Health Psychology

Time to abandon small-sample cohort research in health psychology?
Comments on the original article, "Avoidant coping as a predictor of mortality in veterans with end-stage renal disease" by E. J. Wolf and D. L. Mori (see record 2009-06704-009), in which the authors report that among 61 patients with endstage renal disease (ESRD), avoidant coping more than doubled the odds of mortality in multivariable analysis. The authors concluded that evaluating coping style in patients with ESRD would be clinically useful and that interventions targeting avoidant coping should be investigated. In this commentary, the current authors note that Wolf and Mori’s (2009) finding was based on a sample where only 23 patients died over 9 years, and results were evaluated using a Cox regression model with six covariates, a ratio of only 3.8 outcome events per variable—well below recommended thresholds (e.g., Babyak, 2004; Peduzzi et al., 1995). Beyond this, the model did not assess key variables typically included in studies of ESRD outcomes (e.g., transplant status, cardiovascular problems). Wolf and Mori chose to focus on the relationship between avoidant coping and mortality. However, bivariable correlations and confidence intervals reported or generated from data in the article showed that the association between avoidant coping and mortality (r=.28, 95% CI [.03 to .50]) was not significantly stronger than two other correlations that were in the opposite direction of what would have been expected: hypertension with mortality (r=−.39, 95% CI [−.15 to −.59]) and medication compliance with mortality (r=.16, 95% CI [−.10 to .40]). Oddities of this sort are often encountered in very small datasets and, as a result, stronger evidence must be accrued from larger, more robust samples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
"Avoidant coping as predictor of mortality in veterans with end-stage renal disease": Response to Jewett, Newton, Smith, & Thombs (2010).
Responds to the comments by L. R. Jewett, E. G. Newton, S. Smith, and B. D. Thombs (see record 2010-14873-001) on the current authors' original article, "Avoidant coping as predictor of mortality in veterans with end-stage renal disease" (see record 2009-06704-009). In their commentary, Jewett et al note that oddities often encountered in very small datasets—such as the one used by Wolf and Mori—and, as a result, stronger evidence must be accrued from larger, more robust samples. In this response, Jewett et al acknowledge that theirs is a preliminary study of a small and highly select sample and recognize the limited generalizability of our results. Jewett et al maintain that they do not assert that there should be radical changes in clinical or research programs based on their study results, but instead, suggest that further follow-up would be valuable and that readily available and commonly used assessment and intervention procedures may be appropriate in ameliorating avoidant coping in the endstage renal disease (ESRD) population. At the same time, given the focus on mortality, the risk of doing nothing because the evidence is preliminary far outweighs the minimal costs associated with assessing and addressing avoidant coping, particularly since psychological assessment, including of coping behavior, is part of the standard of practice in this population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Predicting distress-induced eating with self-reports: Mission impossible or a piece of cake?
Comments on the original article, "Assessing yourself as an emotional eater: Mission impossible?" by C. Evers, D. T. D. de Ridder, and M. A. Adriaanse (see record 2009-20990-009). Results of a functional MRI study (Bohon, Stice, & Spoor, 2009) contradict the assertion that it is "impossible" to self-assess emotional eating because the self-report emotional eating scale of the Dutch Eating Behavior Questionnaire (DEBQ-em) predicted important individual differences in reward response during negative moods. Evers et al advance their argument in the context of results of four experiments where self-reported “emotional eaters” (DEBQ-em) did not eat more food during emotional encounters as compared to control conditions or “no emotional eaters.” However, the core characteristic of emotional eaters is not that they eat so much during distress (though binge eaters may do), but that they do not show the typical stress response of eating less (the typical stress response being loss of appetite because of physiological effects that mimic satiety) (Gold & Chrousos, 2002). Accordingly, the moderator effect of emotional eating during distress would be that. “No emotional eaters” eat less and “emotional eaters” eat the same or more compared to control conditions. Close inspection of the results of Evers et al reveals that their “no emotional eaters” did not show the typical stress response of eating less. This opens the possibility that the null findings of Evers et al may be simply explained by misclassification of “no emotional eaters” versus “emotional eaters” because of their use of median splits (a procedure notorious for possible misclassification of subjects into distinct groups). (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Adequately predicting emotional eating with self-reports: Not as easy as pie.
