Psychosomatic Medicine 67:S47-S53 (2005)
© 2005 American Psychosomatic Society
Psychologic Functioning and Physical Health: A Paradigm of Flexibility
Alan Rozanski, MD and
Laura D. Kubzansky, PhD
From the Division of Cardiology, St. Luke's–Roosevelt Hospital Center, and the Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (A.R.); and the Department of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts (L.K.).
Address correspondence and reprint requests to Alan Rozanski, MD, Division of Cardiology, St. Luke's–Roosevelt Hospital Center, 1111 Amsterdam Ave, New York, NY 10025. E-mail: AR77{at}columbia.edu
 |
ABSTRACT
|
|---|
Recent evidence suggests that positive psychologic factors may be protective against coronary artery disease (CAD). We consider this possibility through a paradigm that explores three interrelated factors that may promote healthy psychologic functioning: vitality, emotional flexibility, and coping flexibility. Vitality is a positive and restorative emotional state that is associated with a sense of enthusiasm and energy. Flexibility is related both to the ability to regulate emotions effectively and cope effectively with challenging daily experiences. A variety of factors may diminish vitality, including chronic stress and negative emotions. Pathophysiologically, chronic stress and negative emotional states can both invoke a "chronic stress response" characterized by increased stimulation of the sympathetic nervous system and hypothalamic–pituitary–adrenal axis, with resultant peripheral effects, including augmented heart rate and blood pressure responsiveness and delayed recovery to stressful stimuli. Research indicates a wide array of stressful conditions—associated with either elements of relative inflexibility in psychologic functioning and/or relatively unabated stressful stimulation—that are associated with this type of exhausting hyperarousal. Conversely, new data suggest that positive psychologic factors, including positive emotions, optimism, and social support, may diminish physiological hyperresponsiveness and/or reduce adverse clinical event rates. Still other positive factors such as gratitude and altruistic behavior have been linked to a heightened sense of well-being but have not yet been tested for beneficial physiological effects. Pending further study, these observations could serve as the basis for expanding the potential behavioral interventions that may be used to assist patients with psychosocial risk factors for CAD.
Key Words: positive psychology • stress • psychologic • emotions • cardiovascular diseases
Abbreviations: CAD = coronary artery disease; SNS = sympathetic nervous system; HPA = hypothalamic–pituitary–adrenal.
|
INTRODUCTION
|
|---|
Both depression and chronic stress accelerate atherosclerosis and promote the development of adverse cardiac events (1). These conditions share overlapping characteristics. For example, depressive symptoms are a common consequence of chronic stress, such as that seen among those experiencing job strain (2,3). In addition, depression shares features of a chronic stress response whereby physiologically arousing emotions such as fear and anxiety commonly co-occur, as do symptoms of physiological hyperarousal such as increase in resting heart rate and high circulating norepinephrine levels (4), and also somatic hyperarousals such as insomnia and early-morning awakening (5). Recently, adverse clinical events have been linked to a variety of other conditions associated with hyperarousal, including pessimism (6,7), worry (8), sleeplessness (9), and lack of vacation time (10,11). Together, these observations raise a series of broad questions: Is the presence of continual hyperarousal one common factor explaining the link between adverse life conditions such as stressful job overload and caregiver strain, and the development and acceleration of coronary artery disease (CAD)? If so, what is the pathophysiological basis for this association? Moreover, can positive psychosocial conditions buffer the relationship between psychosocial factors known to promote CAD through hyperarousal, and if so, by what mechanism(s)?
We address these questions by first examining paradigms for healthy physical and psychologic functioning, and then assess how both negative and positive psychosocial factors might induce their effects in the context of this framework.
|
CHARACTERISTICS OF PHYSICAL WELL-BEING
|
|---|
Healthy physiological systems are characterized by a great degree of complexity (12), which translates into highly variable values for physiological parameters. Because competing autoregulatory influences are generally present, these systems function under conditions of nonlinear dynamics (e.g., nonproportional dose–response relationships) rather than linear dynamics (e.g., proportional dose–response relationships). This nonlinearity may result in healthy variability in measurements of "response"—but not tightly "controlled"—physiological parameters. For example, narrow variation through tight feedback control is desirable for controlled parameters such as blood pressure and arterial blood gas as well as hormone levels. Other parameters, however, tend to change in response to alterations in the controlled parameters (e.g., heart rate changes reflexively with blood pressure and respiration changes with alterations in blood gas). Thus, high heart rate variability is a sign of physiological health, but high blood pressure variability is not. Along these lines, a reduction in homeostatic efficacy of the baroreceptor reflex results in greater variability in blood pressure (the controlled parameter) and reduced variability in heart rate (the response parameter). Overall, variability of measurements such as heart rate intervals is reflective of a large capacity in physiological responsiveness and the ability to quickly return physiological activity to a "relative" baseline after stress. For example, healthy cardiovascular conditioning is associated with a relatively rapid decline postexercise. Anatomic systems are also characterized by complexity that manifests itself as fractal (i.e., self-similar or branching "treelike") patterns such as the branching nature of the nervous, pulmonary, circulatory and His-Purkinje systems. Such anatomic design promotes the rapid transfer of information or nutrients and provides excess capacity and nonlinear capability for dealing with unexpected stress.
