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BACKGROUND: Current clinical guidelines identify several psychological treatments for irritable bowel syndrome (IBS). IBS patients, however, have elevated trauma, life stress, relationship conflicts, and emotional avoidance, which few therapies directly target. We tested the effects of emotional awareness and expression training (EAET) compared to an evidence-based comparison condition-relaxation training-and a waitlist control condition. METHODS: Adults with IBS (N=106; 80% female, Mean age=36 years) were randomized to EAET, relaxation training, or waitlist control. Both EAET and relaxation training were administered in three, weekly, 50-minute, individual sessions. All patients completed the IBS Symptom Severity Scale (primary outcome), IBS Quality of Life, and Brief Symptom Inventory (anxiety, depressive, and hostility symptoms) at pretreatment and at 2 weeks posttreatment and 10 weeks follow-up (primary endpoint). KEY RESULTS: Compared to waitlist controls, EAET, but not relaxation training, significantly reduced IBS symptom severity at 10-week follow-up. Both EAET and relaxation training improved quality of life at follow-up. Finally, EAET did not reduce psychological symptoms, whereas relaxation training reduced depressive symptoms at follow-up (and anxiety symptoms at posttreatment). CONCLUSIONS & INFERENCES: Brief emotional awareness and expression training that targeted trauma and emotional conflicts reduced somatic symptoms and improved quality of life in patients with IBS. This emotion-focused approach may be considered an additional treatment option for IBS, although research should compare EAET to a full cognitive-behavioral protocol and determine which patients are best suited for each approach. Registered at clinicaltrials.gov (NCT01886027).

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Arab migrants-both immigrants and refugees-are exposed to pre- and post- migration stressors increasing their risk for health problems. Little is known, however, about rates of, or factors associated with, healthcare utilization among these two groups. A sample of 590 participants were interviewed approximately 1 year post-migration to the United States. Factors associated with healthcare utilization, including active and passive coping strategies, were examined using logistic regressions. Compared to national healthcare utilization data, immigrants had significantly lower, and refugees had significantly higher rates of healthcare utilization. Being a refugee, being married, and having health insurance were significantly associated with medical service utilization. Among refugees, less use of psychological services was associated with the use of medications and having problem-focused (active) strategies for dealing with stress. Healthcare utilization was significantly higher among refugees, who also reported a greater need for services than did immigrants.

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BACKGROUND: Patients with rheumatic diseases may face 'discounting' (denying and patronising) or 'lack of understanding' because of having symptoms without external clinical signs, but instruments to assess such invalidation experiences are lacking. OBJECTIVES: To develop and evaluate the Illness Invalidation Inventory (3*I), to compare invalidation experiences of two groups of patients who differ in visual signs and laboratory findings-rheumatoid arthritis (RA) and fibromyalgia-and to examine the association of invalidation with health status. METHODS: A questionnaire (eight items with respect to five sources: spouse, family, medical professionals, work environment and social services) was constructed. It was completed by 142 patients with RA and 167 patients with fibromyalgia. RESULTS: Principal axis factoring with oblimin rotation yielded two factors with high internal consistency (α>0.70): 'discounting' (five items) and 'lack of understanding' (three items). Patients with fibromyalgia experienced significantly more discounting and lack of understanding from their family, medical professionals, colleagues and social services than did patients with RA. Both patient groups experienced more invalidation from social services, colleagues and family than from medical professionals and spouses. More discounting and lack of understanding correlated with poorer mental well-being and social functioning in both patient groups. Discounting correlated with more physical disability and pain in patients with RA. CONCLUSIONS: The 3*I is a brief, reliable instrument for assessing patients' perceptions of invalidation from different sources, which differ between patient groups and are associated with health status. Future validation research should clarify the clinical impact of invalidation on treatment adherence and outcome.

