Article Summaries for September 2019 Psychosomatic Medicine, Volume 81, Issue 7
No abstract available
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Another Step Toward Clarifying the Benefits and Burdens of Selective Serotonin Reuptake Inhibitors
Selective serotonin reuptake inhibitors (SSRIs) have substantial beneficial effects for the treatment of major depressive mood disorders and other conditions but can also result in unwanted clinical outcomes. One of the reported disadvantages of SSRIs, based on cross-sectional studies, is their adverse effects on glycemic control. However, in this issue of Psychosomatic Medicine, Tharmaraja et al. report a meta-analysis of 16 randomized controlled trials, demonstrating beneficial effects of SSRIs on changes in glycemia. In this editorial, the advantages of meta-analysis in biobehavioral medicine are highlighted as well as the importance of the study designs (observational studies versus randomized controlled trials) on which the meta-analyses are based. This article concludes with an outline for future research directions in the area of SSRIs and glycemic control.
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The Association Between Selective Serotonin Reuptake Inhibitors and Glycemia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
 Objective Individual studies have reported conflicting effects of selective serotonin reuptake inhibitors (SSRIs) on glycemia. We systematically reviewed the effects of SSRIs on glycemia and whether metabolic and psychological factors moderated these effects. Methods We systematically searched for placebo-controlled randomized controlled trials investigating the effect of SSRIs on glycemia (fasting blood glucose or HbA1c) as a primary or secondary outcome. Random effects meta-analysis was conducted to compute an overall treatment effect. Meta-regression tested whether depression, type 2 diabetes, insulin resistance, treatment duration, and weight loss moderated treatment effects. Results Sixteen randomized controlled trials (n = 835) were included and glycemia was usually a secondary outcome. Overall, SSRIs improved glycemia versus placebo (pooled effect size (ES) = −0.34, 95% confidence interval (CI) = −0.48 to −0.21; p < .001, I2 = 0%). Individually, fluoxetine (ES = −0.29, 95% CI = −0.54 to −0.05; p = .018) and escitalopram/citalopram (ES = −0.33, 95% CI = −0.59 to −0.07; p = .012) outperformed placebo, but paroxetine (ES = −0.19, 95% CI = −0.58 to 0.19; p = .33) did not. Results were similar in populations selected for depression as those not. Across studies, baseline insulin resistance (p = .46), treatment duration (p = .47), diabetes status (p = .41), and weight loss (p = .93) did not moderate changes. Heterogeneity for all analyses was nonsignificant. Conclusions SSRIs seem to have an association with improvement in glycemia, which is not moderated by depression status, diabetes status, or change in weight across studies. Future powered trials with longer treatment duration are needed to confirm these findings. Registration PROSPERO ID: CRD4201809239.
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Borderline Personality Disorder in Patients With Medical Illness: A Review of Assessment, Prevalence, and Treatment Options
 Objective Borderline personality disorder (BPD) occurs in 0.7% to 3.5% of the general population. Patients with BPD experience excessive comorbidity of psychiatric and somatic diseases and are known to be high users of health care services. Because of a range of challenges related to adverse health behaviors and their interpersonal style, patients with BPD are often regarded as “difficult” to interact with and treat optimally. Methods This narrative review focuses on epidemiological studies on BPD and its comorbidity with a specific focus on somatic illness. Empirically validated treatments are summarized, and implementation of specific treatment models is discussed. Results The prevalence of BPD among psychiatric inpatients (9%–14%) and outpatients (12%–18%) is high; medical service use is very frequent, annual societal costs vary between €11,000 and €28,000. BPD is associated with cardiovascular diseases and stroke, metabolic disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases, and HIV infection as well as sleep disorders. Psychotherapy is the treatment of choice for BPD. Several manualized treatments for BPD have been empirically validated, including dialectical behavior therapy, transference-focused psychotherapy, mentalization-based therapy, and schema-focused therapy. Conclusions Health care could be substantially improved if all medical specialties would be familiar with BPD, its pathology, medical and psychiatric comorbidities, complications, and treatment. In mental health care, several empirically validated treatments that are applicable in a wide range of clinical settings are available.
