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1.  Reviewer acknowledgement 2014 
Contributing reviewers
The BioPsychoSocial Medicine editorial team would like to thank the following colleagues who contributed to peer review for the journal in Volume 8 (2014).
doi:10.1186/s13030-015-0033-5
PMCID: PMC4324041
2.  Effect of prolonged stress on the adrenal hormones of individuals with irritable bowel syndrome 
Background
The purpose of this study was to investigate the effect of prolonged stress on the salivary adrenal hormones (cortisol, dehydroepiandrosterone [DHEA], DHEA-sulfate [DHEA-S]) of individuals with irritable bowel syndrome (IBS).
Methods
The participants were female college students, including 10 with IBS and 16 without IBS (control group), who were scheduled for a 2-week teaching practice at a kindergarten. Participants were asked to collect saliva for determining adrenal hormones immediately and 30 min after awakening and before sleep, 2 weeks before the practice, the first week of the practice, the second week of the practice, and a few days after the practice.
Results
Regarding cortisol/DHEA ratio, significantly increased levels were found during the first week of the practice, and a significant interaction between group and time was found; the ratio at 30 min after awakening in the IBS group was higher than that in the control group. For the other adrenal hormone indexes, no significant differences due to the presence of IBS were found.
Conclusions
Individuals with IBS showed an elevated cortisol/DHEA ratio after awakening compared with individuals without IBS, and the elevated ratio peaked under the prolonged stress. The present study suggests that the cortisol effect is dominant in individuals with IBS under prolonged stress.
doi:10.1186/s13030-015-0031-7
PMCID: PMC4308893  PMID: 25632298
Irritable bowel syndrome; Cortisol; Dehydroepiandrosterone; Saliva; Prolonged stress
3.  Psychosocial factors are preventive against coronary events in Japanese men with coronary artery disease: The Eastern Collaborative Group Study 7.7-year follow-up experience 
Background
The Japanese Coronary-prone Behaviour Scale (JCBS) is a questionnaire developed by the Eastern Collaborative Group Study (ECGS), a multi-centre study of coronary-prone behaviour among Japanese men. Subscale C of the JCBS consists of 9 items that have been independently associated with the presence of coronary artery disease (CAD) in patients undergoing coronary angiography (CAG). There have been no reports of a relationship between any behavioural factor and the prognosis of CAD in Japan. The purpose of the current study was to investigate behavioural correlations with the prognosis of CAD as a part of the ECGS.
Methods
We examined the mortality and coronary events of 201 men (58 ± 10, 27-86 years) enrolled in the ECGS from 1990 to 1995, who underwent diagnostic coronary angiography and were administered the JCBS and the Japanese version of the Jenkins Activity Survey (JAS) Form C. Their health information after CAG was determined by a review of their medical records and by telephone interviews that took place from 2002 to 2003.
Results
Cardiac events during the follow-up period (7.7 ± 4.2 years) included 13 deaths from CAD, 25 cases of new-onset myocardial infarction, 26 cases of percutaneous coronary intervention, and 19 cases of coronary artery bypass graft surgery. There was no difference in established risk factors between groups with and without cardiac events. Seven factors were extracted by principal component analysis in order to clarify which factors were measured by the JCBS. Stepwise multivariate Cox-hazard regression analysis, in which 9 standard coronary risk factors were forced into the model, showed that Factor 4 from the JCBS (namely, the Japanese spirit of ‘Wa’) was independently associated with coronary events (hazard ratio: 0.21; p = 0.01). By other Cox-hazards regression analyses of coronary events using each set of JAS scores and the JCBS Scale C score instead of Factor 4 as selectable variables, the JAS scores or the JCBS Scale C score were not entered into the models.
Conclusion
The Japanese spirit of ‘Wa’ is a preventive factor against coronary events for Japanese men with CAD.
doi:10.1186/s13030-015-0030-8
PMCID: PMC4304146  PMID: 25621004
Coronary artery disease; Prognosis; Risk; Behavioural medicine; Psychosocial factor; Japanese
4.  Development of an ecological momentary assessment scale for appetite 
Background
An understanding of eating behaviors is an important element of health education and treatment in clinical populations. To understand the biopsychosocial profile of eating behaviors in an ecologically valid way, ecological momentary assessment (EMA) is appropriate because its use is able to overcome the recall bias in patient-reported outcomes (PROs). As appetite is a key PRO associated with eating behaviors, this study was done to develop an EMA scale to evaluate the within-individual variation of momentary appetite and uses this scale to discuss the relationships between appetite and various psychological factors.
Methods
Twenty healthy participants (age 23.6 ± 4.2 years old) wore a watch-type computer for a week. Several times a day, including just before and after meals, they recorded their momentary psychological stress, mood states, and ten items related to appetite. In addition, they recorded everything they ate and drank into a personal digital assistant (PDA)-based food diary. Multilevel factor analysis was used to investigate the factor structure of the scale, and the reliability and validity of the scale were also explored.