Advancing age is associated with progressive loss of complexity in physiological and anatomic systems that produce adverse changes such as diminution in heart rate variability, reduced muscle and joint mechanics, and increased vascular wall stiffness. Similarly, medical illness can produce loss of complexity and resultant regularization among specific target systems such as the regularization in function that is observed for respiration in heart failure, for gait in Parkinson's disease, for white blood cell counts in leukemia, or for diminution of heart rate variability (reflecting autonomic nervous system dysfunction) across many disease states.
Thus, healthy physiological functioning is characterized by inherent flexibility and resiliency, and both age and disease are characterized by loss of flexibility, resulting in a decreased ability to compensate for changes in the internal or external environment. Accordingly, it would be reasonable to postulate that conditions of chronic psychosocial stress may also diminish this inherent physiological flexibility. We might also ask whether flexibility—in the psychologic domain—characterizes healthy functioning and/or influences pathophysiology and subsequent physical health outcomes.
|
FLEXIBILITY AND HEALTHY PSYCHOLOGIC FUNCTIONING
|
|---|
As suggested by healthy anatomic and physiological systems, there are numerous interrelated components likely to contribute to healthy psychologic functioning in a nonlinear fashion. This complexity allows for rapid response to environmental challenges (through the emotions) and provides reserve capacity for coping with the myriad of different experiences and situations with which individuals are daily confronted. To understand how a paradigm of flexibility applies to these response mechanisms, we identify and consider three potentially relevant components of healthy psychological functioning, as discussed subsequently (see Fig. 1).
View larger version (45K):
[in this window]
[in a new window]
|
Figure 1. A paradigm of psychologic well-being based on 3 interrelated components. Central to this paradigm is "vitality," a positive energetic state that is characterized by enthusiasm and a sense of aliveness. The energy associated with vitality helps to foster the work needed to regulate positive and negative emotions and to cope with life problems. This relationship is bidirectional because effective emotional competence and coping skills, in turn, help to preserve vitality by diminishing the frequency of energy-depleting negative emotions and/or taxing life problems. Emotional and coping flexibility are seen as key indicators of one's ability to successfully manage negative emotions and solve problems effectively.
|
|
Recent work has suggested that a sense of vitality is a particularly relevant barometer of both physical and emotional health (13,14). The definition of "vitality" varies somewhat according to theorists, but most agree that it is a positive state that is associated with a sense of enthusiasm and energy (6). Vitality is a composite of positive emotions, including a sense of joy and a sense of interest (15,16), and may be considered both restorative and regenerative. When these emotions are blended, a sense of positive energy and well-being is generated, which in turn, appears to enhance a variety of resources, including the ability to concentrate, problem-solving and intellectual performance, the ability to mobilize social resources, and the willingness to take on new challenges, as outlined by Fredrickson (17). Vitality, then, connotes a sense of "freshness"—a certain excitement and energy for living.
Both physical factors such as fatigue and medical illness, and psychologic factors may diminish vitality. Two broad psychologic categories are prominent in this regard. The first is states of chronic stress, particularly if accompanied by conflicts and/or demands that negatively affect one's sense of autonomy, being able to cope, or interpersonal relationships. The second is states of chronic negative emotion. Whereas positive emotions are transiently energizing, negative emotions have the opposite effect (when they are acute, some negative emotions such as anger or anxiety may also provide a sense of energy or arousal, but they do not contribute to a sense of vitality (13)). Chronic negative emotions can be self-sustaining and may also be viewed as inflexible states that deplete energy and impair coping. Thus, either chronic stress or negative emotions may initiate a vicious cycle, which reduce one's ability to respond adaptively to life's inherent challenges.
A consideration of the factors that diminish vitality may suggest the importance of flexibility for healthy psychologic functioning. Specifically, flexibility may broadly characterize two key aspects of psychologic functioning that contribute to maintaining vitality: the ability to regulate negative emotions effectively and the ability to cope effectively with chronic stress.
