ACBS June 19 th , 2014

ACBS June 19th, 2014

Immune-Spectrum Disease and

Repetitive Thought in Female Veterans

Elizabeth A. Mullen-Houser, Ph.D., Susan K. Lutgendorf, Ph.D., Michelle A.

Mengeling, Ph.D., James C. Torner, Ph.D., Brian L. Cook, D.O.,

Brenda M. Booth, Ph.D. , Anne G. Sadler, Ph.D.

1

THE CENTER FOR

Comprehensive Access &Delivery Research and

Evaluation

2

Background Overview

1. Stress and Health 1.1 Stress and health overview

1.2 Stress and health in female veterans

2. Repetitive Thought2.1 Perseverative Cognition Hypothesis2.2 Dimensions of repetitive thought

3. Inflammatory disorders4. Maladaptive repetitive thought and

inflammatory disorders

3

1.1 Stress and Health (Background)

Poorer health with chronic stress Prolonged presence of threat or

perception of threat (Miller et al., 2007)

Immune dysregulation in stressors lasting more than one month (Kiecolt-Glaser et al., 2002)

time to wound healing in caregivers (Kiecolt-Glaser et al.,1995)

4

1.2 Stress and Health in Female Veterans (Background)

17% of Reserve and National Guard (Department of Veteran Affairs, 2007)

Military sexual trauma (Sadler et al., 2001)

79% harassed, 36% assaulted 60% with PTSD Perpetrated by coworkers

75% of inflammatory disorders occur in women, often during childbearing years (NIH, 2005)

2.1 Repetitive Thought(Background)

Stressor

Short Stres

s Resp-onse

Coping & Appraisal

Prolonged Stress

Response

Pathogenic state

Organic Disease

Perseverative Cognition

about Stressor

6

Perseverative Cognition Hypothesis(Brosschot, Gerin & Thayer, 2006)

2.2 Repetitive Thought: Dimensions (Background)

Self-absorption paradox (Trapnell & Campbell, 1999)

Maladaptive Rumination, worry Brooding about implications of mistakes,

passive, evaluative (Coarocco, Vohs & Baumeister, 2010; Segerstrom et al., 2003)

Form of avoidant coping (Dickson et al., 2012; Walser & Hayes, 2006)

Adaptive Reflective pondering Error correction or goal attainment,

non-evaluative (Coarocco, Vohs & Baumeister, 2010 ; Watkins & Teasdale, 2004)

7

3. Inflammatory Disorders (Background)

Immune Mediated Inflammatory Disorder Immune system attacks own tissues cortisol, proinflammatory cytokines

(Calcagni & Elenkov, 2006)

80+ inflammatory-related diseases (NIH, 2005)

Rheumatoid arthritis, Lupus, Crohn’s Disease, Multiple sclerosis, Ulceritive Colitis

Newer: Chronic fatigue, fibromyalgia (Robinson et al., 2006)

8

4. Maladaptive Repetitive Thought and Inflammatory Disorders (Background)

Elevated trait maladaptive repetitive thought predicts: biological dysregulation

cortisol stress response (Zoccola et al., 2008)

inflammatory response (Segerstrom et al., 2008)

Worse physical functioning, treatment response maladaptive repetitive thought prevalence in lupus (Siegle, 2008)

mobility, grip in arthritis (Evers et al., 2008)

Psoriasis treatment (Fortune et al., 2008)

9

Determine if maladaptive repetitive thought is associated with greater immune-spectrum disease and disease-related disability

Objective10

Measures

Maladaptive repetitive thought operationalized as brooding rumination (RSQ; Nolen-Hoeksema & Morrow, 1991)

Physical disease number of inflammatory diseases

reported physical functioning subscale of SF-12

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Ruminative Responses Scale (RRS): Brooding Rumination Subscale

Treynor, Gonzalez and Nolen-Hoeksema (2003)

People say and do many different things when they feel distressed. Please indicate whether you never, sometimes, often, or always think or do each one when you feel distressed. Please indicate what you generally do, not what you think you should do.