Results
Multilevel factor analyses found two factors at the within-individual level (hunger/fullness and cravings) and one factor at the between-individual level. Medians for the individually calculated Cronbach’s alphas were 0.89 for hunger/fullness, 0.71 for cravings, and 0.86 for total appetite (the sum of all items). Hunger/fullness, cravings, and total appetite all decreased significantly after meals compared with those before meals, and hunger/fullness, cravings, and total appetite before meals were positively associated with energy intake. There were significant negative associations between both hunger/fullness and total appetite and anxiety and depression as well as between cravings, and depression, anxiety and stress.
Conclusions
The within-individual reliability of the EMA scale to assess momentary appetite was confirmed in most subjects and it was also validated as a useful tool to understand eating behaviors in daily settings. Further refinement of the scale is necessary and further investigations need to be conducted, particularly on clinical populations.
doi:10.1186/s13030-014-0029-6
PMCID: PMC4302437  PMID: 25614760
Appetite; Ecological momentary assessment; Food diary; Multilevel factor analysis
5.  Absence of change in the gray matter volume of patients with ulcerative colitis in remission: a voxel based morphometry study 
Background
Recent neuroimaging studies have investigated the brain involvement in patients with Crohn's disease (CD) and Ulcerative Colitis (UC). Functional studies found abnormalities in cognitive and emotional functions in CD and UC, while a voxel based morphometry (VBM) study found morphological changes in CD. We conducted a VBM study to compare the gray matter (GM) volume of UC patients and controls.
Methods
Eighteen UC patients in remission and eighteen healthy controls underwent structural MRI. VBM is a fully automated technique allowing identification of regional differences in the amount of GM, which enables an objective analysis of the whole brain. VBM was used for comparisons between patients and controls.
Results
UC patients were all in remission and had a mild clinical course. There were no differences between patients and controls in GM volume.
Conclusion
The brain morphology of patients with UC in remission is similar to controls. The lack of GM abnormalities in UC patients might reflect the mild clinical course of the inflammatory bowel disorder. Further research involving patients with different degrees of disease severity or during flares could shed more light on potential brain structural changes in UC.
doi:10.1186/s13030-014-0028-7
PMCID: PMC4302580  PMID: 25614759
Ulcerative Colitis; Voxel based morphometry; Gray matter volume
6.  Isometric yoga improves the fatigue and pain of patients with chronic fatigue syndrome who are resistant to conventional therapy: a randomized, controlled trial 
Biopsychosocial Medicine  2014;8(1):27.
Background
Patients with chronic fatigue syndrome (CFS) often complain of persistent fatigue even after conventional therapies such as pharmacotherapy, cognitive behavioral therapy, or graded exercise therapy. The aim of this study was to investigate in a randomized, controlled trial the feasibility and efficacy of isometric yoga in patients with CFS who are resistant to conventional treatments.
Methods
This trial enrolled 30 patients with CFS who did not have satisfactory improvement after receiving conventional therapy for at least six months. They were randomly divided into two groups and were treated with either conventional pharmacotherapy (control group, n = 15) or conventional therapy together with isometric yoga practice that consisted of biweekly, 20-minute sessions with a yoga instructor and daily in-home sessions (yoga group, n = 15) for approximately two months. The short-term effect of isometric yoga on fatigue was assessed by administration of the Profile of Mood Status (POMS) questionnaire immediately before and after the final 20-minute session with the instructor. The long-term effect of isometric yoga on fatigue was assessed by administration of the Chalder’s Fatigue Scale (FS) questionnaire to both groups before and after the intervention. Adverse events and changes in subjective symptoms were recorded for subjects in the yoga group.
Results
All subjects completed the intervention. The mean POMS fatigue score decreased significantly (from 21.9 ± 7.7 to 13.8 ± 6.7, P < 0.001) after a yoga session. The Chalder’s FS score decreased significantly (from 25.9 ± 6.1 to 19.2 ± 7.5, P = 0.002) in the yoga group, but not in the control group. In addition to the improvement of fatigue, two patients with CFS and fibromyalgia syndrome in the yoga group also reported pain relief. Furthermore, many subjects reported that their bodies became warmer and lighter after practicing isometric yoga. Although there were no serious adverse events in the yoga group, two patients complained of tiredness and one of dizziness after the first yoga session with the instructor.
Conclusions
Isometric yoga as an add-on therapy is both feasible and successful at relieving the fatigue and pain of a subset of therapy-resistant patients with CFS.
Trial registration
University Hospital Medical Information Network (UMIN CTR) UMIN000009646.
doi:10.1186/s13030-014-0027-8
PMCID: PMC4269854  PMID: 25525457
Chronic fatigue syndrome; Isometric yoga; Fatigue; Treatment; Fibromyalgia
7.  Management of post-hyperventilation apnea during dental treatment under monitored anesthesia care with propofol 
Biopsychosocial Medicine  2014;8(1):26.