Responds to the comments by T. van Strien (see record 2010-14873-003) on the current authors' original article, "Assessing yourself as an emotional eater: Mission impossible?" (see record 2009-20990-009). In her commentary, van Strien suggests that it may not be "impossible" to self assess for emotional eating, as a close inspection of the results of Evers et al reveals that their “no emotional eaters” did not show the typical stress response of eating less. This opens the possibility that the null findings of Evers et al may be simply explained by misclassification of “no emotional eaters” versus “emotional eaters” because of their use of median splits (a procedure notorious for possible misclassification of subjects into distinct groups). In this reply Evers et al address this criticism and other critiques of their study, and conclude that their results are in line with studies that have indicated that self-assessed emotional eating may reflect beliefs about emotional eating rather than one’s actual eating behavior when being emotional. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Increased attention but more efficient disengagement: Neuroscientific evidence for defensive processing of threatening health information.
Objective: Previous studies indicate that people respond defensively to threatening health information, especially when the information challenges self-relevant goals. The authors investigated whether reduced acceptance of self-relevant health risk information is already visible in early attention processes, that is, attention disengagement processes. Design: In a randomized, controlled trial with 29 smoking and nonsmoking students, a variant of Posner's cueing task was used in combination with the high-temporal resolution method of event-related brain potentials (ERPs). Main Outcome Measures: Reaction times and P300 ERP. Results: Smokers showed lower P300 amplitudes in response to high- as opposed to low-threat invalid trials when moving their attention to a target in the opposite visual field, indicating more efficient attention disengagement processes. Furthermore, both smokers and nonsmokers showed increased P300 amplitudes in response to the presentation of high- as opposed to low-threat valid trials, indicating threat-induced attention-capturing processes. Reaction time measures did not support the ERP data, indicating that the ERP measure can be extremely informative to measure low-level attention biases in health communication. Conclusion: The findings provide the first neuroscientific support for the hypothesis that threatening health information causes more efficient disengagement among those for whom the health threat is self-relevant. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Communication neuroscience as a tool for health psychologists.
Comments on the original article, "Increased attention but more efficient disengagement: Neuroscientific evidence for defensive processing of threatening health information" by L. T. E. Kessels, R. A. C. Ruiter, and B. M. Jansma (see record 2010-14873-005). Kessler et al present an example of Communication Neuroscience as a tool for understanding the mechanisms that lead some health messages to be processed in a way that facilitates impact whereas other messages are ignored. Kessels et al used event-related brain potentials (ERPs), a high temporal resolution method, to monitor neural activity in the moment that messages are presented. They use this technology to provide insight about the low-level attention processes through which individuals at highest risk (in this case, smokers) disengage from self-relevant health messages (threatening and nonthreatening smoking images). The findings of Kessels et al are convergent with prior theory and empirical work demonstrating that high threat messages may not achieve the desired effect if presented in isolation (Brown & Locker, 2009; Leventhal, Safer, & Panagis, 1983; Liberman & Chaiken, 1992). By using the tools of neuroscience, however, Kessels et al elucidate a mechanism that was not apparent through self-report or implicit (reaction time) measures. They demonstrate that high threat messages lead to increased attention capture, but more efficient disengagement when threatening messages are self-relevant; this in turn helps to explain why high threat messages may not have the desired effect, despite successfully capturing people’s attention. As such, this study illustrates one benefit of combining the tools of neuroscience with more familiar methods in health psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Effect of high-dose nicotine patch on the characteristics of lapse episodes.