The regulation of negative emotions can involve a variety of skills such as the ability to control impulses, the ability to positively reappraise stimuli that might initiate a negative emotional experience, the ability to inhibit various evoked emotional responses according to situational demands (e.g., such as induced anxiety or fear during public interactions), and the ability to process one's emotional experiences effectively. People who are skilled in such abilities are more likely to manifest "emotional flexibility," which can be defined operationally as the ability to flexibly regulate emotions across a wide range of situations (18,19). Although the concept of emotional flexibility has hardly been assessed relative to medical outcomes, Bonanno et al. recently demonstrated that the ability to flexibly enhance and suppress emotions under experimental laboratory conditions among entering college freshman was associated with reduced levels of subjective psychologic distress over 1.5 years of follow up (20). Similarly, other data indicate that failure to express emotions is associated with the buildup of negative thoughts and a tendency to ruminate, a decreased ability to achieve emotional closure, and negative physiological consequences (21,22). By contrast, experimental research has indicated the health benefit associated with the expression of upsetting or traumatic experiences through expressive writing assignments (23).
Coping flexibility has also been proposed as a hallmark of the ability to respond effectively to chronic stress (24,25). Like with the regulation of negative emotions, there are a variety of coping responses that may be used to deal with life problems such as adjusting goals or priorities to cope with changing circumstances, setting limits, invoking social support, or seeking advice or counseling. Although these are all useful responses to stress, Cheng has recently postulated that it is coping flexibility, per se, rather than the use of specific coping responses that best predicts successful adaptation to stressful circumstances (25). Coping flexibility may have a number of relevant dimensions. For example, one aspect of coping flexibility may be the ability to flexibly switch between coping strategies that are oriented toward problem management versus those oriented toward emotional regulation. Problem-oriented coping strategies have been deemed more appropriate for situations involving controllable stress, whereas emotional regulation may be more appropriate for uncontrollable stress (26,27). A second aspect of coping flexibility may be "appraisal flexibility." For example, flexible appraisers are those who can flexibly appraise some stressors as controllable and others as not. By contrast, depressed individuals are prone to appraising any stressor as uncontrollable, whereas individuals who strongly desire control are often more likely to appraise stressors as controllable even when they are not (28). A third aspect of coping flexibility revolves around individuals' abilities to flexibly adjust goals to changing life circumstances. This ability may be of particular importance to medical patients, because changes in health status can often have profound effects on one's ability to pursue cherished life goals.
Vitality, emotional flexibility, and coping flexibility form a dynamic and complex system of psychologic functioning. The excitement and energy that accompanies a sense of vitality may serve to enhance the flexibility and creativity with which individuals respond to the environment in terms of their ability both to regulate emotions and to use effective coping strategies. Such effects, however, are likely bidirectional. When emotion regulatory processes and effective coping mechanisms are in place, they also serve to conserve energy and help augment one's sense of vitality.
|
SOURCES OF CHRONIC STRESS THAT MAY LEAD TO INFLEXIBILITY
|
|---|
Chronic stress adversely affects both sides of the bidirectional relationship associated with vitality and flexibility by both promoting emotional inflexibility and by draining vitality. For example, job strain promotes depression (2,3) and, as demonstrated in the recent Maastricht Cohort Study on Fatigue at Work (29), it also promotes fatigue, failure to unwind, and even frank burnout. Under such circumstances, it becomes increasingly difficult to regulate emotions or use effective coping strategies. This type of exhausting hyperarousal has now been linked to a variety of conditions associated with the development of CAD and/or adverse clinical outcomes, including negative cognitive states (e.g., pessimism) (6,7), depression (1), work stress (30–32), marital stress (33–36), caregiver strain (37–38), lack of vacations (10,11), inadequate sleep (independent of depression) (9), and low socioeconomic status (39,40) (see Fig. 2).
View larger version (35K):
[in this window]
[in a new window]
|
Figure 2. Patterns of inflexibility that have been shown to be associated with the development of abnormal cardiovascular pathophysiology and/or adverse clinical outcomes ranging from negative cognitive states (such as rumination, pessimism, and worry) to lifestyles that are likely to be associated with chronic physiological overload such as chronic job stress or caregiver strain.
|
|
|
THE PHYSIOLOGICAL BASIS OF A CHRONIC STRESS RESPONSE
|
|---|
Troubling life problems and the failure to resolve negative emotional states such as depression may generate continual physiological stimulation, frequently invoking a chronic physiological stress response. The continual stimulation of the sympathetic nervous system (SNS) and the hypothalamic–pituitary–adrenal (HPA) axis that results from such chronic stress can produce a cascade of negative pathophysiological consequences, as illustrated in Figure 3. Normally, elevations of cortisol that are associated with acute stress serve to downregulate HPA function through a negative feedback mechanism. However, under chronic stress, cortisol binds to central nervous system receptors, resulting, paradoxically, in a continued secretion of cortisol (41). This hypercortisolemia is associated with a loss in the normal physiological plasticity of the HPA, as manifested by reduced variability in cortisol secretion measurements and diminution in the normal sensitivity of the HPA axis to exogenous suppression using dexamethasone. The enhanced SNS activation that is evoked under conditions of chronic stress may also lead to elevated resting heart rates and autonomic nervous system imbalance, as characterized, for example, by reduced resting heart rate variability (4). In addition, impaired function of the parasympathetic nervous system is known to cause reduced recovery in rest heart rates after exercise, and although the pathophysiological mechanisms remain to be clarified, slow recovery of resting heart rate and blood pressure has been noted in the presence of both acute and chronic forms of psychologic stress as well.