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The Effects of Positive Psychological Interventions on Medical Patients’ Anxiety: A Meta-analysis
 Objective Positive psychology interventions, which involve systematic completion of activities designed to promote well-being, are being increasingly studied in medically ill patients. However, the extent to which these interventions ameliorate patient anxiety remains unclear. Therefore, the aim of the study was to conduct a meta-analysis to determine the efficacy of positive psychology interventions in reducing anxiety in medical patients. Methods Electronic databases Medline, PsycINFO, SciELO, Cochrane (Central), and ClinicalTrials.gov were searched from inception to June 18, 2018, to identify studies of positive psychology interventions that included a validated measure of anxiety as an outcome measure. Results The search generated a total of 1024 studies. Twelve randomized controlled trials (n = 1131) delivered to medical patients were included in the review, and a further 11 nonrandomized trials (n = 300) were included in a secondary analysis. Positive psychology interventions were effective at reducing patient anxiety relative to a control with a small to medium effect size (g = −0.34, 95% confidence interval = −0.50 to −0.18), and results were maintained at a mean of 8-week follow-up (g = −0.31, 95% confidence interval = −0.54 to −0.08). Clinician-led interventions seemed to be more effective than self-administered interventions, and longer interventions were more effective than shorter interventions. Secondary analysis of nonrandomized trials also found that positive psychology interventions are associated with reduced anxiety. Conclusions Positive psychology interventions seem to be effective at reducing medical patient anxiety. Future research is needed to determine optimal intervention characteristics, including dose and intervention content, that maximize the observed treatment effects.
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Duration of Perseverative Thinking as Related to Perceived Stress and Blood Pressure: An Ambulatory Monitoring Study
 Objective Psychological distress may be intensified and prolonged by perseverative thinking (e.g., rumination, worry). The tendency to engage frequently in perseverative thinking has been linked to increased blood pressure (BP). Research is needed to investigate the physiological consequences of time spent perseverating by testing the momentary association between the duration of perseverative thinking and BP. The present study examines the extent to which the duration of perseverative thinking is associated with momentary perceived stress and ambulatory BP elevations during daily life. Methods Participants (N = 373) drawn from a larger project on BP and cardiovascular health completed 24-hour ambulatory BP monitoring accompanied by ecological momentary assessments of their perseverative thoughts and feelings. Multilevel models tested associations among perseveration duration, momentary perceived stress, and systolic and diastolic BP, adjusting for person-level and momentary covariates. Results Higher within-subject perseveration duration was associated with higher stress (B = 0.29; 95% confidence interval [CI] = 0.24–0.33; p < .001). Although higher perseveration duration was not associated with substantially higher systolic (B = 0.16 mm Hg; 95% CI = 0.00–0.33 mm Hg; p = .056) or diastolic (B = 0.07 mm Hg; 95% CI = −0.05 to 0.19 mm Hg; p = .25) BP, the associations between higher perseveration duration and higher systolic (p = .032) and diastolic (p = .036) BP were significantly mediated by a higher intensity of momentary perceived stress. Conclusions Findings support the clinically important notion that physiological consequences of perceived stress can be maintained and even heightened by maladaptively prolonged mental activity.
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Mapping the Affective Dimension of Embodiment With the Sensation Manikin: Validation Among Chronic Pain Patients and Modification by Mindfulness-Oriented Recovery Enhancement
 Objective Mindfulness-based interventions target novel pain relief mechanisms not captured by legacy pain scales, including 1) cultivating awareness of pleasant and neutral sensations proximal to unpleasant sensations and 2) interoceptively mapping sensation location and spatial distribution. Methods We created a digital sensation manikin (SM) by overlaying a human figure silhouette with a grid of 469 “sensation” pixels. A series of five research questions examined the SM’s discriminant validity, construct validity, incremental validity, convergence with an objective measure of pain attentional bias, and sensitivity to a mindfulness-based psychological treatment, Mindfulness-Oriented Recovery Enhancement (MORE). A sample of opioid treated chronic pain patients (n = 108; age, 53.79 (12.94) years; female, 65%) was recruited to answer research questions 1 to 5, and a sample of healthy controls (n = 91; age, 36.47 (13.50) years; female, 55%) was recruited as the comparison group for research question 1. Results Chronic pain patients reported significantly more unpleasant sensations than did healthy controls (p < .001, d = 1.23) and significantly fewer pleasant sensations (p = .001, d = 0.50). The SM also evidenced expected relationships with multiple measures of pain (r = 0.26–0.29) and well-being (r = −0.21 to 0.28), uniquely predicted pain interference (β = −0.18), and exhibited a significant association with pain attentional bias (r = 0.25). Finally, mindfulness-based intervention via MORE significantly increased the ratio of pleasant to unpleasant sensations reported by chronic pain patients relative to an active control condition (p = .036, d = 0.51). Conclusions This study supports the SM’s validity and indicates that assessing both pleasant and unpleasant sensations broadens the scope of pain measurement. Although the SM would benefit from further optimization, its continued use is likely to contribute to improved assessment and treatment options for chronic pain patients.