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BACKGROUND AND OBJECTIVES: Non-transferrin bound iron (NTBI) is associated with increased morbidity in a number of transfusion-dependent disease states such as the severe haemoglobinopathies. We hypothesized that this may be related to excess NTBI present in plasma-depleted red blood cell units that are free of clear haemolysis. MATERIALS AND METHODS: The level of NTBI was determined using the bleomycin assay in samples from 20 stored plasma-depleted red cell units, at approximate 5-day intervals up to day 33 after donation. Forty units of fresh-frozen plasma (FFP) and 40 units of platelet concentrates were used as negative controls, and samples from 12 units of FFP were also serially assessed. RESULTS: Median [interquartile range (IQR)] NTBI was 0 microm (0-0.35) in samples taken from units 3-10 days after donation. Thereafter, the levels of NTBI increased, becoming significant (median 3.05; IQR: 0.05-6.7 microm) 17-22 days after donation. After 30 days, NTBI was detectable in all red cell units. NTBI was undetectable in platelet concentrates and FFP. CONCLUSIONS: Increased levels of NTBI become detectable 17-22 days after donation and increase further with storage time. This excess NTBI may promote bacterial infection in iron-loaded individuals.

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OBJECTIVE: This study examined associations of two types of optimism (Peterson and Seligman's optimistic explanatory style and Scheier and Carver's dispositional optimism) with each other as well as with symptoms and immune status among human immunodeficiency virus (HIV)-infected men. METHOD: We related both types of optimism to HIV symptoms and to CD4 counts in a cross-sectional study of 78 men, and to change in CD4 counts in a 2-year prospective study of a subsample of these men. RESULTS: Analyses controlled for age, education, employment status, duration since diagnosis, and azidothymidine (AZT) use. The two types of optimism were only minimally related to each other (r=.25). Cross-sectionally, higher levels of both types of optimism were associated with having fewer HIV symptoms, but a more optimistic explanatory style was related to having poorer immune status (lower CD4). Prospectively, an optimistic explanatory style was a substantial predictor of greater decline in CD4 counts after 2 years, after controlling for baseline CD4. Dispositional optimism was unrelated to CD4 counts. Neither health behaviors nor coping strategies mediated these relationships, and the relationships of optimistic explanatory style (and to a lesser extent, dispositional optimism) were independent of negative affectivity. CONCLUSIONS: These optimism measures tap different types of optimism, and although both are related to better subjective health in HIV-infected men, an optimistic explanatory style predicts greater decline in immune status over time. This latter relationship may be related to the unique stress and life experiences associated with having HIV.

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PURPOSE: The NICHD Fetal Cell Isolation Study (NIFTY) was a multicentered project to isolate fetal cells from maternal blood to detect fetal chromosomal abnormalities. The project included a psychosocial component, which is the basis of this article. We examined the attitudes of high-risk pregnant women toward the availability of a maternal blood test to identify fetal chromosomal abnormalities, how women would respond to hypothetical normal and abnormal maternal blood testing results, and the factors associated with a woman's preference to have an invasive procedure in response to a normal maternal blood test. METHODS: High-risk pregnant women (N = 854) planning to have prenatal diagnostic invasive testing (amniocentesis or chorionic villus sampling) completed a survey. RESULTS: The women highly favored maternal blood testing. Almost all women would seek invasive testing after an abnormal blood test. Only half of the women would seek invasive testing after a normal blood test; these women were older, more willing to terminate their pregnancy, and valued the increased accuracy of invasive testing more highly than women who would not have invasive testing after a normal maternal blood test. CONCLUSIONS: Women having invasive diagnostic testing welcome a noninvasive procedure that uses fetal cells in maternal blood, and its availability would decrease invasive testing by approximately 50%. Research needs to examine the attitudes and anticipated responses of other risk groups as well as the effects of information about maternal blood test sensitivity and specificity on attitudes and responses.