View larger version (35K):
[in this window]
[in a new window]
|
Figure 3. Individuals with chronic emotional disorders such as depression or who experience chronic stress may be subject to chronic physiological stress responses characterized by chronic overstimulation of the hypothalamic–pituitary–adrenal (HPA) axis and sympathetic nervous system (SNS). The resultant dysregulation of these systems may lead to decreased cortisol variability, hypercortisolemia, high norepinephrine levels, autonomic dysfunction, elevated resting heart rates, and other peripheral affects that are not shown. The chronic stress response is also characterized by a prolonged recovery to physiological stimulation and to enhanced cardiovascular reactivity to novel stressors.
|
|
Chronic stress also appears to produce an intrinsic increase in "cardiovascular reactivity" (i.e., heightened heart rate and blood pressure responsivity to acute physiological stimuli) that, in recent animal studies, has been linked to the activation of an anatomic chronic stress network, involving several specific brain centers (42). This pathophysiological change may be particularly important in light of recent studies that link heightened cardiovascular reactivity to a greater presence and/or progression of subclinical atherosclerosis (43–46). Of note, physiological hyperreactivity to acute stressors appears to be characteristic among various states indicated in Figure 2. For example, among cognitive states, job-related worry has recently been linked to higher cortisol levels on work days (47), and preliminary studies suggest that laboratory-induced state rumination may prolong recovery of heart rate and blood pressure after acute physiological stimulation (48). Similarly, among emotional disorders, both depressed subjects (4) and those with hostility (49) show heightened neuroendocrine responses in the laboratory compared with normal subjects. Among life situations, chronic job strain as characterized by high job demand but low job latitude (30) has also been linked to prolonged heart rate and blood pressure elevations after work, which, in the case of blood pressure, may last for days at a time (50), to higher cortisol levels while at work (47), and to both enhanced blood pressure responsivity to pharmacologic challenge (phenylephrine) and decreased baroreflex sensitivity (51). The accompanying feeling of being unable to relax after work (32) may represent a clinical mirror of reduced physiological plasticity. Lack of adequate sleep may also result in neuroendocrine activation (52), and low SES has been similarly linked to physiological hyperreactivity (53).
The heightened output from the HPA and SNS associated with chronic stress serves to produce a variety of other changes that have been strongly linked to CAD, including signs of increased inflammation, central obesity, hyperinsulinemia, diabetes, hypertension, and endothelial dysfunction, as reviewed elsewhere (1).
|
POSITIVE PSYCHOLOGIC FACTORS AS A POTENTIAL BUFFER
|
|---|
Whether the model of psychologic functioning we have proposed actually protects cardiac health remains to be tested empirically. Until recently, little was known concerning the ability of positive psychologic factors to promote health and longevity and to act as a potential buffer against the adverse effects associated with chronic psychologic stress. However, recent studies have linked various positive factors to beneficial outcomes. For example, both optimistic explanatory style (6) and dispositional optimism (7) have been linked to lower overall mortality rates and dispositional optimism to reduced progression of atherosclerosis as demonstrated by carotid ultrasound (54) and enhanced recovery after myocardial infarction (55), heart transplantation (56), and coronary bypass surgery (57,58). Other data have linked greater social connectedness or emotional social support to lower adverse clinical event rates (1). Several studies have also linked positive emotions to a number of health outcomes, including longer longevity among nuns (59), reduced susceptibility to the common cold (60), and reduced likelihood of having diabetes or developing hypertension over 2 years of follow up in adults aged 55 and over (61).
In addition, investigators have increasingly focused on the potential impact of positive psychologic factors on cardiovascular pathophysiology. For instance, Fredrickson et al. used an experimental design to demonstrate that positive emotions could shorten the recovery of physiological indices after exposing experimental subjects to a stimulus designed to induce negative emotions (62). Positive social support (a coping resource) also has been shown to reduce physiological reactivity to acute laboratory stressors (63). Moreover, those scoring highly on trait measures of forgiveness have been shown to exhibit less cardiovascular reactivity to acute stressors (64), suggesting that this and other positive traits may merit more study relative to their beneficial physiological effects. Similar results have been noted preliminarily among those demonstrating trait optimism (Willem J. Kop, personal communication). Together, these studies suggest positive psychologic factors can reduce cardiovascular reactivity to stress in direct opposition to the heightened reactivity that may be induced by chronic stress and depression.
|
FUTURE DIRECTIONS
|
|---|
These observations suggest areas of needed investigation. First, the potential clinical and pathophysiological benefits associated with positive emotions are based on sparse data that needs to be confirmed by further clinical studies and extended to assess a wider variety of positive traits and emotions. For example, although traits such as altruistic behavior (65) and gratitude (66) have been linked to higher levels of psychologic well-being, their ability to influence the clinical course of CAD remains to be determined.