Although hyperventilation syndrome generally carries a good prognosis, it is associated with the risk of developing severe symptoms, such as post-hyperventilation apnea with hypoxemia and loss of consciousness. We experienced a patient who suffered from post-hyperventilation apnea. A 17-year-old female who suffered from hyperventilation syndrome for several years developed post-hyperventilation apnea after treatment using the paper bag rebreathing method and sedative administration during a dental procedure. We subsequently successfully provided her with monitored anesthesia care with propofol. Monitored anesthesia care with propofol may be effective for the general management of patients who have severe hyperventilation attacks and post-hyperventilation apnea. This case demonstrates that appropriate emergency treatment should be available for patients with hyperventilation attacks who are at risk of developing post-hyperventilation apnea associated with hypoxemia and loss of consciousness.
doi:10.1186/s13030-014-0026-9
PMCID: PMC4260203  PMID: 25493097
Post-hyperventilation apnea; Propofol; Dental treatment
8.  Orthostatic responses in adolescent chronic fatigue syndrome: contributions from expectancies as well as gravity 
Background
Orthostatic intolerance is common in chronic fatigue syndrome (CFS), and several studies have documented an abnormal sympathetic predominance in the autonomic cardiovascular response to gravitational stimuli. The aim of this study was to explore whether the expectancies towards standing are contributors to autonomic responses in addition to the gravitational stimulus itself.
Methods
A total of 30 CFS patients (12–18 years of age) and 39 healthy controls underwent 20° head-up tilt test and a motor imagery protocol of standing upright. Beat-to-beat cardiovascular variables were recorded.
Results
At supine rest, CFS patients had significantly higher heart rate, diastolic blood pressure, and mean arterial blood pressure, and lower stroke index and heart rate variability (HRV) indices. The response to 20° head-up tilt was identical in the two groups. The response to imaginary upright position was characterized by a stronger increase of HRV indices of sympathetic predominance (power in the low-frequency range as well as the ratio low-frequency: high-frequency power) among CFS patients.
Conclusions
These results suggest that in CFS patients expectancies towards orthostatic challenge might be additional determinants of autonomic cardiovascular modulation along with the gravitational stimulus per se.
doi:10.1186/1751-0759-8-22
PMCID: PMC4166398  PMID: 25237387
Adolescence; Autonomic nervous system; Chronic fatigue syndrome; Expectancies; Orthostatic intolerance
9.  The outcome of treatment for anorexia nervosa inpatients who required urgent hospitalization 
Background
This study was done to determine which psychosocial factors are related to the urgent hospitalization of anorexia nervosa patients (AN) due to extremely poor physical condition and to evaluate their outcome after inpatient treatment.
Methods
133 hospitalized AN patients were classified into an urgent hospitalization (n = 24) or a planned hospitalization (n = 109) group. Multiple regression analysis was done of clinical features, body mass index (BMI), psychological tests [The Minnesota Multiphasic Personality Inventory (MMPI), alexithymia, relationship with parents, and the Eating Disorder Inventory (EDI)]. The effectiveness of treatment was prospectively determined two years after discharge by the Global Clinical Score (GCS). The hospitalized weight gain and the frequency of outpatient visits were evaluated.
Results
Of the factors assessed, only BMI at admission was related to the necessity of urgent hospitalization (β = − 1.063, P = 0.00). The urgent group had significantly more weight loss after discharge and poorer social adaptation on the GCS, even when the patient had a sufficient increase in body weight during inpatient treatment and an equivalent number of outpatient consultations.
Conclusion
None of the parameters of the psychosocial tests studied were significantly different between the groups. The outcome of the urgent group was poor. Two years after discharge they had difficulty maintaining weight and continued to have poor social adaptation.
doi:10.1186/1751-0759-8-20
PMCID: PMC4163679  PMID: 25225574
Anorexia nervosa; Urgent hospitalization; Outcome; BMI; MMPI; EDI
10.  Development of a novel, short, self-completed questionnaire on empowerment for patients with type 2 diabetes mellitus and an analysis of factors affecting patient empowerment 
Background
Patient empowerment has recently been proposed as an important concept in self-management for effective glycemic control. A concise self-completed questionnaire for patients with type 2 diabetes mellitus was created to comprehensively evaluate their empowerment on the basis of self-managed dietary/exercise behaviors, psychological impact, and family support. The reliability and validity of this short questionnaire were tested and factors relating to patient empowerment were analyzed.
Methods
The self-completed empowerment questionnaire was based on questionnaires for self-managed dietary and exercise behaviors, the Appraisal of Diabetes Scale, and the Diabetes Family Behavior Checklist. The questionnaire was trialed on 338 male and female patients with type 2 diabetes mellitus who lived with family. The validity and reliability of the questionnaire were investigated and stepwise multiple linear regression analysis was used to identify factors that affect patient empowerment.
Results
The self-completed patient empowerment questionnaire included 13 questions on background data (e.g., age, gender, and HbA1c) and 18 questions within five scales to assess self-managed dietary behaviors, self-managed exercise behaviors, and psychological impact of diabetes, as well as positive and negative feedback in patient-family communication. The questionnaire showed sufficient internal consistency, construct validity, reproducibility, factorial construct validity, and concurrent validity. The results were generally satisfactory, and the questionnaire reflected the particular characteristics of treatment methods. Multiple linear regression analysis showed that patient empowerment was strongly affected by the number of disease-related symptoms, age, and gender.
