Emotional Processing In Patients with Ischemic Heart Diseases

Open Access Maced J Med Sci electronic publication ahead of print, published on September 20, 2018 as https://doi.org/10.3889/oamjms.2018.325 ID Design Press, Skopje, Republic of Macedonia Open Access Macedonian Journal of Medical Sciences. https://doi.org/10.3889/oamjms.2018.325 eISSN: 1857-9655 Clinical Science Emotional Processing In Patients with Ischemic Heart Diseases 1 2 3 2 Shirali Kharamin , Mohammad Malekzadeh , Arash Aria , Hamide Ashraf , Hamid Reza Ghafarian Shirazi 1 4* 2 Clinical Psychology, Yasuj University of Medical Sciences, Yasuj, Iran; Health Psychology, Yasuj University of Medical 3 4 Sciences, Yasuj, Iran; Internal Medicine, Yasuj University of Medical Sciences, Yasuj, Iran; Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran Abstract Citation: Kharamin S, Malekzadeh M, Aria A, Ashraf H, Ghafarian Shirazi HR. Emotional Processing In Patients with Ischemic Heart Diseases. Open Access Maced J Med Sci. https://doi.org/10.3889/oamjms.2018.325 Keywords: IHD; Emotional processing; CVD; Stress; Psychosomatic *Correspondence: Hamid Reza Ghafarian Shirazi. Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran. E-mail: [email protected] Received: 18-Jul-2018; Revised: 23-Aug-2018; Accepted: 27-Aug-2018; Online first: 20-Sep-2018 Copyright: © 2018 Shirali Kharamin, Mohammad Malekzadeh, Arash Aria, Hamide Ashraf, Hamid Reza Ghafarian Shirazi. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0) Funding: This research did not receive any financial support Competing Interests: The authors have declared that no competing interests exist BACKGROUND: Cardiovascular disease is the most prevalent public health problem on a worldwide scale, and ischemic heart disease accounts for approximately one-half of these events in high-income countries. One of the most important risk factors for this disease is mental and psychological especially stressful experiences. AIM: This research was established to compare emotional processing, as a key factor in stress appraisal, between IHD patients and people with no cardiovascular disease. METHODS: Using simple sampling, fifty patients were selected from people who diagnosed as IHD in the hospital and referred for treatment after discharging care and treatment. Control group participants were selected as control group peoples, using neighbourhood controls selection. The Emotional Processing Scale was filled by all members of the two groups. RESULTS: There were significant differences between the two groups on the EPS-25 total scores, as well as on emotional processing dimensions of signs of unprocessed emotion, unregulated emotion; avoidance and impoverished. Also, there was no significant difference between the two groups in the dimension of Suppression. The final step of regression revealed a β of 10.15 and 1.05 for AVO and IEE subscales respectively. CONCLUSION: The result showed that patients with IHD are using more negative emotional processing styles. Introduction Cardiovascular disease (CVD) is the most prevalent public health problem on a worldwide scale [1], and ischemic heart disease (IHD) accounts for approximately one-half of these events in high-income countries [2]. Despite an improvement in treatments and prevention, IHD still caused over 2.1 million deaths (23% of all deaths) in Europe in 2015 and resulted in over 165 million disability-adjusted lifeyears (DALYs) lost in 2012 (6% of all disability claims) [3] [4]. The relationships between psychosocial risk factors and CVD have been investigated in a variety of laboratory [5] [6] and epidemiologic studies [7] [8] [9] [10]. This connection has been the subject of an ever-growing body of literature over the last 50 years [11] [12]. The majority of these studies have demonstrated the relationship between the chronic and acute stress [13] [14] [15] [16] [17], and its aversive emotional and psychological consequences, such as depression [18] [19] [20], anger [21] [22], PTSD [23] [24], anxiety [25] [26], and CVD. Therefore, the role of negative emotion in CVD has been notable in recent works [27] [28] [29]. To explain associations between psychosocial factors (especially stressor) and CVD, several biological and behavioural mechanisms have been proposed, including inflammatory processes, lack of exercise, and lifestyle-related factors [5] [30]. Negative emotions are a common