The finding of a persistent association between CAD and even mild negative emotions (67) may also provide insight into aspects of healthy psychologic functioning that may be important, particularly in relation to chronic hyperarousal. For example, Steptoe et al. have recently demonstrated that the physiological effects of an acute stressor can vary among those experiencing job strain, depending on whether that stressor is experienced as a controllable or uncontrollable stress (68). In other recent work, caregiving stress was only associated with excess cardiovascular events if a sense of emotional strain was also felt (38). These observations suggest that healthy psychologic functioning, including emotional and coping flexibility and the presence of factors that promote vitality (e.g., work that is perceived as meaningful), may mitigate against the atherogenic effects of conditions associated with chronic hyperarousal such as job or caregiver strain. Such possibility could be addressed by considering the relationship of both positive and negative psychosocial factors and their interrelationships with chronic stress in future epidemiologic investigations.
|
CLINICAL RELEVANCE
|
|---|
A variety of life situations have been linked with poor cardiac outcomes and may be linked with depleted psychologic health as outlined earlier in Figure 2. If healthy psychologic functioning and flexibility indeed mitigate effects of chronic stress, this suggests that clinical attention to patients' emotional states and life circumstances may yield important information about both risk for future events and also potential targets for intervention. Viewed through this lens, the particular characteristics of a given situation or exposure may be optimally assessed by also considering its related drain on emotional health. Shifting focus to an individual's capacity for renewal and regeneration may help clinicians to provide concrete help to their patients. Such interventions may be targeted at reducing negative cognitive patterns such as rumination or pessimism, at promoting more rest and relaxation through better sleeping habits and/or more vacations, at helping patients prone to overwork change their work habits, at building a greater range of positive emotions and experiences, or at building greater emotional and coping flexibility. A number of specific strategies that may be helpful have been outlined in a recent paper (1).
Taken together, the available evidence suggests there may be a clinical rationale both for increasing our understanding of the links between psychologic functioning and cardiac health, and for assessing the cardiovascular effects of behavioral interventions designed to reduce chronic physiological stimulation and enhance healthy psychologic functioning.
The authors thank Dr. Patrice Saab, Dr. Elliot Brown, and Dr. Deborah A. Scheuer for comments on an earlier version of the manuscript.
|
NOTES
|
|---|
In accordance with CME accreditation guidelines, the authors of this article disclosed no real or potential conflicts of interest.
DOI:10.1097/01.psy.0000164253.69550.49
|
REFERENCES
|
|---|
- Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol 2005;45:637–51.[Abstract/Free Full Text]
- Mausner-Dorsch H, Eaton WW. Psychosocial work environment and depression: epidemiologic assessment of the demand-control model. Am J Public Health 2000;90:1765–70.[Abstract/Free Full Text]
- Stansfeld SA, Fuhrer R, Shipley MJ, Marmot MG. Work characteristics predict psychiatric disorder: prospective results from the Whitehall II study. Occup Environ Med 1999;56:302–7.[Abstract]
- Carney RM, Freedland KE, Veith RC. Depression, the autonomic nervous system, and coronary heart disease. Psychosom Med. In press.
- Gold PW, Chrousos GP. The endocrinology of melancholic and atypical depression: relation to neurocircuitry and somatic consequences. Proc Assoc Am Physicians 1998;111:22–34.