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Medically Unexplained Symptoms and Antecedent Sexual Abuse: An Observational Study of a Birth Cohort
 Objective Medically unexplained symptoms (MUS) are common and associated with high consumption of health care resources. Cross-sectional studies in selected and clinical populations show consistent linkages between history of childhood sexual abuse (CSA) and presentation with MUS and somatization. However, there are almost no well-controlled prospective studies in population samples. Methods Data were gathered in a longitudinal study of a New Zealand birth cohort born in 1977. Hospital e-record data for the period 2008–2015 (age, 30–38 years) were searched for a subsample of 408 study participants who were resident in one District Health Board region, and details of MUS contacts were recorded. Retrospective reports of CSA (<16 years) were obtained at ages 18 and 21 years. Associations between CSA and MUS were sequentially adjusted using logistic regression methods for both childhood confounders assessed before age 16 years and potential mediating mental health/family context up to age 30 years. Results Twenty (4.9%) participants were classified as having MUS, of whom 11 had a history of CSA. Severe CSA involving attempted/completed sexual penetration was strongly associated with risk of MUS (odds ratio = 11.6, 95% confidence interval = 4.3–31.7, p < .001). A substantial association remained after statistically adjusting for confounding and mediating mental health/family context (adjusted odds ratio = 5.1, 95% confidence interval = 1.2–21.3, p = .024). This strong association was specific to severe CSA (as opposed to childhood physical abuse) and to MUS rather than medically explained symptoms. Conclusions CSA involving attempted/completed penetration was strongly associated with attendance at secondary level care for MUS. Implications for prevention and treatment of MUS are discussed.
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Mental Health of a Large Group of Adults With Disorders of Sex Development in Six European Countries
 Objective The aim of the study was to evaluate psychiatric symptoms among 1022 persons with various disorders of sex development (DSDs). Methods The study was a European multicenter cross-sectional clinical evaluation in six countries. The mean (SD) age of participants was 32.1 (13.4) years. The cohort consisted of 325 individuals with Turner syndrome, 219 individuals with Klinefelter syndrome (KS), female individuals with various XY-DSD conditions (107 with and 67 without androgenization), 87 male individuals with XY-DSD conditions, and 221 female individuals with congenital adrenal hyperplasia. The Hospital Anxiety and Depression Scale, the Short Autism Spectrum Quotient, the Adult Attention-Deficit/Hyperactivity Disorder Self-Report Scale, and self-reported mental health history were used to assess psychiatric symptoms. Results Across the six DSD diagnostic groups, clinical cutoff symptom scores were reached in 19.5% of participants for anxiety, in 7.1% for depression, in 4.1% for attention-deficit/hyperactivity disorder, and in 9.1% for autism. The mean depression and anxiety scores were higher compared with population norms in men with KS and men with XY-DSD. Compared with participants with other DSD conditions, men with KS reported significantly more mental health symptoms. Self-esteem, satisfaction with care, body dissatisfaction, and experiences of shame were associated with psychiatric symptoms in many DSD conditions. Conclusions A substantial minority of adults with DSD, with KS in particular, experience psychiatric morbidity. Across DSD conditions, adults may share feelings of shame. Developing a positive self-esteem and body image may be challenging. Multidisciplinary DSD care that involves specialized mental health support can be of important value. Trial Registration German Clinical Trials Register DRKS00006072.
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Fine Particle Air Pollution and Physiological Reactivity to Social Stress in Adolescence: The Moderating Role of Anxiety and Depression
 Objective Exposure to high levels of fine particle air pollution (PM2.5) is associated with adolescent pathophysiology. It is unclear, however, if PM2.5 is associated with physiology within psychosocial contexts, such as social stress, and whether some adolescents are particularly vulnerable to PM2.5-related adverse effects. This study examined the association between PM2.5 and autonomic reactivity to social stress in adolescents and tested whether symptoms of anxiety and depression moderated this association. Methods Adolescents from Northern California (N = 144) participated in a modified Trier Social Stress Test while providing high-frequency heart rate variability and skin conductance level data. PM2.5 data were recorded from CalEnviroScreen. Adolescents reported on their own symptoms of anxiety and depression using the Youth Self-Report, which has been used in prior studies and has good psychometric properties (Cronbach’s α in this sample was .86). Results Adolescents residing in neighborhoods characterized by higher concentrations of PM2.5 demonstrated greater autonomic reactivity (i.e., indexed by lower heart rate variability and higher skin conductance level) (β = .27; b = .44, p = .001, 95% CI = 0.19 to 0.68) in response to social stress; this association was not accounted for by socioeconomic factors. In addition, adolescents who reported more severe anxiety and depression symptoms showed the strongest association between PM2.5 and autonomic reactivity to social stress (β = .53; b = .86, p < .001, 95% CI = 0.48 to 1.23). Conclusions Exposure to PM2.5 may heighten adolescent physiological reactivity to social stressors. Moreover, adolescents who experience anxiety and depression may be particularly vulnerable to the adverse effects of PM2.5 on stress reactivity.
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