Conclusions
The results suggest that the concise self-completed empowerment questionnaire developed here is useful for measuring the empowerment of individual patients and evaluating the impact of symptoms and therapies on empowerment.
doi:10.1186/1751-0759-8-19
PMCID: PMC4151376  PMID: 25183994
Type 2 diabetes mellitus; Empowerment questionnaire; Appraisal of diabetes scale; Diabetes family behavior checklist; Self-managed behavior
11.  Why do general practitioners prescribe antidepressants to their patients? A pilot study 
Background
The frequency of antidepressant (ADs) prescription is high, with general practitioners (GPs) responsible for about 80% of the prescriptions. Some studies considered prescriptions meet DSM criteria, while others stress inadequate use. The importance of biological and psychosocial determinants of GP prescription behaviour remains little explored. We aimed to describe the importance of these biological and psychosocial determinants and their weight in the daily practice of GPs’.
Methods
During a week chosen at random, 28 GPs collected the AD prescriptions made within the previous six months, regardless of the reason for the patient contact. Bio psychosocial and AD treatment characteristics were recorded for all patients. In a random sample of 50 patients, patient characteristics were assessed via a structured face-to-face interview with the GP.
Results
The frequency of AD prescription was 8.90% [3.94 -17.02]. The GPs initiated 65.6% [60.1-70.8] of the prescriptions. The rate of AD prescription for non-psychiatric conditions was 18%. Patients had from 1 to 9 conditions, showing a high level of multi-morbidity. There was a strong influence of past medical history and contextual problems, such as work related problems.
Conclusion
AD prescription is related to complex contextual situations and multi-morbid patients. GPs use a bio psycho social approach, rather than a purely biological assessment. Awareness of these influences could improve prescription by GPs.
doi:10.1186/1751-0759-8-17
PMCID: PMC4126991  PMID: 25110516
Antidepressants; Primary care; General practitioner; Prescription; Off label use
12.  Psychosocial perception of adults with onychomycosis: a blinded, controlled comparison of 1,017 adult Hong Kong residents with or without onychomycosis 
Background
A survey was conducted amongst 1,017 Hong Kong residents ages 18 and over to determine their knowledge of fungal nail infections (onychomycosis) and the psychosocial impact of the disease on the relationships, social lives and careers of sufferers.
Methods
The Fungal Nail Perception Survey was conducted by email and online between May 29th and June 10th, 2013. Participants were shown three photographs of people with and without onychomycosis of the toenails. Respondents were asked ten questions (repeated for each picture) to ascertain their perceptions of the people in the pictures. Questions were related to perceptions around the ability of sufferers and non-sufferers to form relationships with others, social activities of sufferers and non-sufferers, perceptions of the effect of the disease on the potential for career success, and awareness of fungal nail disease and health. The sub-population who themselves suffered from onychomycosis were asked about self-perception as well as their perception of others with onychomycosis.
Results
Compared with non-sufferers, survey respondents perceived those with onychomycosis as less likely to be able to form good relationships. They also indicated that they would be more likely to exclude sufferers than non-sufferers from social activities and that they would be more likely to feel uncomfortable when sitting or standing beside an infected person than beside an uninfected person. Respondents perceived people with onychomycosis to be less able to perform well in their chosen career than with someone without onychomycosis. Interestingly, those respondents who themselves were infected felt socially excluded, upset and embarrassed by their infection.
Conclusions
Onychomycosis may lead to stigmatization and social exclusion. Misconceptions of onychomycosis are high and education about the disease needs to be improved. Early recognition and treatment of the disease is essential to avoid complications and improve treatment outcomes, which would lead to reduced psychosocial impact on those with fungal nail infections.
doi:10.1186/1751-0759-8-15
PMCID: PMC4107486  PMID: 25057286
Onychomycosis; Hong Kong; Perception; Fungal nail infection; Psychosocial
13.  Effects of gender, age, family support, and treatment on perceived stress and coping of patients with type 2 diabetes mellitus 
Background
We previously found that the empowerment of patients with type 2 diabetes mellitus can be strongly affected by gender and age in addition to self-managed diet and exercise behaviors and treatment. This study was to examine the effects of gender, age, family support, and treatment on the perceived stress and coping of patients with type 2 diabetes mellitus living with family.
Methods
A survey was conducted of 140 adults with type 2 diabetes mellitus who were living with family. There was no significant difference in hemoglobin A1c (HbA1c) between male and female. Perceived stress and coping were measured with the Japanese version of the Appraisal of Diabetes Scale and the Lazarus Type Stress Coping Inventory. Stepwise regression analysis and path analysis were performed to identify factors that affect the perceived stress and coping of patients.
Results
(1) Perceived stress and coping were strongly affected by gender. (2) Perceived stress and coping were affected by age for males, but perceived stress was not affected by age for females. However, females showed a greater “psychological impact of diabetes” than did males. Females aged between 50 and 69 years engaged in active problem solving, but awareness of diabetes was low. (3) Treatment regimens had an effect on HbA1c for both sexes, and diet therapy affected the awareness of diabetes of males and coping of females. (4) For females, “sense of self-control” was strongly associated with coping, and those who were living with non-spouse family members had a greater psychological impact of diabetes than those living with only their spouse. (5) For males, coping was strongly affected by living with their spouse.