1. Think “What am I doing to deserve this?”

2. Think “Why do I always react this way?”

3. Think about a recent situation, wishing it had gone better.

4. Think “Why do I have problems other people don’t have?”

5. Think “Why can’t I handle things better?”

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Sample

N=665

OEF/OIF-era Reserve and National Guard (RNG) women

Five Midwestern states (IA, IL, MO, KS, NE)

Computer-based telephone interview

Response rate 70%

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Sample

Mean age=37.9 (SD=10.4) 16.4% report inflammatory disease

diagnosis Ethnicity %:

American Indian 0.3 Asian 1.5 African American or Black 15.9 Native Hawaiian or Pacific Islander 0.5 Caucasian 79.5 More than One Race 0.8 Other 1.5

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Sample: Trauma

97% reported a lifetime history of trauma exposure Higher than previous reports in female

veterans and civilians

14.8% met criteria for PTSD Similar to other reports in female veterans (10-

19%) Bean-Mayberry et al., 2011

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Maladaptive Repetitive Thought and Physical Disease: Hypothesized Model

PhysicalDisease

InflamatoryDisorder

Prevalence

FunctionalDisability

MaladaptiveRT

16


PhysicalDisease

Reexperiencing

Avoidance

Arousal

InflammatoryDisorder

Prevalence


MaladaptiveRT

PosttraumaticStress

Symptoms

MRTx

Posttraumatic Stress Symptoms

17


PhysicalDisease

Reexperiencing

Avoidance

Arousal

Smoking Alcohol Use Sleep


Prevalence


MaladaptiveRT

PosttraumaticStress

Symptoms

MRTx



PhysicalDisease

Reexperiencing

Avoidance

Arousal



Prevalence


MaladaptiveRT

DepressionChildhood

Trauma

PosttraumaticStress

Symptoms

MRTx


Greater Maladaptive Repetitive Thought Related to Less Physical Disease

PhysicalDisease

Reexperiencing

Avoidance

Arousal



Prevalence


Maladaptive Repetitive Thought

xPosttraumatic Stress

Symptoms

MaladaptiveRepetitive Thought

DepressionChildhood

Trauma

PosttraumaticStress

Symptoms

.72**

.80**

.89**

.06

.07 -.22**

-.06

.40**

.82**

.10**.33**-.16**.03

χ2= .07- 39.48 (p = .02 -.99)χ 2/df=.02-1.65CFI= .99-1.00RMSEA= .00-.03SRMR= .00-.02

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Maladaptive Repetitive Thought Unrelated to Disease When Depression Not Included in Model


ChildhoodTrauma

Posttraumatic Stress

Symptoms

PhysicalDisease

-.12.04χ2= 26.04 (p = .21)χ 2/df=1.24CFI= 1.00RMSEA= .02SRMR= .02

21




Symptoms

Maladaptive Repetitive Thought Unrelated to Disease When Depression Not Included in Model


MRTChildhood

Trauma

Posttraumatic Stress

Symptoms

PhysicalDisease

.32**

.07 -.17** -.13**

-.12 .14**.04χ2= 26.04 (p = .21)χ 2/df=1.24CFI= 1.00RMSEA= .02SRMR= .02

22



Symptoms

Greater Maladaptive Repetitive Thought Related to Less Physical Disease

PhysicalDisease

Reexperiencing

Avoidance

Arousal



Prevalence


MRTx



DepressionChildhood

Trauma

PosttraumaticStress

Symptoms

.72**

.80**

.89**

.06

.07 -.22**

-.06

.40**

.82**

.10**.33**-.16**.03

χ2= .07- 39.48 (p = .02 -.99)χ 2/df=.02-1.65CFI= .99-1.00RMSEA= .00-.03SRMR= .00-.02

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Repetitive Thought, Depression and Disease

Maladaptive repetitive thought unrelated to disease when depression not included as covariate

When depression was included, higher repetitive thought was associated with reduced physical disease Negative affect: Predisposition to

experience negative mood states (Thomsen, 2006; Watson & Clark, 1984)