- Kubzansky LD, Sparrow D, Vokonas P, Kawachi I. Is the glass half empty or half full? A prospective study of optimism and coronary heart disease in the normative aging study. Psychosom Med 2001;63:910–6.[Abstract/Free Full Text]
- Giltay EJ, Geleijnse JM, Zitman FG, Hoekstra T, Schouten EG. Dispositional optimism and all-cause and cardiovascular mortality in a prospective cohort of elderly Dutch men and women. Arch Gen Psychiatry 2004;61:1126–35.[Abstract/Free Full Text]
- Kubzansky LD, Kawachi I, Spiro A III, Weiss ST, Vokonas PS, Sparrow D. Is worrying bad for your heart? A prospective study of worry and coronary heart disease in the Normative Aging Study. Circulation 1997;95:818–24.[Medline]
- Leineweber C, Kecklund G, Janszky I, Akerstedt T, Orth-Gomer K. Poor sleep increases the prospective risk for recurrent events in middle-aged women with coronary disease. The Stockholm Female Coronary Risk Study. J Psychosom Res 2003;54:121–7.[CrossRef][Medline]
- Eaker ED, Pinsky J, Caastelli WP. Myocardial infarction and coronary death among women: psychosocial predictors from a 20-year follow-up of women in the Framingham study. Am J Epidemiol 1992;135:854–64.[Abstract/Free Full Text]
- Gump BB, Matthews KA. Are vacations good for your health? The 9-year mortality experience after the multiple risk factor intervention trial. Psychosom Med 2000;62:608–12.[Abstract/Free Full Text]
- Goldberger AL. Non-linear dynamics for clinicians: chaos theory, fractals, and complexity at the bedside. Lancet 1996;347:1312–4.[CrossRef][Medline]
- Ryan RM, Frederick C. On energy, personality, and health: subjective vitality as a dynamic reflection of well-being. J Pers 1997;65:529–65.[CrossRef][Medline]
- Penninx BWJH, Guralnik JM, Bandeen-Roche K, Kasper JD, Simonsick EM, Ferrucci L, Fried LP. The protective effect of emotional vitality on adverse health outcomes in disabled older women. J Am Geriatr Soc 2000;48:1359–66.[Medline]
- Deci E. On the nature and functions of motivation theories. Psychol Sci 1992;3:167–71.
- Izard CE, Ackerman BP. Motivational, organizational, and regulatory functions of discrete emotions. In: Lewis M, Haviland JS, eds. Handbook of Emotions. New York: The Guilford Press, 2000:253.
- Fredrickson BL. What good are positive emotions? Review of General Psychology 1998;2:300–19.[CrossRef]
- Parrott WG. Beyond hedonism: motives for imbibing good moods and for maintaining bad moods. In: Wegner DM, Pennebaker JW, eds. Handbook of Mental Control. Englewood Cliffs, NJ: Prentice-Hall, 1993:278–308.
- Consedine N, Magai C, Bonanno GA. Moderators of the emotion inhibition–health relationship: a review and research agenda. Review of General Psychology 2002;6:204–38.[CrossRef]
- Bononno GA, Papa A, O'Neil K, Westphal M, Coifman K. The importance of being flexible: the ability to enhance and suppress emotional expression predicts long-term adjustment. Psychol Sci 2004;15:482–7.[CrossRef][Medline]
- Gross JJ. Antecedent and response-focused emotion regulation: divergent consequences for experience, expression, and physiology. J Pers Soc Psychol 1998;74:224–37.[CrossRef][Medline]
- Gross JJ. The emerging field of emotion regulation: an integrative review. Review of General Psychology 1998;2:271–99.[CrossRef]
- Pennebaker JW, Seagal JD. Forming a story: the health benefits of narrative. J Clin Psychol 1999;55:1243–54.[CrossRef][Medline]
- Lester N, Smart L, Baum A. Measuring coping flexibility. Psychology and Health 1994;9:409–24.
- Cheng C. Assessing coping flexibility in real-life and laboratory settings: a multimethod approach. J Pers Soc Psychol 2001;80:814–33.[CrossRef][Medline]
- Compas BE, Malcarne V, Fondacaro KM. Coping with stressful events in older children and young adolescents. J Consult Clin Psychol 1988;56:405–11.[CrossRef][Medline]
- Vitaliano PP, DeWolfe DJ, Maiuro RD, Russo J, Katon W. Appraisal changeability of a stressor as a modifier of the relationship between coping and depression: a test of the hypothesis of fit. J Pers Soc Psychol 1990;59:582–92.[CrossRef][Medline]
- Clark LK, Miller SM. Self-reliance and desire for control in the type A behavior pattern. J Social Behav Personality 1990;5:405–18.