Conclusions
The results suggest that perceived stress, coping, and diet regimen are deeply associated with gender and age and that a male with type 2 diabetes mellitus living with his spouse is strongly dependent on support from the spouse. It is important to take into account gender, age, and family environment to provide patients with an individualized approach to addressing perceived stress and to provide education program for coping that can maximize treatment and maintain better, continuous glycemic control.
doi:10.1186/1751-0759-8-16
PMCID: PMC4114439  PMID: 25075211
Appraisal of Diabetes Scale; Type 2 diabetes mellitus; Stress Coping Inventory; Gender; Spouse
14.  Psychosocial distress and functioning of Greek youth with cystic fibrosis: a cross-sectional study 
Background
To assess psychosocial functioning and distress of children and adolescents with cystic fibrosis compared to healthy controls.
Methods
Thirty-six patients with cystic fibrosis aged 8–18 years (24 boys, mean age ± SD: 11.5 ± 2.6 years) and 31 sex- and age-matched healthy control subjects (18 boys, mean age ± SD: 12 ± 2.5 years) were enrolled in the study. In order to assess the self-esteem, social adjustment, and family functioning of these young people, the Culture-free Self-esteem Inventory, the Social Adjustment Scale–Self-Report, and the Family Assessment Device were administered. Emotional/ behavioral problems were assessed through the Youth Self Report and the Child Behavior Checklist given to both the subjects and their parents.
Results
No significant differences were found for self-esteem between the two study groups. Regarding social adjustment, children with cystic fibrosis reported significantly worse friendship and overall adjustment (P < 0.05). Moreover, no difference was found in the levels of family functioning between the two groups. No significant differences between the groups were found in emotional/ behavioral problems from the self-reports. On the contrary, parents of children with cystic fibrosis reported significantly higher levels of withdrawal/ depression, thought problems, and delinquent behavior (P ≤ 0.01) as compared to controls.
Conclusions
Children and adolescents with cystic fibrosis appear to be a psychosocially vulnerable group. A biopsychosocial approach should emphasize the assessment and treatment of the psychosocial distress of these patients alongside multiple somatic treatments.
doi:10.1186/1751-0759-8-13
PMCID: PMC4060862  PMID: 24940354
Children and adolescents; Cystic fibrosis; Family functioning; Psychopathology; Self-esteem; Social adjustment
15.  Modeling students’ instrumental (mis-) use of substances to enhance cognitive performance: Neuroenhancement in the light of job demands-resources theory 
Background
Healthy university students have been shown to use psychoactive substances, expecting them to be functional means for enhancing their cognitive capacity, sometimes over and above an essentially proficient level. This behavior called Neuroenhancement (NE) has not yet been integrated into a behavioral theory that is able to predict performance. Job Demands Resources (JD-R) Theory for example assumes that strain (e.g. burnout) will occur and influence performance when job demands are high and job resources are limited at the same time. The aim of this study is to investigate whether or not university students’ self-reported NE can be integrated into JD-R Theory’s comprehensive approach to psychological health and performance.
Methods
1,007 students (23.56 ± 3.83 years old, 637 female) participated in an online survey. Lifestyle drug, prescription drug, and illicit substance NE together with the complete set of JD-R variables (demands, burnout, resources, motivation, and performance) were measured. Path models were used in order to test our data’s fit to hypothesized main effects and interactions.
Results
JD-R Theory could successfully be applied to describe the situation of university students. NE was mainly associated with the JD-R Theory’s health impairment process: Lifestyle drug NE (p < .05) as well as prescription drug NE (p < .001) is associated with higher burnout scores, and lifestyle drug NE aggravates the study demands-burnout interaction. In addition, prescription drug NE mitigates the protective influence of resources on burnout and on motivation.
Conclusion
According to our results, the uninformed trying of NE (i.e., without medical supervision) might result in strain. Increased strain is related to decreased performance. From a public health perspective, intervention strategies should address these costs of non-supervised NE. With regard to future research we propose to model NE as a means to reach an end (i.e. performance enhancement) rather than a target behavior itself. This is necessary to provide a deeper understanding of the behavioral roots and consequences of the phenomenon.
doi:10.1186/1751-0759-8-12
PMCID: PMC4046050  PMID: 24904687
Neuroenhancement; Study demands; Burnout; Job demands resources theory; Students
16.  Possible benefits of singing to the mental and physical condition of the elderly 
Background
The evaluation and management of stress are important for the prevention of both depression and cardiovascular disease. In addition, the maintenance of the oral condition of the elderly is essential to enable them to stay healthy, especially to prevent aspiration pneumonia and improve mental health in an aging society. Therefore, we examined the efficacy of singing on the oral condition, mental health status, and immunity of the elderly to determine if singing could contribute to the improvement of their physical condition.
Methods
Forty-four subjects (10 men, 34 women), aged 60 years or older, participated in this study. The efficacy of singing on mental health status and immunocompetence was examined by swallowing function, oral condition, blood, and saliva tests, as well as through questionnaires taken before and after singing.
Results
The results showed that the amount of saliva increased and the level of cortisol, a salivary stress marker, decreased after singing. The Visual Analog Scale (VAS) scores for feeling refreshed, comfortable, pleasurable, light-hearted, relieved, and relaxed; the tension and confusion subscale score; and the total mood disturbance (TMD) score of the Profile of Mood States (POMS) all showed improvements. Furthermore, the same tendencies were shown regardless of whether or not the subjects liked singing.