reaction to stressful experiences, and different approaches to processing these emotions may have distinct consequences for the stress response trajectory [31]. In other words, the types of emotion regulation or processing could change the consequences of stressors as fundamental factors contributing to the pathophysiology of CVD. Therefore, recently, researchers have investigated whether poor emotion regulation and processing capacity could be associated with CVD [31] [32] [33]. Emotional processing can be either helpful or harmful, and the consequences of attending to emotions may depend on the nature of the emotional processing. Emotional _______________________________________________________________________________________________________________________________ Open Access Maced J Med Sci. 1 Clinical Science _______________________________________________________________________________________________________________________________ process can be referred to as psychological, psychophysiological and psycho-neurological mechanisms by which distressed emotional reactions in individuals are converted or changed to nondistressed reactions [34]. According to Rachman paper [35], the incomplete abortion or processing emotion could result in direct and indirect signs. The role of this mechanism in the emergence or maintenance of some psychological disorders such as PTSD [36], panic disorder [37], depression [38] has been investigated in many studies. Also, its contribution to psychosomatic disorders including fibromyalgia [39], chronic fatigue [40] chronic pain [41], inflammatory bowel disease [42] and functional gastrointestinal disorders [43] has been proposed. Literature also showed a relationship between the excessive emotional regulation and some physical illnesses such as cancer [44], cardiovascular diseases [33] and multiple sclerosis [45]. It has also been considered as an important factor in psychotherapy [46] [47]. Despite the strong evidence reporting the role of emotional processing in consequence of stress and linking negative emotion (as the consequence of stress), few studies have been able to examine this relation to the development of CHD, [29][48]. For example, Kubzansky and Thurston [29] reported that those reporting high levels of emotional vitality (is characterized by a sense of energy and positive wellbeing in addition to being able to regulate emotions effectively) had multivariate-adjusted relative risks of 0.81 (95% confidence interval, 0.69-0.94) for Coronary Heart Diseases (CHD). In spite of these studies, (majority investigated emotional regulation), the relationship of emotional processing and CVD has been remained provocative. Therefore, the existence of a comprehensive study with all aspects of its emotional processing is completely felt. This research aimed to investigate this relationship. This study was based on the hypothesis that emotional processes play a key role in IHD; therefore, they should report higher scores in emotional processing scale. Methods Using simple sampling, fifty IHD patients were selected. The patients were selected from people who diagnosed as IHD in the hospital and referred to Heart clinic for treatment for after discharging care and treatment. Fifty non-patient people were selected as control group peoples, using neighbourhood controls selection Emotional processing scale (EPS). The Emotional Processing Scale (EPS) is a 25-item, five- factor self-report questionnaire designed to measure emotional processing styles and deficits [49]. The scale is rated on a ten-point scale (0 for completely disagree to 9 for completely agree). It measures five dimensions namely: suppression (SUP), signs of unprocessed emotion (SUE), unregulated emotion (UE), avoidance (AVO) and impoverished emotional experience (IEE). This scale has reported favourable psychometric properties, including high internal consistency and high temporal reliability. The coefficient α value for the scale was .92. Internal consistency was high (α ≥ 0.80) for three factors and moderate for two (α ≥ 0.70). The Pearson's test-retest correlation coefficient obtained for the entire scale was 0.74. The psychometric data on final 25-item version also showed internal consistency 0.92, 0.88 and 0.90 for the UK, Italian and Italian & UK data respectively [50] [51]. During one month all questionnaires (EPS) were completed by patients who referred