- Bultmann U, Kant IJ, Van de Brandt PA, Kasl SV. Psychosocial work characteristics as risk factors for the onset of fatigue and psychological distress: prospective results from the Maastricht Cohort Study. Psychol Med 2002;32:333–45.[Medline]
- Karasek R, Baker D, Marxer F, Ahlbom A, Theorell T. Job decision latitude, job demands, and cardiovascular disease: a prospective study of Swedish men. Am J Public Health 1981;71:694–705.[Abstract/Free Full Text]
- Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol 1996;1:27–41.[CrossRef][Medline]
- Suadicani P, Hein HO, Gyntelberg F. Are social inequalities associated with the risk of ischaemic heart disease a result of psychosocial working conditions? Atherosclerosis 1993;101:165–75.[CrossRef][Medline]
- Mittleman MA. Marital stress worsens prognosis in women with coronary heart disease: the Stockholm Female Coronary Risk Study. JAMA 2000;284:3008–14.[Abstract/Free Full Text]
- Coyne JC, Rohrbaugh MJ, Shoham V, Sonnega JS, Nicklas JM, Cranford JA. Prognostic importance of marital quality for survival of congestive heart failure. Am J Cardiol 2001;88:526–9.[CrossRef][Medline]
- Matthews KA, Gump BB. Chronic work stress and marital dissolution increase risk of posttrial mortality in men from the Multiple Risk Factor Intervention Trial. Arch Intern Med 2002;162:309–15.[Abstract/Free Full Text]
- Gallo LC, Troxel WM, Kuller LH. Marital status, marital quality, and atherosclerotic burden in postmenopausal women. Psychosom Med 2003;65:952–62.[Abstract/Free Full Text]
- Lee S, Colditz GA, Berkman LF, Kawachi I. Caregiving and risk of coronary heart disease in US women: a prospective study. Am J Prev Med 2003;24:113–9.[CrossRef][Medline]
- Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA 1999;282:2215–9.[Abstract/Free Full Text]
- Marmot MG, Rose G, Shipley M, Hamilton PJS. Employment grade and coronary heart disease in British civil servants. J Epidemiol Community Health 1978;32:244–9.[Abstract]
- Marmot MG, Davey Smith G, Stansfeld SA, Marmot MG. Health inequalities among British Civil Servants: the Whitehall II study. Lancet 1991;337:1387–93.[CrossRef][Medline]
- Dallman MF, La Fluer S, Pecoraro NC, Gomez F, Houshyar H, Akana SF. Minireview: glucocorticoids—food intake, abdominal obesity, and wealthy nations in 2004. Endocrinology 2004;145:2633–8.[Abstract/Free Full Text]
- Bhatnagar S, Dallman M. Neuroanatomical basis for facilitation of hypothalamic–pituitary–adrenal responses to a novel stressor after chronic stress. Neuroscience 1998;84:1025–39.[CrossRef][Medline]
- Kamarck TW, Everson SA, Kaplan GA, Manuck SB, Jennings JR, Salonen R, Salonen JT. Exaggerated blood pressure responses during mental stress are associated with enhanced carotid atherosclerosis in middle-aged Finnish men: findings from the Kuopio Ischemic Heart Disease Study. Circulation 1997;96:3842–8.[Medline]
- Matthews KA, Owens JF, Kuller LH, Sutton-Tyrrell K, Lassila HC, Wolfson SK. Stress induced pulse pressure change predicts women's carotid atherosclerosis. Stroke 1998;29:1525–30.[Abstract/Free Full Text]
- Barnett PA, Spence JD, Manuck SB, Jennings JR. Psychological stress and the progression of carotid artery disease. J Hypertens 1997;15:49–55.[CrossRef][Medline]
- Everson SA, Lynch JW, Chesney MA, Kaplan GA, Goldberg DE, Shade SB, Cohen RD, Salonen R, Salonen JT. Interaction of workplace demands and cardiovascular reactivity in progression of carotid atherosclerosis: population based study. BMJ 1997;314:553–8.[Abstract/Free Full Text]
- Schlotz W, Hellhammer J, Schulz P, Stone AA. Perceived work overload and chronic worrying predict weekend-weekday differences in the cortisol awakening response. Psychosom Med 2004;66:207–14.[Abstract/Free Full Text]
- Glynn LM, Christenfeld N, Gerin W. The role of rumination in recovery from reactivity: cardiovascular consequences of emotional states. Psychosom Med 2002;64:714–26.[Abstract/Free Full Text]
- Suarez EC, Kuhn CM, Schanberg SM, Williams RB Jr, Zimmermann EA. Neuroendocrine, cardiovascular, and emotional responses of hostile men: the role of interpersonal challenge. Psychosom Med 1998;60:78–88.[Abstract/Free Full Text]
- Vrijkotte TG, van Doornen LJ, de Geus EJ. Effects of work stress on ambulatory blood pressure, heart rate, and heart rate variability. Hypertension 2000;35:880–6.[Abstract/Free Full Text]
- Thomas KS, Nelesen RA, Ziegler MG, Bardwell WA, Dimsdale JE. Job strain, ethnicity, and sympathetic nervous system activity. Hypertension 2004;44:895–6.
- Spiegal K, Leproult R, Cauter EV. Impact of sleep debt on metabolic and endocrine function. Lancet 1999;354:1435–9.[CrossRef][Medline]
- Steptoe A, Kunz-Ebrecht S, Owen N, Feldman PJ, Willemsen G, Kirschbaum C, Marmot M. Socioeconomic status and stress-related biological responses over the working day. Psychosom Med 2003;65:461–70.[Abstract/Free Full Text]
- Matthews KA, Raikkonen K, Sutton-Tyrrell K, Kuller LH. Optimistic attitudes protect against progression of carotid atherosclerosis in healthy middle-aged women. Psychosom Med 2004;66:640–4.[Abstract/Free Full Text]
- Agarwal M, Dalal AK, Agarwal DK, Agarwal RK. Positive life orientation and recovery from myocardial infarction. Soc Sci Med 1995;40:125–30.