Inclusion of depression may have statistically removed negative affect from maladaptive repetitive thought, leaving adaptive repetitive thought

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Stressor

Short Stres

s Resp-onse

Coping & Appraisal

Prolonged Stress

Response

Pathogenic state

Organic Disease

Perseverative Cognition

about Stressor

25

Stressor

Short Stress Resp-onse

Coping & Appraisal

Prolonged Stress

Response

Pathogenic state

Organic Disease

Adaptive Cognition about Stressor


26

Clinical Implications: Adaptive Repetitive Thought Intervention

Maladaptive Repetitive Thought Rumination, worry Brooding about implications of mistakes,

passive, evaluative (Coarocco, Vohs & Baumeister, 2010; Segerstrom et al., 2003)

Form of avoidant coping (Dickson et al., 2012; Walser & Hayes, 2006)

Adaptive Repetitive Thought Reflective pondering Error correction or goal attainment, non-

evaluative (Coarocco, Vohs & Baumeister, 2010 ; Watkins & Teasdale, 2004)

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Clinical Implications: Adaptive Repetitive Thought Intervention Error correction or goal attainment

Non-evaluative

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Error correction or goal attainment ACT values clarification and increasing

value-guided behavior Values interventions and physical health

Improved cortisol response to stress after a value affirmation exercise (Creswell et al., 2005)

Seizure improvements with an ACT intervention mediated by value attainment (Lundgren, Dahl & Hayes, 2008)

Physical functioning improvements in chronic pain with greater values-based action (McCracken & Vellemen, 2010)

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Non-evaluative (Coarocco, Vohs & Baumeister, 2010 ; Watkins & Teasdale, 2004)

Mindfulness skills: Observing with awareness, non-judging attention

Mindfulness and repetitive thought (Segerstrom et al., 2011)

Observing by itself associated with less adaptive repetitive thought and more general repetitive thought

Non-judging observing associated with more adaptive repetitive thought, less general repetitive thought

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Clinical Implications: Repetitive Thought Intervention Mindfulness and Health

Physical health improvements with MBSR interventions (Meta-analysis; Grossman et al., 2004)

medical symptoms, physical pain, physical impairment, and physical quality of life

Improved immune function and regulation with mindfulness interventions (Davidson et al., 2003; Jacobs et al., 2010)

Joint tenderness reduction after a mindfulness intervention in rheumatoid arthritis patients with chronic depression (Zautra et al., 2008)

Multiple practice sessions needed (Evans et al., 2014)

31

Limitations and Future Directions Counterintuitive repetitive thought

results needs replication Operationalize repetitive thought

with a greater number of measures (Evans & Segerstrom, 2011)

Replicate with a more ethnically diverse participant sample

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Acknowledgements

VA HSR&D Grant DHI 05-059 to Dr. Sadler

University of Iowa Graduate College research fellowship

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2.3 Maladaptive Repetitive Thought vs. PTSD Intrusions (Background)

Dimension Intrusions Maladaptive Repetitive Thought

Content Memory Evaluative

Type of Cognition

Sensory Verbal Thoughts

Duration Seconds Minutes/

Hours

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IMIDs and PTSD in Veterans

IMID prevalence in veterans (Dominick et al., 2006),

including those without PTSD (Frayne, 2004)

PTSD severity presence of one IMID and overall number

of IMIDs (Boscarino, 2004; O’Toole & Catts, 2008)

Dose-response IMID risk (Seng et al., 2006)

risk in female veterans (Frayne, 2004)

35

Maladaptive Repetitive Thought and Negative Affect Negative affect

Predisposition to experience negative mood states (Thomsen, 2006; Watson & Clark, 1984)

Spurious relationship between maladaptive repetitive thought and physical health?

MRT contributes to morbidity independent of negative affect Health anxiety (Marcus, Hughes and Arnau, 2008)

Cortisol dysregulation (Roger & Najarian, 1998)

Physiologic emotional arousal (Feldner et al., 2006)

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Deployment37

Documents

ACBS June 19 th , 2014