to Heart clinic for treatment after discharge from the hospital. All patients were diagnosed by hospital cardiologist as IHD. After selection, the IHD patient, his/her house address had been determined and among 4 neighbourhoods from left and 4 from right the most similar person to the patient (age, education, gender, economic status, marriage status and ….) was selected as a matched control person. The patient would have been removed from the case group if he/she had reported any psychiatric disorders, additional physical diseases or any cognitive inability. Data were analysed using SPSS version 22. Frequencies and score means were obtained for demographic variables and were analysed by independent T-test (for age) and chi-square (for gender, education and marital status variables). The average scores of two groups were compared by using independent T-test for SUP and SUE subscales (met criteria for normality) and because of significant level for normality test, Mann-Whitney U test for UE, AVO, IEE subscales and total scores. Also, a logistic regression (backward model) was conducted to determine odds ratios of developing IHD for each variable of interest. The five subscales were included in the analysis as predictor variables and IHD as the dependent variable. A p-value < 0.05 was considered to be statistically significant. Results The demographic statistics of the research participants are presented in Table 1. The sample size was 100 (50 IHD and 50 control group). The mean age of the IHD group was 59.84 years (SD = 14.78; ranged 24-88). The mean age of the control group was 58.2 years (SD = 14.60; ranged 22-90). _______________________________________________________________________________________________________________________________ 2 https://www.id-press.eu/mjms/index Ghafarian Shirazi et al. Emotional Processing In Patients with Ischemic Heart Diseases _______________________________________________________________________________________________________________________________ Table 1: Sample demographic data Variables Age Sex (%) Male Female Education (%) Primary to high school Education Academic Education Marriage status Married Single MI group 59.84 (14.63) Controlled group 58.2 (14.78) Values of differences T = 0.56,df 98, Sig 0.59 23 (46) 25 (50) 27 (54) 25 (50) x2 = 0.16, df 1, Sig 0.84 46 (92) 43 (86) x2 = 0.9, df 1, Sig 0.26 4 (8) 7 (14) 47 (94) 3 (6) 48 (96) 2 (4) Table 3: Logistic regression for exploring the correlates (emotional processing) of IHD Step 1 Step 2 x2 = 1.04, df 1, Sig 0.31 Step 3 The result showed that majority of participants in both groups had under academic education (92% for IHD and 86% for control group) and 95% of them were married (94% for IHD and 96% for control group). Using independent T-test for comparing the age and chi-square for sex, education, and marital status, there was no significant difference between the two groups. The result indicated that mean of total scores in EPS was 140.26 ± 27.81 for IHD group and 123.56 ± 26.71 for control group. Table 2 presents the group means and standard deviations for the total scores of EPS-25 and the five dimensions of emotional processing. There were significant differences between two groups on the EPS-25 total scores (Z = 3.048, p < 0.002), as well as on emotional processing dimensions of: signs of unprocessed emotion (T (98) = 2.39, p < 0.001), unregulated emotion (Z = 2.33, p < 0.02); avoidance (Z = 3.48, p < 0.001) and impoverished (Z = 2.94, p < 0.003). In addition, there was no significant difference between two groups in dimension of Suppression (T (98) = 0.37, p < 0.7). Table 2: Means and standard deviations MI and control groups’ scores in EPS Items SUP SUE MI group 25.28(9.38) 29.68(6.84) UE AVO IEE Total 57.26 60.59 59.03 59.34 Means(SD) Controlled group 24.62 (14.8) 26.46 (6.66) Mean rank 43.74 40.41 41.97 41.66 Total 24.95 (8.78) 28.08 (6.90) T P Value 0.37 0.71 2.39 0.01 Mann-Whitney 912 0.02 745.5 0.0001 823.5 0.003 808 0.002 Suppression (SUP); signs of unprocessed emotion (SUE); unregulated emotion (UE); avoidance (AVO) and impoverished emotional experience (IEE). Table 3 showed the data resulted from logistic regression. The Omnibus Test showed a chi-square of 16.74, df = 2 and p < 0.0001. The Hosmer and Lemenshow Test also showed a chi-square of 5.21, df = 8 and p < 0.73. Also, the overall predicted percentage for the model was 66, and