Negative emotions and health: Why do we keep stalking bears, when we only

find scat in the woods?

Presentation at European Health Psychology Society Conference, Innsbruck, Austria, September 2014

James C. Coyne, PhDProfessor Emeritus, University of Pennsylvania

Professor, University of Groningen, University Medical Center Groningen (UMCG), The Netherlands

  

For over half a century, researchers in psychosomatic medicine have stalked an elusive trophy bear, a modifiable connection between negative emotion and morbidity and mortality.

Claims of finding one have attract considerable attention again and again, only to lead to embarrassing disconfirmations.

We are witnessing the demise of Type D personality as latest contender, but

more await promoting.

Depressive symptoms linked to

Death, dementia, coronary artery disease, cancer, asthma, diabetes, Parkinson’s disease, COPD, headaches, insomnia, acne, health problems after pregnancy, lower back pain, anorgasmia, premature ejaculation, impotence, hypertension, HIV viral load, poor glycemic control, constipation, diarrhea, nausea, chronic pelvic pain, incontinence, …and flatulence.

The National Heart Lung and Blood Institute ENRICH-D trial was an expensive attempt to show we could save cardiac patients from re-infarction and death by improving the outcome of their depression.

Clinical depression was the identified bear.

But in hindsight, ENRICH-D does not seem to have been on the trail of a bear. Maybe was just making too much of scat in the woods.

Bear (Bär) Scat (Scat)

ENRICH-D presumed clinical depression was the long sought bear-modifiable risk factor. 

Target may only have been scat on the trail—uniformative risk marker. 

Shooting scat does not reduce mortality associated with the illusive bear. .

Key Distinction

Modifiable Risk Factor

Versus

Uninformative Risk Marker

When the first outbreak of AIDS occurred in San Francisco

It was observed that the afflicted men were more likely to have Judy Garland records than nonafflicted men.

When the first outbreak of AIDS occurred in San Francisco

It was observed that the afflicted men were more likely to use poppers than nonafflicted men.

May cause asphyxia, arrhythmias, cardiovascular depression, carbon monoxide poisoning, hepatorenal toxicity, methemoglobinemia, neurologic and pulmonary dysfunction, mucosal, skin irritation and facial dermatitis and are immunosuppressive.

Alkyl Nitrate PoppersAlkyl Nitrate Poppers

But destroying Judy Garland LPs or banning poppers would not reduce the risk of HIV/AIDS.

Not modifiable risk factors.

The Flavor of the month

A recent fad is to identify PTSD-like symptoms, not depressive symptoms as a risk for negative outcomes after a coronary event. Some groups turn out cookie-cutter copies of a basic correlational design with no evidence of causality.

Use of the nonspecific Impact of Events Scale adds problems to the already poor quality research.

Another widely used but invalid measure

Hospital Anxiety and Depression Scale.

Please take a look at the items, reverse wording, reverse and variable response keys, and limite content validity before using!

Hospital Anxiety and Depression Scale

Applications of different factor analytic techniques fail to identify separate anxiety and depression subscales,

At best, the items of the HADS converge on a single general distress factor.

Problems with HADS in translation. Patients unable to follow changes in

response keys, direction of items.

Coyne JC, van Sonderen E: The Hospital Anxiety and Depression Scale (HADS) is dead, but like Elvis, there will still be citings. Journal of Psychosomatic Research. 73:77-78.

Meehl (1990) applied “crud factor” to the broader tendency of self-reported negative factors to be correlated in ways that cannot readily be unambiguously differentiated. 

Ketterer MW, Denollet J, Goldberg AD, McCullough PA, John S, Farha AJ, et al. The big mush: psychometric measures are confounded and non-independent in their association with age at initial diagnosis of Ischaemic Coronary Heart Disease. J Cardiovasc Risk 2002; 9(1): 41-48.

Lesperance and Frasure-Smith

Denollet et al. added a new term – the distressed personality (Type D) – to a field congested with related concepts including type A personality, anger and hostility, psychological stress, vital exhaustion, major depression, depressive symptoms, and social isolation. Each of these concepts enjoyed a period of prime time exposure following publication of one or more epidemiological reports linking it to mortality in patients with CHD and then declined in popularity.…

John Ioannidis

Most “discoveries” in biomedical literature are premature, exaggerated, or simply false.

Apparent discoveries are created and perpetuated by a combination of confirmatory bias, flexible rules of design, data analysis and reporting, and significance chasing.

Beware of unexpected large findings from small samples.

The psychological sciences may be particularly susceptible because many of the psychological variables and outcomes measured and analyzed are often convoluted, complex, and highly correlated.

There is large flexibility in definitions, uses of cut-offs, modeling, and statistical handling of the data, hence large room for exploratory analyses.

John Ioannidis (2012)

Obliged replication: Proponents of dominant view are so strong in controlling the publication venues that they can largely select and mold the results, wording, and interpretation of studies eventually published.

John MacLeod and George Davey Smith

Challenge of distinguishing causal influence of negative affect from other negative environmental and physical health variables.

 High likelihood of noncausal relationships generated by confounding between self-reported negative affect and physical health outcomes.

 Residual confounding often impossible to rule out.

Plausible biological mechanism can almost always be cited, so not a good way of excluding spurious findings.

Statistical Controls

Using statistical controls to rule out spurious relationships depends on

Knowing all the relevant variables to control as “confounds.”

Measuring these variables perfectly.

Breslow N. Design and analysis of case–control studies. Annual Rev Public Health 1982; 3:29-54.

“Statistical adjustment by an excessive number of variables or parameters, uninformed by substantive knowledge (e.g. lacking coherence with biologic, clinical, epidemiological, or social knowledge)…can obscure a true effect or create an apparent effect when none exists.”

Hans Ormel -- Neuroticism: a non-informative marker of vulnerability

Broad set of items describing anxiety, insecurity, irritability, anger, hostility, worry, depression, frustration, self-consciousness, emotionality, sensitivity to criticism, stress reactivity, and impulsiveness.

Hans Ormel -- Neuroticism: a non-informative marker of vulnerability

Prospective studies of associations of neuroticism with mental health outcomes are basically futile, and largely tautological since scores on any characteristic with substantial within-subject stability will predict, by definition, that characteristic and related variables at later points in time.

“Negative emotion predicts mortality”

Another unexpected large effect from small study? Really?

Flexible rules of collecting, analyzing interpreting data?

Spurious association convincingly ruled out?

Only that negative emotion?

What if you add or subtract covariates in sensitivity analysis?

Risk factor or uninformative risk indicator?

What’s wrong with continuing to stalk the bear?

Continued embarrassment, decreased credibility

Squandering of research and clinical resources

Denigrating of genuine accomplishments of behavioral medicine in terms of reducing behavioral risk factors

AvaIIable distorted by obliged replication Bad message to junior scientists

The effective end to confusing scat with a bear?

Making Spurious Claims

Should become more difficult or at least more detectable with pre-registration of hypotheses and analytic plans (including specification of covariates, as well as required availability of data for reanalysis.