Objective: Nicotine patch improves treatment outcomes, but lapses are still common. To understand the process of relapse on patch, we investigated differences in the antecedents (withdrawal, setting, triggers) of lapse episodes experienced on high-dose (35 mg) nicotine patches versus placebo. Design: Participants were smokers who lapsed during a randomized, double-blind trial of active patches (n = 100) versus placebo (n = 85). Participants used electronic diaries to monitor their smoking, affect, and activities in real time for 5 weeks during their cessation attempt. Results: We analyzed 490 lapse episodes (active: 266; placebo: 224). Lapses on nicotine patch were characterized by significantly lower positive affect and higher negative affect than placebo lapses. Participants treated with high-dose patch were also significantly more likely to lapse in situations involving little or no craving. Situational antecedents of lapses on patch resembled those on placebo. Conclusion: The results suggest that treatment with patch may set a higher threshold for affective stimuli to provoke lapses, but does not change the proximal cues that trigger lapses. This suggests that behavioral relapse-prevention strategies developed for unmedicated smokers should also apply to those treated with nicotine patch. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Need for cognition as a predictor and a moderator of outcome in a tailored letters smoking cessation intervention.
Objective: To analyze whether baseline need for cognition (NFC) was a predictor or a moderator of treatment outcome in a tailored letters intervention for smoking cessation. Design: A total of 1,499 daily smokers were recruited from general medical practices in Germany within a quasi-randomized trial testing the efficacies of two brief interventions for smoking cessation: (a) computer-generated tailored letters and (b) physician-delivered brief counseling versus assessment-only. For this study, we used data from 1,097 daily smokers who were assigned to the tailored letters or the assessment-only condition. Main Outcome Measures: self-reported 6-month prolonged abstinence from tobacco smoking assessed at 12-, 18-, and 24-month follow-ups, and smoking cessation self-efficacy assessed at 6- and 24-month follow-ups. Results: Baseline NFC predicted 6-month prolonged smoking abstinence (p = .01) and smoking cessation self-efficacy (p .05) but on smoking cessation self-efficacy (p = .05). Tailored letters resulted in higher smoking cessation self-efficacy only for persons with higher NFC. Conclusion: Higher levels of NFC are required to increase smoking cessation self-efficacy in computer-tailored interventions for smoking cessation. Considering an individual's NFC might improve the efficacy of written interventions for smoking cessation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
The automatic component of habit in health behavior: Habit as cue-contingent automaticity.
Objective: Habit might be usefully characterized as a form of automaticity that involves the association of a cue and a response. Three studies examined habitual automaticity in regard to different aspects of the cue-response relationship characteristic of unhealthy and healthy habits. Design, Main Outcome Measures, and Results: In each study, habitual automaticity was assessed by the Self-Report Habit Index (SRHI). In Study 1 SRHI scores correlated with attentional bias to smoking cues in a Stroop task. Study 2 examined the ability of a habit cue to elicit an unwanted habit response. In a prospective field study, habitual automaticity in relation to smoking when drinking alcohol in a licensed public house (pub) predicted the likelihood of cigarette-related action slips 2 months later after smoking in pubs had become illegal. In Study 3 experimental group participants formed an implementation intention to floss in response to a specified situational cue. Habitual automaticity of dental flossing was rapidly enhanced compared to controls. Conclusion: The studies provided three different demonstrations of the importance of cues in the automatic operation of habits. Habitual automaticity assessed by the SRHI captured aspects of a habit that go beyond mere frequency or consistency of the behavior. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Goal priming and eating behavior: Enhancing self-regulation by environmental cues.
Objective: Several lines of research have shown that the confrontation with attractive food can trigger overeating, especially in restrained eaters. This effect may be driven by a hedonic orientation toward food which temporarily overrules the goal of dieting in the regulation of behavior. The present study was designed to provide an experimental demonstration of this effect in a naturalistic setting, and to show that reactivating the goal of dieting by a subtle prime in the environment can help restrained eaters to regulate their eating behavior in tempting situations. Design: In a local store where the smell of grilled chicken was present, we observed the number of free meat snacks customers sampled from a tray after they had been primed with the dieting goal or not. Main Outcome Measures: Number of snacks consumed. Results: Consistent with hypotheses, restrained eaters ate more than unrestrained eaters in the control condition. However, they reduced their eating behavior when primed with dieting, whereas this manipulation did not affect unrestrained eaters. Conclusion: This study shows that unobtrusively priming the goal of dieting can enhance self-regulation in tempting eating situations. These results are discussed in the context of recent advances in our understanding of nonconscious behavior regulation and their applications to health behavior. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Control yourself or just eat what you like? Weight gain over a year is predicted by an interactive effect of response inhibition and implicit preference for snack foods.