it explained between 15.6 to 20.8 percentages of variances. In the final step of the backward system of analysis (step 4), the result showed that the only predictor variable with a significant value in this equation was AVO with β = 1.16 (95% C.I. = 1.03-1.30). In addition, IEE showed a significant value near to significant level with β = 1.05 (95% C.I. = 0.99-1.10 and significant value = 0.06) Step 4 SUP SUE UE AVO IEE Constant SUE UE AVO IEE Constant UE AVO IEE Constant AVO IEE Constant B -0.005 -0.009 0.012 0.140 0.047 -4.907 -0.009 0.013 0.140 0.045 -5.027 0.012 0.138 0.041 -5.098 0.140 0.048 -4.979 S.E. 0.027 0.045 0.035 0.053 0.040 1.662 0.045 0.034 0.053 0.038 1.532 0.033 0.052 0.033 1.486 0.051 0.026 1.446 Wald 0.033 0.043 0.125 7.035 1.379 8.722 0.036 0.157 7.018 1.404 10.762 0.135 7.115 1.571 11.764 7.408 3.396 11.853 df 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Sig. 0.855 0.836 0.723 0.008 0.240 0.003 0.849 0.692 0.008 0.236 0.001 0.713 0.008 0.210 0.001 0.006 0.065 0.001 Exp (B) 0.995 0.991 1.012 1.150 1.048 0.007 0.991 1.014 1.150 1.046 0.007 1.012 1.148 1.042 0.006 1.150 1.049 0.007 95% CI. for EXP(B) Lower Upper 0.945 1.048 0.907 1.083 0.946 1.083 1.037 1.276 0.969 1.134 0.908 0.948 1.037 0.971 1.083 1.083 1.276 1.126 0.948 1.037 0.977 1.081 1.271 1.111 1.040 0.997 1.273 1.105 Discussion The role of psychological factors, especially stress, in heart diseases has been investigated in health psychology literature and possesses from rich evidence-based credit. It seems that the impact of stressors could be changed as a consequence of emotional processing styles. The present study aimed to compare the emotional processing style between IHD patients and normal people. Demographic data revealed no significant differences between two groups that confirm an acceptable matched samples selection. In another word, the result shows that two groups in the majority of variables that could be confounding are (to some extent) the same. The IHD is the only variable which was different in the two groups. To our knowledge, this is the first study that examined the relation between IHD and comprehensive aspects (five domains) of emotion processing. We found that patients in four domains (from five domains) of emotional processing had significantly higher scores. That was also the case in total scores of emotional processing. Therefore, the hypothesis that negative emotional processing in IHD is more than none patients group was supported. Similar to previous studies [13] [18], this study showed that patients with IHD reported higher scores in EPS. In this study, result showed that IHD patients reported significantly higher scores in subscales of SUE, UE, AVO, IEE and total scores than none patients group. The higher scores in this scale, the intended negative emotional processing is used more. In other words, emotional processing with potentially distinct effects on the stress response trajectory is more negative in this group of patients. The binary logistic analysis confirmed the goodness of fit for the model. Although the result of regression showed that only AVO subscale (and to some extent IEE) was a significant predictor variable for IHD, the high correlation between subscale (as a dimension of unit _______________________________________________________________________________________________________________________________ Open Access Maced J Med Sci. 3 Clinical Science _______________________________________________________________________________________________________________________________ structure) could be accounted for removing other subscales (SUE, UE) from modelling [52]. This implies that people with more score in AVO are more vulnerable to IHD Several biological and behavioural mechanisms could be proposed to explain this association. First, the positive emotional processing and regulation of may lead to health-protective behaviours and lifestyle system [32] [53] [54]. For example, Pressman and Cohen found that greater emotional vitality was significantly associated with less smoking, alcohol consumption, and more physical activity. Second, it may alter disease susceptibility by acting directly on biological systems [54]. For example, recent investigations have demonstrated associations of positive affect with lower heart rate, lower levels of cortisol, and attenuated fibrinogen stress responses as well as with reduced