poor adjustment after CABG surgery.

Psychological reactions in men screened for prostate cancer.

OBJECTIVE: To investigate the possible negative psychological impact of screening for prostate cancer with special focus on the impact of false positive and true positive test results. SUBJECTS AND METHODS: As part of an early detection study for prostate cancer psychological and psychophysiological reactions to various phases of the diagnostic procedures were examined in 2400 randomly selected men divided into various groups. Their psychophysiological reactions were assessed by measurements of serum cortisol and their psychological reactions by questionnaires directed at determining emotional states and sleep disturbance. In a stratified sample of the population (100 men) measurements were made at the time of the screening examination and again 2 weeks later. In patients undergoing biopsy (307 men) measurements were made 2 weeks after screening, but before they were informed of the biopsy results, and again 4 and 16 weeks after screening. RESULTS: Serum cortisol levels at the screening examination were higher than corresponding levels of a comparable sample of Swedish men during normal daily activity, indicating that an invitation to examination for prostate cancer per se might create emotional stress. Two weeks after the screening the elevated levels had decreased to normal. The highest cortisol levels were found in men who had undergone biopsy, immediately before they were informed of the results 2 weeks after screening. After they were informed, cortisol levels fell, regardless of the results of the biopsy. The patterns of emotional state and sleep disturbance were similar except that sleep disturbance was delayed. CONCLUSION: In screening programmes for prostate cancer it is important to define clearly the high-risk groups to minimize the risk of adverse psychological reactions in those subjects with a low risk of having the disease. The results also emphasize the need to reduce the number of false positive results by choosing diagnostic tests of high specificity. The interval between a test and informing the subject of the results should be minimized to decrease the duration of the increased emotional stress.

Minimum heart rate and coronary atherosclerosis: independent relations to global severity and rate of progression of angiographic lesions in men with myocardial infarction at a young age.

The relations of hemodynamic factors, plasma fibrinogen concentration, serum lipoprotein levels, and clinical risk indicators to coronary atherosclerosis were studied in 56 men who had survived a first myocardial infarction before the age of 45 years and who subsequently underwent two coronary angiographies with an intervening time interval of 4 to 7 years. Presence, severity, and rate of progression of both diffuse lesions and distinct stenoses were determined by means of separate classification systems in 15 proximal coronary arterial segments. High minimum heart rate measured during a 24-hour period in connection with the reangiography was associated with progression of both diffuse lesions and distinct stenoses. High minimum heart rate also correlated positively with angiographic scores of global severity of diffuse atherosclerosis and stenoses. Progression of disease was predicted independently by minimum heart rate and low-density lipoprotein/high-density lipoprotein ratio, whereas lipoprotein A, fibrinogen levels, hypertension, smoking, and beta-adrenergic receptor blockade treatment did not discriminate between patients with and without progression.

Job strain and ambulatory blood pressure profiles.

Occupational characteristics were used to study the role of job stress in the pathogenesis of hypertension. Ambulatory 24-h recordings of blood pressure were made for 161 men with borderline hypertension. From the occupational classification system scores for psychological demands, control, support, physical demands, and occupational hazards were obtained. The results indicated that the ratio between psychological demands and control (strain) was significantly associated with diastolic (but not systolic) blood pressure at night and during work. The association between job strain and diastolic blood pressure at night and during work was greatly strengthened when the subjects with occupations classified as physically demanding were excluded from the analysis. The conclusion was reached that a measure of job strain derived from the occupational classification is useful in predicting variations in diastolic blood pressure levels during sleep and work for men with borderline hypertension.

The role of paid work in Swedish chronic dialysis patients--a nation-wide survey: paid work and dialysis.

The role of paid work in chronic illness has been investigated in this nation-wide study of all Swedish-speaking patients on chronic dialysis above the age of 16 years, who were not too tired or severely ill to participate and who had been treated for at least 3 months. Young age and female gender were consistently associated with increased prevalence of self-reported depression, poor psychological health, psychosomatic symptoms and sleep disturbance. In multivariate analyses paid work, strong emotional support, and care at intermediate or small units were independently associated with a good quality of life. Chronic dialysis patients who did paid work (19.6% of the patients below 65 years of age) perceived their work as more socially supportive than did men and women in the normal working population. It may be concluded that paid work is of particular importance to this patient group because it may give extra social support to patients whose social network is in general rather poor.