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This study examined relationships of stress (negative event frequency during the last year) to reports of illness among 92 children, aged 10 to 13 years. Children's health status was reported separately by children and parents, and children's skill in identifying and communicating their feelings was tested for direct and buffering relationships on illness reports. Analyses controlled for demographics and negative affect of both children and parents, and children's verbal ability was also tested for confounding. Results showed that stress correlated positively with children's poor health, whether the children's health status was reported by children or by parents. Children's emotional skill was correlated with better health when health was reported by children, but with worse health when health was reported by parents. Further, moderator analyses indicated that the relationship between negative event frequency and children's poor health as reported by parents held only for children with high levels of skill in identifying and communicating feelings. These findings suggest that negative life events impair children's health, but that the health reports of children and parents are quite different, and parents' views may be affected by children's skill in communicating their internal states.

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Recently, there has been growing interest in the relation between pain and emotion. Numerous recent studies have been conducted in this area. This article provides an introduction to this interesting area by highlighting selected research topics including studies on: stress and pain, negative emotional states and pain, catastrophizing and pain, the fear of pain, emotional regulation processes and pain, the effects of enhancing emotional regulation on pain, and the relation of emotional distress to treatment seeking in persons having pain. The article concludes with a discussion of important directions for future research in this area.

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OBJECTIVE: This study examined associations between alexithymia and objective characteristics of sleep (latencies, stages, and amount and patterning of REM sleep) that may contribute to subjective reports of poor sleep quality and impaired dream recall among alexithymic people. METHODS: Fifty healthy, normally sleeping adults from the community completed the 20-item Toronto Alexithymia Scale and slept uninterrupted for one night in the laboratory while polysomnography was conducted. Various measures of sleep latency, sleep stages, and REM sleep-related variables were obtained, and analyses correlated these sleep measures with alexithymia, controlling for age, sex, and level of depressed affect. RESULTS: Higher alexithymia scores were significantly related to increased stage 1 (light) sleep and decreased stage 3/4 (deep) sleep. Alexithymia was unrelated to overall sleep efficiency or percentage of stage 2 sleep. Alexithymia was related to more frequent REM episodes and more stage 1 sleep during and immediately after REM episodes but was unrelated to the absolute amount of REM sleep. Alexithymia was also related to an earlier onset of the first REM episode. CONCLUSIONS: Alexithymia is associated with more light sleep and less deep sleep, which may contribute to subjective reports of poor sleep and increased sleepiness, fatigue, and somatic symptoms. Although alexithymia is not associated with an overall reduction of REM sleep, the increased frequency of episodes of REM that are interrupted and followed by light sleep rather than complete awakenings may contribute to limited dream recall.

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PURPOSE: To implement intensity-modulated radiation therapy (IMRT) for primary nasopharynx cancer and to compare this technique with conventional treatment methods. METHODS AND MATERIALS: Between May 1998 and June 2000, 23 patients with primary nasopharynx cancer were treated with IMRT delivered with dynamic multileaf collimation. Treatments were designed using an inverse planning algorithm, which accepts dose and dose-volume constraints for targets and normal structures. The IMRT plan was compared with a traditional plan consisting of phased lateral fields and a three-dimensional (3D) plan consisting of a combination of lateral fields and a 3D conformal plan. RESULTS: Mean planning target volume (PTV) dose increased from 67.9 Gy with the traditional plan, to 74.6 Gy and 77.3 Gy with the 3D and IMRT plans, respectively. PTV coverage improved in the parapharyngeal region, the skull base, and the medial aspects of the nodal volumes using IMRT and doses to all normal structures decreased compared to the other treatment approaches. Average maximum cord dose decreased from 49 Gy with the traditional plan, to 44 Gy with the 3D plan and 34.5 Gy with IMRT. With the IMRT plan, the volume of mandible and temporal lobes receiving more than 60 Gy decreased by 10-15% compared to the traditional and 3D plans. The mean parotid gland dose decreased with IMRT, although it was not low enough to preserve salivary function. CONCLUSION: Lower normal tissue doses and improved target coverage, primarily in the retropharynx, skull base, and nodal regions, were achieved using IMRT. IMRT could potentially improve locoregional control and toxicity at current dose levels or facilitate dose escalation to further enhance locoregional control.