ambulatory systolic blood pressure assessed 3 years later [54] [55]. Third, it may change the stress reaction such as negative emotion. Gross in his theory showed that the individual differences in using different methods of cognitive emotion regulation would carry out different emotional, cognitive, and social consequences. For example, the use of reappraisal styles is related to positive emotional experiences and better intrapersonal practices, and higher well-being [56]. Therefore, better emotion regulation capacity could modify stress reactions associated with certain mental disorders (such as depression, anxiety and anger). For example, the relationship between anger outbursts, depression and anxiety and CHD may (partly) have its basis in emotion regulation [57] [53]. To conclude, the current findings suggest that negative emotional processing style may be associated with producing IHD by potentially distinct effects on the stress response trajectory. In other words, patients with IHD are using more negative emotional processing styles. This study contains some limitations that are important to acknowledge. The sample consisted of only IHD population. Therefore, it is recommended to use other types of CVD with different types. Secondly, this research studied the emotional processing in this group of patients after the appearance of IHD. Therefore it should be better to investigate this variable in a cohort study in general population and during a long period. accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study. References 1. Yusuf S, Reddy S, Ôunpuu S, Anand S. Global burden of cardiovascular diseases: Part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation. 2001; 104(23):2855-64. https://doi.org/10.1161/hc4701.099488 PMid:11733407 2. Murray CJ, Abraham J, Ali MK, Alvarado M, Atkinson C, Baddour LM, Bartels DH, Benjamin EJ, Bhalla K, Birbeck G, Bolliger I. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. Jama. 2013; 310(6):591-606. https://doi.org/10.1001/jama.2013.13805 PMid:23842577 PMCid:PMC5436627 3. WHO. Health statistics and information systems. Disease burden. Estimates for 2000–2012 by region, 2013. 4. WHO. Projections of mortality and causes of death, 2015 and 2030 , 2014. 5. Kaplan JR, Manuck SB. Ovarian dysfunction and the premenopausal origins of coronary heart disease. Menopause. 2008; 15(4):768-76. https://doi.org/10.1097/gme.0b013e31815eb18e 6. Kaplan J, Manuck S, Anthony M, Clarkson T. Premenopausal social status and hormone exposure predict postmenopausal atherosclerosis in female monkeys, Obstetrics & Gynecology. 2002; 99(3):381-388. PMid:11864663 7. Ramadan R, Sheps D, Esteves F, Maziar Zafari A, Douglas Bremner J, Vaccarino V, Quyyumi AA. Myocardial ischemia during mental stress: role of coronary artery disease burden and vasomotion. Journal of the American Heart Association. 2013; 2(5):e000321. https://doi.org/10.1161/JAHA.113.000321 PMid:24145741 PMCid:PMC3835239 8. Arrighi JA, Burg M, Cohen IS, Kao AH, Pfau S, Caulin-Glaser T, Zaret BL, Soufer R. Myocardial blood-flow response during mental stress in patients with coronary artery disease. The Lancet. 2000356(9226):310-1. https://doi.org/10.1016/S01406736(00)02510-1 9. Shah AJ, Vaccarino V. Psychosocial risk factors and coronary artery disease. In: Psychotherapy for Ischemic Heart Disease. Springer, Cham. 2016:29-44. https://doi.org/10.1007/978-3-31933214-7_2 10. Lampert R. Emotion and sudden cardiac death. Expert review of cardiovascular therapy. 2009; 7(7):723-5. https://doi.org/10.1586/erc.09.75 PMid:19589107 Ethical approval All procedures performed in studies involving human participants were by the Yasuj University of Medical Sciences Research Ethics Committee and in 11. Roncella A. and Pristipino C. Psychotherapy for Ischemic Heart Disease Springer International Publishing Switzerland 2016 12. Proietti R, Mapelli D, Volpe B, Bartoletti S, Sagone A, Dal Bianco L, DalientoLMental stress and ischemic heart disease: evolving awareness of a complex association. Future Cardiol. 2011; 7(3):425-37. https://doi.org/10.2217/fca.11.13 PMid:21627481 13. Kubzansky LD, Park N, Peterson C, Vokonas P, Sparrow D. _______________________________________________________________________________________________________________________________ 4 https://www.id-press.eu/mjms/index Ghafarian Shirazi et al. Emotional Processing In Patients with Ischemic Heart Diseases _______________________________________________________________________________________________________________________________ Healthy psychological functioning and incident coronary heart disease: the importance of self-regulation. Arch Gen Psychiatry. 