The effects of the strain of returning to work on the risk of cardiac death after a first myocardial infarction before the age of 45.

Seventy-nine men who had suffered a myocardial infarction before the age of 45 while they were vocationally active in the greater Stockholm area were followed for five years. Forty-nine survived without cardiac complications and 13 died due to ischaemic heart disease during the period of follow-up. These two contrasting groups were compared with regard to psychosocial risk factors at work before the first myocardial infarction (as reported by the patient when he was interviewed during the weeks after the onset of disease). It was hypothesized that returning to stressful work (high demands and limited possibilities of influencing decisions and developing skills) would be associated with an increased risk of death. All the subjects who died had returned to the work that they had performed prior to the first myocardial infarct. Work performed by these patients was described as having significantly higher psychological demands in relation to the possibility of learning new things and higher demands in relation to variety as well as almost significantly higher demands in relation to influence. Multivariate logistic regression with these factors concerning employment, together with biomedical risk factors recorded at the same time, showed that increasing age, increasing degree of coronary atherosclerosis and number of stenosed coronary arteries, as well as high demands in relation to the possibility of learning new things, were independent predictors of death due to coronary arterial disease. The remaining 17 subjects either survived a re-infarction, or had coronary arterial by-pass surgery during the period of follow-up. This heterogeneous group occupied intermediate positions with regard to psychosocial job factors.

Cardiovascular and sympathoadrenal responses to mental stress: a study of sensory intake and rejection reactions.

Cardiovascular, sympathoadrenal and subjective responses to mental stress induced by two mental challenges eliciting sensory intake (word identification test = WIT) and sensory rejection (colour word conflict test = CWT) reactions were studied in 10 healthy males. Pressor responses to these stressors have been proposed to differ haemodynamically. Sympathoadrenal activity was assessed by arterial and femoral venous plasma catecholamine determinations and direct recordings of muscle sympathetic activity in the right peroneal nerve (MSA). Basal measurements differed little from those made during an active relaxation procedure, with the exception of MSA, which decreased. Both stress tasks elicited increases in heart rate, cardiac output, calf blood flow and brachial and pulmonary arterial blood pressures. WIT and CWT elicited qualitatively similar responses, but the amplitudes of the circulatory responses were lower with WIT, which also was rated as a weaker stressor. MSA increased during CWT, while marginal increases were seen during WIT. Arterial adrenaline showed a transient increase by 0.14 nmol l-1 during WIT. During CWT arterial adrenaline increased significantly by 50%. Increases in arterial adrenaline and subjective stress ratings were related to increases in cardiac output and reductions of systemic vascular resistance. Arterial and femoral venous noradrenaline increased during CWT, while changes during WIT were small. MSA and noradrenaline responses did not correlate to local vascular responses in the calf. Differences in the responses to mental challenges evoking sensory intake or rejection seem to be of a quantitative rather than a qualitative character.

Muscle sympathetic activity and norepinephrine release during mental challenge in humans.

Muscle sympathetic nerve activity (MSA; peroneal nerve) and arterial and femoral venous plasma norepinephrine (NE) were studied in 10 volunteers at rest, during a relaxation procedure (RELAX), and during two mental challenges, a word identification test (WIT) and a color word test (CWT). [3H]NE infusions were used to assess NE spillover to and clearance from plasma. Net NE overflow from the leg was calculated. RELAX reduced MSA and femoral venous NE concentrations. CWT increased blood pressure, cardiac output (thermodilution), and calf flow and reduced systemic vascular resistance. Responses to WIT were less marked. CWT increased MSA by 25%, femoral venous NE concentrations by 25%, and NE overflow from the leg by 26% at 3 min. Fractional epinephrine and [3H]NE extractions were flow related and decreased during CWT. The arterial contribution to femoral venous NE (about half) increased by 10% during CWT. Arterial NE levels and spillover increased, but NE clearance was unchanged. Femoral venous NE concentrations and NE spillover (not based on flow measurements) and regional NE overflow correlated with MSA. Thus NE concentrations in plasma reflect spillover rather than clearance at rest and during mental challenge. Biochemical and neurophysiological indexes of sympathetic activity correlate when assessed in the same region. Mental stress increases sympathetic activity in leg muscle.