Conclusions
Our results suggest that singing can be effective in improving the mental health and oral condition of the elderly.
doi:10.1186/1751-0759-8-11
PMCID: PMC4033614  PMID: 24864162
17.  Gastrointestinal specific anxiety in irritable bowel syndrome: validation of the Japanese version of the visceral sensitivity index for university students 
Objective
The visceral sensitivity index (VSI) is a useful self-report measure of the gastrointestinal symptom-specific anxiety (GSA) of patients with irritable bowel syndrome (IBS). Previous research has shown that worsening GSA in IBS patients is related to the severity of GI symptoms, suggesting that GSA is an important endpoint for intervention. However, there is currently no Japanese version of the VSI. We therefore translated the VSI into Japanese (VSI-J) and verified its reliability and validity.
Material and methods
Participants were 349 university students aged 18 and 19 years and recruited from an academic class. We analyzed data from the VSI-J, Anxiety Sensitivity Index (ASI), Hospital Anxiety and Depression scale (HAD), and Irritable Bowel Syndrome Severity Index (IBS-SI). The internal consistency, stability, and factor structure of the VSI-J and its associations with anxiety, depression and severity measures were investigated.
Results
The factor structure of the VSI-J is unidimensional and similar to that of the original VSI (Cronbach’s α = 0.93). Construct validity was demonstrated by significant correlations with ASI (r = 0.43, p < 0.0001), HAD-ANX (r = 0.19, p = 0.0003), and IBS-SI scores (r = 0.45, p < 0.0001). Furthermore, the VSI-J was a significant predictor of severity scores on the IBS-SI and demonstrated good discriminant (p < 0.0001) and incremental (p < 0.0001) validity.
Conclusion
These findings suggest that the VSI-J is a reliable and valid measure of visceral sensitivity.
doi:10.1186/1751-0759-8-10
PMCID: PMC3994456  PMID: 24655428
Gastrointestinal-specific anxiety; Irritable Bowel Syndrome (IBS); Motility; Psychosomatics; Validation; Visceral Sensitivity Index (VSI)
18.  Reviewer acknowledgement 2013 
Contributing reviewers
The editors of BioPsychoSocial Medicine would like to thank all our reviewers who have contributed to the journal in Volume 7 (2013).
doi:10.1186/1751-0759-8-2
PMCID: PMC3932729  PMID: 24565380
19.  Rational/antiemotional behaviors in interpersonal relationships and the functional prognosis of patients with rheumatoid arthritis: a Japanese multicenter, longitudinal study 
Background
The repression of negative emotions is a personality factor that received considerable attention in the 1950-60s as being relevant to the onset and course of rheumatoid arthritis (RA). Despite subsequent, repeated criticisms of the cross-sectional nature of the earlier studies, even to date few prospective studies have been reported on this issue. This multicenter study prospectively examined if “rational and antiemotional” behavior (antiemotionality), characterized by an extreme tendency to suppress emotional behaviors and to rationalize negative experiences in conflicting interpersonal situations, is associated with the functional prognosis of patients with RA.
Methods
532 patients with RA who regularly visited one of eight hospitals/clinics in Japan in 2000 were recruited for study. All completed a self-administered baseline questionnaire about lifestyle and psychosocial factors including antiemotionality. Two years after, 460 (mean age, 56.1 years; 54 men and 406 women) of 471 patients who continued to visit the clinics agreed to take the follow-up questionnaire. The functional status of the patients was evaluated by rheumatologists based on the ACR classification system.
Results
A multiple logistic regression model that included baseline demographic, disease activity/severity-related, therapeutic, and socioeconomic factors as covariates found a tendency toward higher antiemotionality to be related to poorer functional status at follow-up. This relationship was not explained by lifestyle factors.
Conclusions
Antiemotionality may be a prognostic factor for the functional status of patients with RA. This finding sheds light on a seemingly forgotten issue in the care of patients with RA.
doi:10.1186/1751-0759-8-8
PMCID: PMC3941968  PMID: 24565416
Rheumatoid arthritis; Psychological stress; Personality; Emotions; Function; Prospective studies
20.  Effect of 12 weeks of yoga training on the somatization, psychological symptoms, and stress-related biomarkers of healthy women 
Background
Previous studies have shown that the practice of yoga reduces perceived stress and negative feelings and that it improves psychological symptoms. Our previous study also suggested that long-term yoga training improves stress-related psychological symptoms such as anxiety and anger. However, little is known about the beneficial effects of yoga practice on somatization, the most common stress-related physical symptoms, and stress-related biomarkers. We performed a prospective, single arm study to examine the beneficial effects of 12 weeks of yoga training on somatization, psychological symptoms, and stress-related biomarkers.
Methods
We recruited healthy women who had no experience with yoga. The data of 24 participants who were followed during 12 weeks of yoga training were analyzed. Somatization and psychological symptoms were assessed before and after 12 weeks of yoga training using the Profile of Mood State (POMS) and the Symptom Checklist-90-Revised (SCL-90-R) questionnaires. Urinary 8-hydroxydeoxyguanosine (8-OHdG), biopyrrin, and cortisol levels were measured as stress-related biomarkers. The Wilcoxon signed-rank test was used to compare the stress-related biomarkers and the scores of questionnaires before and after 12 weeks of yoga training.