- Leedham B, Meyerowitz BE, Muirhead J, Frist WH. Positive expectations predict health after heart transplantation. Health Psychol 1995;14:74–9.[CrossRef][Medline]
- Scheier MF, Matthews KA, Owens JF, Magovern GJ Sr, Lefebvre RC, Abbott RA, Carver CS. Dispositional optimism and recovery from coronary artery bypass surgery: the beneficial effects on physical and psychological well-being. J Pers Soc Psychol 1989;57:1024–40.[CrossRef][Medline]
- Scheier MF, Matthews KA, Owens JF, Schulz R, Bridges MW, Magovern GJ, Carver CS. Optimism and rehospitalization after coronary artery bypass graft surgery. Arch Intern Med 1999;159:829–35.[Abstract/Free Full Text]
- Danner DD, Snowdon DA, Friesen WV. Positive emotions in early life and longevity: findings from the nun study. J Pers Soc Psychol 2001;80:804–13.[CrossRef][Medline]
- Cohen S, Doyle WJ, Turner RB, Alper CM, Skoner DP. Emotional style and susceptibility to the common cold. Psychosom Med 2003;65:652–7.[Abstract/Free Full Text]
- Richman L, Kubzansky LD, Maselko J, Kawachi I, Choo P, Bauer M. Positive emotion and health: going beyond the negative. Health Psychol. In press.
- Fredrickson BL, Levenson RW. Positive emotions speed recovery from the cardiovascular sequelae of negative emotions. Cognition and Emotion 1998;12:191–220.
- Gerin W, Pieper C, Levy R, Pickering TG. Social support in social interaction: a moderator of cardiovascular reactivity. Psychosom Med 1992;54:324–36.[Abstract/Free Full Text]
- Lawler KA, Younger JW, Piferi RL, Billington E, Jobe R, Edmondson K, Jones WH. A change of heart: cardiovascular correlates of forgiveness in response to interpersonal conflict. J Behav Med 2003;26:373–93.[CrossRef][Medline]
- Schwartz C, Meisenhelder JB, Ma Y, Reed G. Altruistic social interest behaviors are associated with better mental health. Psychosom Med 2003;65:778–85.[Abstract/Free Full Text]
- Emmons RA, McCullough ME. Counting blessings vs. burdens: an experimental investigation of gratitude and subjective well-being in daily life. J Pers Soc Psychol 2003;84:377–89.[CrossRef][Medline]
- Lesperance F, Frasure-Smith N, Talajic M, Bourassa MG. Five-year risk of cardiac mortality in relation to initial severity and one-year changes in depression symptoms after myocardial infarction. Circulation 2002;105:1049–53.[Abstract/Free Full Text]
- Steptoe A, Cropley M, Joekes K. Job strain, blood pressure, and response to uncontrollable stress. J Hypertens 1999;17:193–200.[Medline]
This article has been cited by other articles:
|
|
|
|
 
L. D. Kubzansky and R. C. Thurston
Emotional Vitality and Incident Coronary Heart Disease: Benefits of Healthy Psychological Functioning
Arch Gen Psychiatry,
December 1, 2007;
64(12):
1393 - 1401.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. G. Surtees, N. W.J. Wainwright, R. L. Luben, N. J. Wareham, S. A. Bingham, and K.-T. Khaw
Adaptation to Social Adversity Is Associated With Stroke Incidence: Evidence From the EPIC-Norfolk Prospective Cohort Study
Stroke,
May 1, 2007;
38(5):
1447 - 1453.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. J. Contrada, D. A. Boulifard, E. L. Idler, T. J. Krause, and E. W. Labouvie
Course of Depressive Symptoms in Patients Undergoing Heart Surgery: Confirmatory Analysis of the Factor Pattern and Latent Mean Structure of the Center for Epidemiologic Studies Depression Scale
Psychosom Med,
November 1, 2006;
68(6):
922 - 930.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. J. Giltay, M. H. Kamphuis, S. Kalmijn, F. G. Zitman, and D. Kromhout
Dispositional optimism and the risk of cardiovascular death: the zutphen elderly study.
Arch Intern Med,
February 27, 2006;
166(4):
431 - 436.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. S. Sheps and A. Rozanski
From Feeling Blue to Clinical Depression: Exploring the Pathogenicity of Depressive Symptoms and Their Management in Cardiac Practice
Psychosom Med,
May 1, 2005;
67(Supplement_1):
S2 - S5.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Rozanski
Integrating Psychologic Approaches Into the Behavioral Management of Cardiac Patients
Psychosom Med,
May 1, 2005;
67(Supplement_1):
S67 - S73.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