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OBJECTIVE: In two studies, we tested two hypotheses about the relationship of alexithymia to dreaming; that dreams of alexithymic people are barren and rarely recalled, and that the dreams are unregulated and nightmarish. METHODS: Study 1 was a retrospective survey of dreaming among several hundred young adults, and Study 2 was a 1-week, prospective diary study of 153 young adults in which recall, content, and length of dreams were assessed. RESULTS: Across both studies, the externally oriented thinking (EOT) facet of the Toronto Alexithymia Scale (TAS)-20 correlated with different dream characteristics than the difficulty identifying feelings (DIF) and difficulty describing feelings (DDF) facets, even after statistically controlling for the other facets. Greater EOT was related to an increased frequency of nights without dream recall, having shorter dreams, having dreams rated as boring and lacking vividness, and not believing in the importance of dreams. In contrast, greater DIF or DDF was related to an increased frequency of nights with disturbing dreams, and having dreams rated as bizarre and aggressive. CONCLUSION: We find support for both hypotheses, but different facets of the multidimensional alexithymia construct account for the two types of dream reports.

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It has been hypothesized that alexithymia is related to an impairment of the right hemisphere or a deficiency in interhemispheric transfer. We used the Toronto Alexithymia Scale-20 (TAS-20) and the tactile finger localization task of Zeitlin et al. to test these relationships on nonclinical samples of college men and women, and also considered the role of short-term memory. Among 47 men, the TAS-20 facets of difficulty identifying feelings or difficulty describing feelings were correlated with poorer performance by the right compared with the left hemisphere in uncrossed trials and poorer interhemispheric transfer of information on crossed trials; short-term memory was not related. Thus, both hemispheric hypotheses were supported for men. However, among 58 women, alexithymia was completely unrelated to either index of hemispheric functioning; instead, poorer short-term memory (specifically digits backwards) strongly predicted poorer interhemispheric transfer. We conclude that deficiencies in right hemisphere function and interhemispheric transfer may contribute to alexithymia in men, but not in women.

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OBJECTIVE: The absence of angina among patients with silent myocardial ischemia (SMI) may be a cardiac phenomenon or may reflect a generalized lack of bodily awareness and symptom reporting. We tested the hypothesis that the silence is generalized, and, therefore, that patients with SMI would make fewer health care visits for noncardiac/chest-pain problems than patients with symptomatic ischemia. METHODS: We counted all out-patient visits to our medical system for the prior 18 months for 95 patients who demonstrated ischemia during treadmill exercise testing and subsequent nuclear scanning: 62 of the patients had SMI during exercise, and 33 of the patients had symptomatic ischemia. RESULTS: Patients with SMI made were significantly less likely to have sought emergency care or primary care and had significantly fewer primary care visits than patients with symptomatic ischemia. Group differences remained after controlling for demographics and health status variables. The two groups did not differ on utilization of specialty care. CONCLUSION: The reduced use of emergency and primary care among patients with SMI suggests that they have a generalized rather than cardiac-specific reduction in somatic awareness and/or symptom reporting.

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Research on psychogenic nonepileptic seizures (PNES) has focused on childhood abuse, but less is known about other stressors and psychosocial risk factors. The authors compared 25 patients with PNES with 33 control subjects with epilepsy on stressful life events and other risk factors for somatoform disorders. Compared with control subjects, patients with PNES reported significantly more prevalent and stressful negative life events (including adulthood abuse) and more current rumination, stress-related diseases, somatic symptoms, bodily awareness, and marginally more anxiety and depression. However, the relationship of many of these variables to PNES was accounted for by life stress. Groups did not differ on illness worry, alexithymia, or psychotic symptoms. The results suggest that PNES are part of a larger pattern of somatic symptoms responses to a wide range of negative events, including stress in adulthood.