Results
After 12 weeks of yoga training, all negative subscale scores (tension-anxiety, depression, anger-hostility, fatigue, and confusion) from the POMS and somatization, anxiety, depression, and hostility from the SCL-90-R were significantly decreased compared with those before starting yoga training. Contrary to our expectation, the urinary 8-OHdG concentration after 12 weeks of yoga training showed a significant increase compared with that before starting yoga training. No significant changes were observed in the levels of urinary biopyrrin and cortisol after the 12 weeks of yoga training.
Conclusions
Yoga training has the potential to reduce the somatization score and the scores related to mental health indicators, such as anxiety, depression, anger, and fatigue. The present findings suggest that yoga can improve somatization and mental health status and has implications for the prevention of psychosomatic symptoms in healthy women.
Trial registration
University Hospital Medical Information Network (UMIN CTR) UMIN000007868.
doi:10.1186/1751-0759-8-1
PMCID: PMC3892034  PMID: 24383884
Yoga; Somatization; Psychological symptom; Stress; Biomarker; Anxiety; Depression; Anger; Hostility; Fatigue
21.  A clinical study of the efficacy of a single session of individual exercise for depressive patients, assessed by the change in saliva free cortisol level 
Background
The efficacy of physical exercise as an augmentation to pharmacotherapy with antidepressants for depressive patients has been documented. However, to clarify the effectiveness of exercise in the treatment of depression, it is necessary to distinguish the effect of the exercise itself from the effect of group dynamics. Furthermore, an objective measurement for estimation of the effect is needed. Previous reports adopted a series of group exercises as the exercise intervention and mainly psychometric instruments for the measurement of effectiveness. Therefore, this clinical study was done to examine the effectiveness of a single session of individual exercise on depressive symptoms by assessing the change in saliva free cortisol level, which reflects hypothalamic-pituitary-adrenocortical axis function that is disturbed in depressive patients.
Method
Eighteen medicated patients, who met the DSM-IV-TR criteria for major depressive disorder, were examined for the change in saliva free cortisol levels and the change in subjective depressive symptoms before and after pedaling a bicycle ergometer for fifteen minutes. Within a month after the exercise session, participants conducted a non-exercise control session, which was sitting quietly at the same time of day as the exercise session.
Results
Depressed patients who participated in this study were in remission or in mild depressive state. However, they suffered chronic depression and had disturbed quality of life. The saliva free cortisol level and subjective depressive symptoms significantly decreased after the exercise session. Moreover, the changes in these variables were significantly, positively correlated. On the other hand, although the subjective depressive symptoms improved in the control session, the saliva free cortisol level did not change.
Conclusion
For the first time in depressive patients, we were able to show a decrease in the saliva free cortisol level due to physical exercise, accompanied by the improvement of subjective depressive symptoms. This identified a possible influence of exercise on the hypothalamic-pituitary-adrenal axis in depression.
These results suggest the utility of assessing the effect of physical exercise by saliva free cortisol level in depressive patients who suffer from bio-psycho-social disability.
doi:10.1186/1751-0759-7-18
PMCID: PMC4029195  PMID: 24314124
Depression; Physical exercise; Saliva free cortisol level; Augmentation therapy; Quality of life
22.  The role of perceived well-being in the family, school and peer context in adolescents’ subjective health complaints: evidence from a Greek cross-sectional study 
Background
During adolescence children are usually confronted with an expanding social arena. Apart from families, schools and neighbourhoods, peers, classmates, teachers, and other adult figures gain increasing importance for adolescent socio-emotional adjustment. The aim of the present study was to investigate the extent to which Greek adolescents’ perceived well-being in three main social contexts (family, school and peers) predicted self-reported Subjective Health Complaints.
Methods
Questionnaires were administered to a Greek nation-wide, random, school-based sample of children aged 12–18 years in 2003. Data from 1.087 adolescents were analyzed. A hierarchical regression model with Subjective Health Complaints as the outcome variable was employed in order to i) control for the effects of previously well-established demographic factors (sex, age and subjective economic status) and ii) to identify the unique proportion of variance attributed to each context. Bivariate correlations and multicollinearity were also explored.
Results
As hypothesized, adolescents’ perceived well-being in each of the three social contexts appeared to hold unique proportions of variance in self-reported Subjective Health Complaints, after controlling for the effects of sex, age and subjective economic status. In addition, our final model confirmed that the explained variance in SHC was accumulated from each social context studied. The regression models were statistically significant and explained a total of approximately 24% of the variance in Subjective Health Complaints.
Conclusions
Our study delineated the unique and cumulative contributions of adolescents’ perceived well-being in the family, school and peer setting in the explanation of Subjective Health Complaints. Apart from families, schools, teachers and peers appear to have a salient role in adolescent psychosomatic adjustment. A thorough understanding of the relationship between adolescents’ Subjective Health Complaints and perceived well-being in their social contexts could not only lead to more effective tailored initiatives, but also to promote a multi- and inter-disciplinary culture in adolescent psychosomatic health.
doi:10.1186/1751-0759-7-17
PMCID: PMC4175490  PMID: 24283390
Subjective Health Complaints (SHC); Adolescence; Family; School; Peers; Well-being; Psychosomatic health; Subjective perceptions; Subjective economic status
23.  Spiritual and religious beliefs: do they matter in the medication adherence behaviour of hypertensive patients? 
Background
Medication non-adherence is often a predominant problem in the management of hypertension and other chronic conditions. In explaining health behaviours, social determinants like spirituality and religiosity are increasingly identified to impact health and treatment. Although a number of researchers have found spirituality and religiosity to be primary resources among persons dealing with chronic disability and illness, studies relating this specifically to medication adherence have been limited.