Objective: Previous research showed a strong relation between response inhibition, overeating and overweight. It was shown that people with ineffective response inhibition are more susceptible to the temptations of palatable food, eat more and are more often overweight or obese. In addition the results of several studies suggest that what needs to be inhibited may be an affect-driven motivation for food. In the present longitudinal study, we therefore investigated the interplay of response inhibition and implicit preferences for snack foods in predicting weight gain. Design: In a sample of predominantly normal weight undergraduate female students, implicit preference for food, response inhibition, and body mass index (BMI) were measured. After 1 year, BMI was measured again. Main Outcome Measures: Weight gain of the participants over a 1-year period. Results and Conclusions: The results strongly confirmed our expectations: participants with strong implicit preferences for snack foods and low inhibitory capacity gained the most weight. These findings imply that ineffective response inhibition may render people vulnerable to excessive or impulsive behavior in general, but that the manifestation thereof is determined by domain-specific preferences or needs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Daily stress, cortisol, and sleep: The moderating role of childhood psychosocial environments.
Objective: The purpose of this study was to explore whether childhood family environments moderated the relation between daily stress and daily biological outcomes (sleep, cortisol output) in healthy young adults. Design: There were 87 participants, ages 19 to 25 who provided information on characteristics of their childhood family environment (conflict, parental warmth). Main Outcome Measures: For 1 week they completed a daily stress checklist via electronic diary, provided salivary cortisol samples 4 times a day, and wore an Actiwatch to measure sleep (minutes, efficiency). Data was analyzed using hierarchical linear modeling. Results: Family risk significantly moderated the relation between daily number of stressors and sleep minutes (b = −12.10, p = .02), such that the more difficult one's childhood environment, the less sleep individuals got on days in which they experienced a greater number of stressors. Parental warmth moderated the relation between stress severity and cortisol output (b = −0.19, p = .04), such that the less parental warmth individuals received during childhood, the more cortisol they secreted on days that they experienced more severe stress. Conclusions: The childhood psychosocial environment may have long-term effects on biological responses to daily stress, creating vulnerability to disease in individuals from difficult childhoods. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
The effects of perceived discrimination on ambulatory blood pressure and affective responses to interpersonal stress modeled over 24 hours.
Objective: This research examined the impact of perceived discrimination on ambulatory blood pressure (ABP) and daily level affect during social interaction. Design: For 24 hrs, adult Black and White participants wore an ABP monitor and completed palm pilot diary entries about their social interactions. Main Outcome Measures: Mean level and time-trend trajectories of blood pressure and heart rate were examined as well as mean level measures of positive and negative affect after stressful and nonstressful social interactions. Results: Analyses showed that, after controlling for important covariates, perceived discrimination predicted the slopes of both wake and nocturnal ABP responses, with those who reported more discrimination having steeper daytime trajectories for systolic and diastolic blood pressure and less nighttime dipping in heart rate over time as compared to those who had reported relatively infrequent discrimination. High levels of perceived discrimination were also related to positive and negative affective responses after stressful encounters. Conclusions: These results suggest that, regardless of race, perceived discrimination is related to cardiovascular and affective responses that may increase vulnerability to pathogenic processes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Mastery is associated with cardiovascular disease mortality in men and women at apparently low risk.