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Archaeological excavations at the site of Dmanisi in the Republic of Georgia have uncovered two partial early Pleistocene hominid crania. The new fossils consist of a relatively complete cranium and a second relatively complete calvaria from the same site and stratigraphic unit that yielded a hominid mandible in 1991. In contrast with the uncertain taxonomic affinity of the mandible, the new fossils are comparable in size and morphology with Homo ergaster from Koobi Fora, Kenya. Paleontological, archaeological, geochronological, and paleomagnetic data from Dmanisi all indicate an earliest Pleistocene age of about 1.7 million years ago, supporting correlation of the new specimens with the Koobi Fora fossils. The Dmanisi fossils, in contrast with Pleistocene hominids from Western Europe and Eastern Asia, show clear African affinity and may represent the species that first migrated out of Africa.

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To investigate the hypothesis that commercial kits for CFU-GM (colony forming unit granulocyte-macrophage) assay will reduce the interlaboratory variation noted by many workers, we carried out a quality assurance exercise in 2 parts. There were 8 participants in the first study and each performed CFU-GM assays using their in-house method and a commercial kit (Stem Cell CFU Kit, Gibco) in parallel. In the second exercise there were 10 participants and each performed CFU-GM with in-house methods and with a different commercial medium (Methocult GF H4534, Stem Cell Technologies). Twelve samples of cryopreserved peripheral blood progenitor cells (PBPC) were analysed by each participant in each part of the study. A very wide range of results was found for the different in-house methods, but standardizing the clonogenic assay with the commercial kits did not reduce the variation seen. To improve the reproducibility of CFU-GM assays between laboratories, scrupulous attention should be paid to all the steps involved in the assays, as little progress will be made by using commercial medium in isolation from efforts to reduce other sources of variation.

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Two studies investigated the nature of nervous breakdown (NB): a mental illness commonly referred to by individuals not professionally related to the field of mental health. The clinical profile of NB was first surveyed among 121 undergraduates using a symptom checklist. Descriptive statistics and analysis of variance indicated NB is a time-limited condition that presents with primarily anxious and depressed features, associated with a series of external precipitating stressors (e.g., interpersonal, employment, and financial losses). Dimensions significantly uncharacteristic of NB included psychoticism, somatization, phobic anxiety, and mania. These results were replicated in a community sample of 189 adults from urban and suburban areas of a large metropolitan city. Respondents held a relatively unitary view of NB: Combined-sample cluster analysis (N = 310) revealed 2 groups with similar symptom profiles that differed primarily with regard to level of distress associated with disorder. Thus, among this population, NB is not an amorphous term for generalized psychiatric disturbance.

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OBJECTIVE: Ethnic groups may experience or report pain differently; thus, we compared ethnic differences on pain coping strategies and control beliefs, and the relationships of these variables to health status, among women with rheumatoid arthritis (RA). METHODS: Using a sample of 100 women (48 African-American, 52 Caucasian), we related pain coping strategies and control beliefs to pain severity, activity levels, and affective state, controlling for socioeconomics, behavioral impairment, and disease activity. RESULTS: Ethnic groups did not differ in pain severity or negative affect, but African-Americans were less physically active. African-Americans used more coping techniques involving diverting attention and praying/hoping; Caucasians used more coping techniques involving ignoring pain. The relationships of praying/hoping and reinterpreting pain to RA adjustment differed by ethnic group. In contrast, ignoring pain, coping statements, and stronger control beliefs predicted better health status, and diverting attention predicted more pain for all patients. CONCLUSION: There are ethnic differences in the use of coping strategies that should be acknowledged when helping RA patients cope with their disease, but control beliefs and several coping strategies predict pain and adjustment, regardless of ethnicity.

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