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ACBS June 19 th , 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. ACBS June 19 th , 2014.

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ACBS June 19 th , 2014

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  1. 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. ACBS June 19th, 2014

  2. Background Overview • Stress and Health 1.1 Stress and health overview 1.2 Stress and health in female veterans • Repetitive Thought 2.1Perseverative Cognition Hypothesis 2.2 Dimensions of repetitive thought • Inflammatory disorders • 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)

  5. 2.1 Repetitive Thought(Background) Perseverative Cognition Hypothesis (Brosschot, Gerin & Thayer, 2006) Stressor Short Stress Resp- onse Prolonged Stress Response Pathogenic state Organic Disease Perseverative Cognition about Stressor Coping & Appraisal

  6. 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; Segerstromet 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. Objective Determine if maladaptive repetitive thought is associated with greater immune-spectrum disease and disease-related disability

  10. 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

  11. 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?”

  12. 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%

  13. 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

  14. Sample: Trauma 15 • 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

  15. Maladaptive Repetitive Thought and Physical Disease: Hypothesized Model Inflamatory Disorder Prevalence Physical Disease Functional Disability Maladaptive RT

  16. Maladaptive Repetitive Thought and Physical Disease: Hypothesized Model Reexperiencing Inflammatory Disorder Prevalence Physical Disease Posttraumatic Stress Symptoms Avoidance Functional Disability Arousal MRT x Posttraumatic Stress Symptoms Maladaptive RT

  17. Maladaptive Repetitive Thought and Physical Disease: Hypothesized Model Smoking Alcohol Use Sleep Reexperiencing Inflammatory Disorder Prevalence Physical Disease Posttraumatic Stress Symptoms Avoidance Functional Disability Arousal MRT x Posttraumatic Stress Symptoms Maladaptive RT

  18. Maladaptive Repetitive Thought and Physical Disease: Hypothesized Model Smoking Alcohol Use Sleep Reexperiencing Inflammatory Disorder Prevalence Physical Disease Posttraumatic Stress Symptoms Avoidance Functional Disability Arousal MRT x Posttraumatic Stress Symptoms Maladaptive RT Depression Childhood Trauma

  19. Greater Maladaptive Repetitive Thought Related to Less Physical Disease Smoking Alcohol Use Sleep Reexperiencing .07 -.22** -.06 .72** Inflammatory Disorder Prevalence .40** Physical Disease Posttraumatic Stress Symptoms Avoidance .80** .06 .82** .89** Functional Disability Arousal .03 -.16** .33** .10** χ2= .07- 39.48 (p = .02 -.99) χ2/df=.02-1.65 CFI= .99-1.00 RMSEA= .00-.03 SRMR= .00-.02 Maladaptive Repetitive Thought Depression Maladaptive Repetitive Thought x Posttraumatic Stress Symptoms Childhood Trauma

  20. Maladaptive Repetitive Thought Unrelated to Disease When Depression Not Included in Model Smoking Alcohol Use Sleep Posttraumatic Stress Symptoms Physical Disease .04 -.12 χ2= 26.04 (p = .21) χ2/df=1.24 CFI= 1.00 RMSEA= .02 SRMR= .02 Maladaptive Repetitive Thought x Posttraumatic Stress Symptoms Maladaptive Repetitive Thought Childhood Trauma

  21. Maladaptive Repetitive Thought Unrelated to Disease When Depression Not Included in Model Smoking Alcohol Use Sleep .07 -.17** -.13** Posttraumatic Stress Symptoms Physical Disease .32** .04 -.12 .14** χ2= 26.04 (p = .21) χ2/df=1.24 CFI= 1.00 RMSEA= .02 SRMR= .02 Maladaptive Repetitive Thought x Posttraumatic Stress Symptoms MRT Childhood Trauma

  22. Greater Maladaptive Repetitive Thought Related to Less Physical Disease Smoking Alcohol Use Sleep Reexperiencing .07 -.22** -.06 .72** Inflammatory Disorder Prevalence .40** Physical Disease Posttraumatic Stress Symptoms Avoidance .80** .06 .82** .89** Functional Disability Arousal .03 -.16** .33** .10** χ2= .07- 39.48 (p = .02 -.99) χ2/df=.02-1.65 CFI= .99-1.00 RMSEA= .00-.03 SRMR= .00-.02 Maladaptive Repetitive Thought Depression MRT x Posttraumatic Stress Symptoms Childhood Trauma

  23. 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

  24. Perseverative Cognition Hypothesis(Brosschot, Gerin & Thayer, 2006) Stressor Short Stress Resp- onse Prolonged Stress Response Pathogenic state Organic Disease Perseverative Cognition about Stressor Coping & Appraisal

  25. Perseverative Cognition Hypothesis(Brosschot, Gerin & Thayer, 2006) Stressor Short Stress Resp- onse Prolonged Stress Response Pathogenic state Organic Disease Adaptive Cognition about Stressor Coping & Appraisal

  26. Clinical Implications: Adaptive Repetitive Thought Intervention • Maladaptive Repetitive Thought • Rumination, worry • Brooding about implications of mistakes, passive, evaluative (Coarocco, Vohs & Baumeister, 2010; Segerstromet 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)

  27. Clinical Implications: Adaptive Repetitive Thought Intervention • Error correction or goal attainment • Non-evaluative

  28. 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)

  29. 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

  30. 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

  32. Acknowledgements • VA HSR&D Grant DHI 05-059 to Dr. Sadler • University of Iowa Graduate College research fellowship

  33. 2.3 Maladaptive Repetitive Thought vs. PTSD Intrusions (Background)

  34. 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) • Cortisoldysregulation(Roger & Najarian, 1998) • Physiologic emotional arousal (Feldner et al., 2006)

  36. Deployment 37

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