Objective: We examine the prospective relationship between mastery, where limited mastery is defined as the inability to control negative emotions (and perceiving stressful experiences as beyond personal control), and cardiovascular disease (CVD) mortality particularly among individuals at apparently low CVD risk. Design: Prospective population-based study of 19,067 men and women, aged 41–80 years with no previous heart disease or stroke at baseline assessment. Main Outcome Measures: Primary outcome measure CVD mortality. Results: A total of 791 CVD deaths were recorded up to June 2009 during a median 11.3 person-years of follow-up. Limited perceived mastery over life circumstances was associated with an increased risk of CVD mortality, independently of biological, lifestyle, and socioeconomic risk factors (hazard ratio 1.11 per SD decrease in mastery score, 95% confidence interval 1.01–1.21). This association was more pronounced among those participants apparently at low CVD risk (p = .01 for test of interaction according to the number of CVD risk factors at baseline). Conclusions: Limited perceived control over life circumstances is associated with an increased risk of CVD mortality, independently of classical cardiovascular risk factors, and particularly among those at apparently low risk. Future attention should be given to this potentially modifiable personal characteristic, through the design of preliminary intervention studies, to reduce cardiovascular risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Electronic monitoring-based counseling to enhance adherence among HIV-infected patients: A randomized controlled trial.
Objective: To investigated the effectiveness of an adherence intervention (AIMS) designed to fit HIV-clinics' routine care procedures. Design: Through block randomization, patients were allocated to the intervention or control group. The study included 2 months baseline measurement, 3 months intervention, and 4 months follow-up. HIV-nurses delivered a minimal intervention (“adherence sustaining”) to patients scoring >95% adherence at baseline, and an intensive intervention (“adherence improving”) to patients with
Interplay of concurrent positive and negative interpersonal events in the prediction of daily negative affect and fatigue for rheumatoid arthritis patients.
Objective: The purpose of this study was to examine the interaction of daily concurrent positive interpersonal events (PIE) and negative interpersonal events (NIE) on the daily experience of negative affect and fatigue in a sample of men and women with rheumatoid arthritis. Two hypotheses were made. The blunting hypothesis predicted that NIE would nullify the beneficial influence of PIE on outcome measures, and the buffering hypothesis predicted that PIE would offset the adverse influence of NIE. Design: Participants completed up to 30 consecutive daily diaries. Multilevel modeling was used to examine the day-to-day dependencies among study variables. Main Outcome Measures: The primary outcomes were daily negative affect and fatigue. Results: In support of the blunting hypothesis, on days when NIE were diminished, PIE were associated with a greater reduction in fatigue. In contrast, consistent with the buffering hypothesis, on days when PIE were elevated, NIE were associated with a lesser increase in negative affect. Conclusion: The examination of concurrent PIE and NIE provides a unique perspective on the role of interpersonal events in affective and physiological outcomes, beyond that which can be gained from the examination of either type of event in isolation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
The impact of social comparison information on motivation in patients with diabetes as a function of regulatory focus and self-efficacy.
Objective: Our aim was to determine whether the impact of upward and downward social comparison information on individuals' motivation to manage their diabetes is dependent on their regulatory focus (promotion or prevention focus) and self-efficacy. Design: The hypotheses were examined in a cross-sectional study. Patients with diabetes (N = 234) read a fictitious interview with a fellow patient, either an upward or a downward target, and they filled out questionnaires. Main Outcome Measures: Motivation to work on diabetes regulation. Results: High promotion-focused patients reported more motivation than low promotion-focused patients when confronted with the upward target (positive role model). High prevention-focused patients reported more motivation than low prevention-focused patients when confronted with the downward target (negative role model). This latter finding was qualified by patients' self-efficacy, as it applied only to patients with relatively high levels of self-efficacy. Conclusion: The current study highlights the importance of considering individual differences when using role models to encourage self-care activities in persons with diabetes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Associations between adult attachment ratings and health conditions: Evidence from the National Comorbidity Survey Replication.