Methods
Our study sought to examine the interrelationship between spirituality/ religiosity and medication adherence among 400 hypertensive patients 18 years old and above. Spiritual Perspective Scale, Duke Religion Index, and the Morisky Medication Adherence Scale were used to determine spirituality, religiosity and medication adherence respectively.
Results
The majority (93.25%) of patients poorly adhered to their medications. While high spiritual and religious beliefs formed core components of the lifestyles of patients, spirituality (p = 0.018) and not religiosity (p = 0.474) related directly with medication non-adherence. Likewise, after controlling for demography and other medical co-morbidities, patients with high spirituality were 2.68 times more likely to be poorly adherent than patients who place lower emphasis on the association between spirituality and health.
Conclusion
Our study suggests that while spirituality/ religiosity was dominant among hypertensive patients, these spiritual attachments of patients with a supreme being potentially increased their trust in the expectation of divine healing instead of adhering adequately with their anti-hypertensive medications.
doi:10.1186/1751-0759-7-15
PMCID: PMC3854617  PMID: 24138844
Spirituality; Religiosity; Medication non-adherence; Co-morbidity; Ghana
24.  TEACCH-based group social skills training for children with high-functioning autism: a pilot randomized controlled trial 
Background
Although social skills training programs for people with high-functioning autism (HFA) are widely practiced, the standardization of curricula, the examination of clinical effectiveness, and the evaluation of the feasibility of future trials have yet to be done in Asian countries. To compensate for this problem, a Japanese pilot randomized controlled trial (RCT) of the Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH)-based group social skills training for children with HFA and their mothers was conducted.
Methods
Eleven children with HFA, aged 5–6 years, and their mothers were randomly assigned to the TEACCH program (n=5) or a waiting-list control group (n=6). The program involved comprehensive group intervention and featured weekly 2-hour sessions, totaling 20 sessions over six months. The adaptive behaviors and social reciprocity of the children, parenting stress, and parent–child interactions were assessed using the Strengths and Difficulties Questionnaire (SDQ), Parenting Stress Index (PSI), Beck depression inventory-II (BDI-II), and Interaction Rating Scale (IRS).
Results
Through this pilot trial, the intervention and evaluation of the program has been shaped. There were no dropouts from the program and the mothers’ satisfaction was high. The outcome measurements improved more in the program group than in the control group, with moderate effect sizes (SDQ, 0.71; PSI, 0.58; BDI-II, 0.40; and IRS, 0.69). This pilot trial also implied that this program is more beneficial for high IQ children and mothers with low stress than for those who are not.
Conclusion
We have standardized the TEACCH program, confirmed the feasibility of a future trial, and successfully estimated the positive effect size. These findings will contribute to a larger trial in the future and to forthcoming systematic reviews with meta-analyses.
Trial registration
UMIN000004560
doi:10.1186/1751-0759-7-14
PMCID: PMC3850504  PMID: 24083413
Randomized controlled trial; Autism; Social skills training; TEACCH (Treatment and Education of Autistic and related Communication Handicapped Children)
25.  Family issues and family functioning of Japanese outpatients with type 2 diabetes: a cross-sectional study 
Background
Previous studies confirmed that the control of diabetes is related to family functioning, but the validity of the tools used to assess family functioning in these studies is questionable. Few studies have focused on family issues. In this study, we used a new assessment tool to evaluate family functioning and family issues of patients with type 2 diabetes.
Methods
A cross-sectional questionnaire was given to outpatients with type 2 diabetes at a community hospital in Aichi, Japan, between August 2001 and March 2002. First, the patients were asked to answer FACESKGIV-16, which measures cohesion and adaptability, questions regarding family issues, daily lifestyle, and HAD. Physical and serological data were measured. Family functioning, family issues, and relationships between each parameter and family functioning or family issues were analyzed.
Results
Of the 133 participants, 121 (33.3%) had some sort of family issue. Family issues included “Health problems of family members” (40.9%), “Family life cycle issues” (22.7%), and others.
The best fit multiple regression model (Adjusted R2: 0.494, p = 0.020) included Plasma Glucose as an independent variable, and the squared value of cohesion score, depression score of HAD, Total calorie intake, Exercise time, Housekeeping time, and BMI were dependent variables. The results show that extremes of family cohesion with either too many or too few issues related to family functioning are correlated with the plasma glucose level.
Conclusions
Family issues were common among patients with type 2 diabetes, and the extremes of family cohesion were associated with the glucose level, in contrast to the common wisdom that a well balanced family leads to good control of diabetes.
doi:10.1186/1751-0759-7-13
PMCID: PMC3700776  PMID: 23799927
Family; Family Research; Diabetes Mellitus; Family Relations; Family Characteristics; Family Members

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