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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.
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THE CENTER FOR
Comprehensive Access &Delivery Research and
Evaluation
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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
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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)
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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)
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2.1 Repetitive Thought(Background)
Stressor
Short Stres
s Resp-onse
Coping & Appraisal
Prolonged Stress
Response
Pathogenic state
Organic Disease
Perseverative Cognition
about Stressor
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Perseverative Cognition Hypothesis(Brosschot, Gerin & Thayer, 2006)
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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)
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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)
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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)
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Determine if maladaptive repetitive thought is associated with greater immune-spectrum disease and disease-related disability
Objective10
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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
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Maladaptive Repetitive Thought and Physical Disease: Hypothesized Model
PhysicalDisease
Reexperiencing
Avoidance
Arousal
InflammatoryDisorder
Prevalence
FunctionalDisability
MaladaptiveRT
PosttraumaticStress
Symptoms
MRTx
Posttraumatic Stress Symptoms
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Maladaptive Repetitive Thought and Physical Disease: Hypothesized Model
PhysicalDisease
Reexperiencing
Avoidance
Arousal
Smoking Alcohol Use Sleep
InflammatoryDisorder
Prevalence
FunctionalDisability
MaladaptiveRT
PosttraumaticStress
Symptoms
MRTx
Posttraumatic Stress Symptoms
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Maladaptive Repetitive Thought and Physical Disease: Hypothesized Model
PhysicalDisease
Reexperiencing
Avoidance
Arousal
Smoking Alcohol Use Sleep
InflammatoryDisorder
Prevalence
FunctionalDisability
MaladaptiveRT
DepressionChildhood
Trauma
PosttraumaticStress
Symptoms
MRTx
Posttraumatic Stress Symptoms
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Greater Maladaptive Repetitive Thought Related to Less Physical Disease
PhysicalDisease
Reexperiencing
Avoidance
Arousal
Smoking Alcohol Use Sleep
InflammatoryDisorder
Prevalence
FunctionalDisability
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
Smoking Alcohol Use Sleep
ChildhoodTrauma
Posttraumatic Stress
Symptoms
PhysicalDisease
-.12.04χ2= 26.04 (p = .21)χ 2/df=1.24CFI= 1.00RMSEA= .02SRMR= .02
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MaladaptiveRepetitive Thought
Maladaptive Repetitive Thought
xPosttraumatic Stress
Symptoms
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Maladaptive Repetitive Thought Unrelated to Disease When Depression Not Included in Model
Smoking Alcohol Use Sleep
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
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Maladaptive Repetitive Thought
xPosttraumatic Stress
Symptoms
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Greater Maladaptive Repetitive Thought Related to Less Physical Disease
PhysicalDisease
Reexperiencing
Avoidance
Arousal
Smoking Alcohol Use Sleep
InflammatoryDisorder
Prevalence
FunctionalDisability
MRTx
Posttraumatic 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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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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Perseverative Cognition Hypothesis(Brosschot, Gerin & Thayer, 2006)
Stressor
Short Stres
s Resp-onse
Coping & Appraisal
Prolonged Stress
Response
Pathogenic state
Organic Disease
Perseverative Cognition
about Stressor
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Stressor
Short Stress Resp-onse
Coping & Appraisal
Prolonged Stress
Response
Pathogenic state
Organic Disease
Adaptive Cognition about Stressor
Perseverative Cognition Hypothesis(Brosschot, Gerin & Thayer, 2006)
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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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Clinical Implications: Adaptive Repetitive Thought Intervention
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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Clinical Implications: Adaptive Repetitive Thought Intervention
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)
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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)
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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