Objective: Attachment insecurity has been hypothesized to be a risk factor for the development of disease and chronic illness. This study was the first to investigate associations between adult attachment ratings and a wide range of health conditions. Design: Cross-sectional data from the National Comorbidity Survey Replication (N = 5645) were used. Measures: Participants completed Hazan and Shaver's (1987) measure of adult attachment and provided reports regarding 15 health conditions. Results: Logistic regression analyses that adjusted for demographic variables indicated that avoidant attachment ratings were positively associated with conditions defined primarily by pain (e.g., frequent or severe headaches). Anxious attachment ratings were positively associated with a wider range of health conditions, including several involving the cardiovascular system (i.e., stroke, heart attack, high blood pressure). Secure attachment ratings were unrelated to the health conditions. Additional analyses investigated whether the attachment ratings accounted for unique variance in the health conditions beyond that accounted for by lifetime histories of depressive, anxiety, and alcohol- or substance-related disorders. In these analyses, anxious attachment ratings continued to have significant positive associations with chronic pain, stroke, heart attack, high blood pressure, and ulcers. Conclusion: The findings were generally supportive of the theory that insecure attachment is a risk factor for the development of disease and chronic illness, particularly conditions involving the cardiovascular system. Further research regarding the role of attachment in the development of specific health conditions is warranted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Choice, numeracy, and physicians-in-training performance: The case of Medicare Part D.
Objective: In this study, we examined the effect of choice-set size and numeracy levels on a physician-in-training's ability to choose appropriate Medicare drug plans. Design: Medical students and internal medicine residents (N = 100) were randomly assigned to 1 of 3 surveys, differing only in the number of plans to be evaluated (3, 10, and 20). After reviewing information about stand-alone Medicare prescription drug plans, participants answered questions about what plan they would advise 2 hypothetical patients to choose on the basis of a brief summary of the relevant concerns of each patient. Participants also completed an 11-item numeracy scale. Main outcome measure: Ability to answer correctly questions about hypothetical Medicare Part D insurance plans and numeracy levels. Results: Consistent with our hypotheses, increases in choice sets correlated significantly with fewer correct answers, and higher numeracy levels were associated with more correct answers. Hence, our data further highlight the role of numeracy in financial- and health-related decision making, and also raise concerns about physicians' ability to help patients choose the optimal Part D plan. Conclusion: Our data indicate that even physicians-in-training perform more poorly when choice size is larger, thus raising concerns about the capacity of physicians-in-training to successfully navigate Medicare Part D and help their patients pick the best drug plan. Our results also illustrate the importance of numeracy in evaluating insurance-related information and the need for enhancing numeracy skills among medical students and physicians. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
A randomized controlled trial of emotionally expressive writing for women with metastatic breast cancer.
Objective: To test the effects of emotionally expressive writing in a randomized controlled trial of metastatic breast cancer patients and to determine whether effects of the intervention varied as a function of perceived social support or time since metastatic diagnosis. Design: Women (N = 62) living with Stage IV breast cancer were randomly assigned to write about cancer-related emotions (EMO; n = 31) or the facts of their diagnosis and treatment (CTL; n = 31). Participants wrote at home for four 20-min sessions within a 3-week interval. Main Outcome Measures: Depressive symptoms, cancer-related intrusive thoughts, somatic symptoms, and sleep quality at 3 months postintervention. Results: No significant main effects of experimental condition were observed. A significant condition × social support interaction emerged on intrusive thoughts; EMO writing was associated with reduced intrusive thoughts for women reporting low emotional support (η2 = .15). Significant condition × time since metastatic diagnosis interactions were also observed for somatic symptoms and sleep disturbances. Relative to CTL, EMO participants who were more recently diagnosed had fewer somatic symptoms (η2 = .10), whereas EMO participants with longer diagnosis duration exhibited increases in sleep disturbances (η2 = .09). Conclusion: Although there was no main effect of expressive writing on health among the current metastatic breast cancer sample, expressive writing may be beneficial for a subset of metastatic patients (including women with low levels of emotional support or who have been recently diagnosed) and contraindicated for others (i.e., those who have been living with the diagnosis for years). (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Health Psychology - Vol 29, Iss 4