2011; 68:400–8. https://doi.org/10.1001/archgenpsychiatry.2011.23 PMid:21464364 14. Appleton AA, Buka SL, Loucks EB, Rimm EB, Martin LT, Kubzansky LD. A prospective study of positive early-life psychosocial factors and favorable cardiovascular risk in adulthood. Circulation. 2013; 127:905–12. https://doi.org/10.1161/CIRCULATIONAHA.112.115782 PMid:23339873 PMCid:PMC3762221 15. Pimple P, Shah AJ, Rooks C et al. Angina and mental stressinduced myocardial ischemia. J Psychosom Res. 2015; 78(5):433– 437. https://doi.org/10.1016/j.jpsychores.2015.02.007 PMid:25727240 PMCid:PMC4380582 16. Steptoe A, Brydon L. Emotional triggering of cardiac events. Neuroscience & Biobehavioral Reviews. 2009; 33(2):63-70. https://doi.org/10.1016/j.neubiorev.2008.04.010 PMid:18534677 17. Backé EM, Seidler A, Latza U, Rossnagel K, Schumann B. The role of psychosocial stress at work for the development of cardiovascular diseases: a systematic review. International archives of occupational and environmental health. 2012; 85(1):6779. https://doi.org/10.1007/s00420-011-0643-6 PMid:21584721 PMCid:PMC3249533 18. Lichtman JH, Froelicher ES, Blumenthal JA, Carney RM, Doering LV, Frasure-Smith N, Freedland KE, Jaffe AS, LeifheitLimson EC, Sheps DS, Vaccarino V. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation. 2014:CIR0000000000000019. https://doi.org/10.1161/CIR.0000000000000019 19. Meijer A, Conradi HJ, Bos EH et al. Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis of 25 years of research. Gen Hosp Psychiatry. 2011; 33(3):203–216. https://doi.org/10.1016/j.genhosppsych.2011.02.007 PMid:21601716 20. Steptoe A, Strike PC, Perkins-Porras L, et al. Acute depressed mood as a trigger of acute coronary syndromes. Biol Psychiatry. 2006; 60(8):837–842. https://doi.org/10.1016/j.biopsych.2006.03.041 PMid:16780810 27. Mirzaei A, Toori MA, Mirzaei N, Shirazi RG. Antioxidant, antimicrobial and antimutogenic potential of 4 Iranian medicinal plants. Life Sci. J. 2013; 10(7):1085-91. 28. Sirois BC, Burg MM. Negative emotion and coronary heart disease: A review. Behavior modification. 2003; 27(1):83-102. https://doi.org/10.1177/0145445502238695 PMid:12587262 29. Mehrabi S, Ghafarian Shirhzi HR, Rasti M. Normal serum prostate specific antigen levels in men in Yasuj province, Islamic Republic of Iran. Eastern Mediterranean Health Journal. 2007; 13(5):1190-4. https://doi.org/10.26719/2007.13.5.1190 PMid:18290413 30. Manuck SB, Kaplan JR, Clarkson TB. Social instability and coronary artery atherosclerosis incynomolgus monkeys. NeurosciBiobehav Rev. 1983; 7(4):485–491. https://doi.org/10.1016/0149-7634(83)90028-3 31. Consoli SM, Lemogne C, Roch B, Laurent S, Plouin PF, Lane RD. Differences in emotion processing in patients with essential and secondary hypertension. Am J Hypertens. 2010; 14(5):515– 521. https://doi.org/10.1038/ajh.2010.9 PMid:20134404 32. Potijk MR, Janszky I, Reijneveld SA, Falkstedt D.Risk of Coronary Heart Disease in Men With Poor Emotional Control: A Prospective Study. Psychosom Med. 2016; 78(1):60-7. https://doi.org/10.1097/PSY.0000000000000254 PMid:26569537 33. Abad NH, Najafi Shala Doulatabad AM, Srazi HR. Treatment of Visual Hallucinations in Schizophrenia by Acetylcholinesterase Inhibitors: a case report. Iranian journal of psychiatry. 2011; 6(4):161. PMid:22952543 PMCid:PMC3395955 34. http://emotionalprocessing.org/definitions/ available 15/12/2017 35. Rachman S. Unwanted intrusive images in obsessive compulsive disorders. J Behav Ther Exp Psychiatry. 2007; 38(4):402-10. https://doi.org/10.1016/j.jbtep.2007.10.008 PMid:18054779 36. Rachman S. Emotional processing, with special reference to post-traumatic stress disorder. International Review of Psychiatry. 2001; 13(3):164-71. https://doi.org/10.1080/09540260120074028 37. Baker R, Holloway J, Thomas PW, Thomas S, Owens M. Emotional processing and panic. Behaviour Research and Therapy. 2004; 42(11):1271-87. https://doi.org/10.1016/j.brat.2003.09.002 PMid:15381438 21. Burg, M., Benedetto, C., Rosenberg, R., &Soufer, R. Depression prior to CABG predicts6-month and 2-year morbidity and mortality.Psychosomatic Medicine. 2001; 63:103. 38. Ali M, Nazir H, Banafshe A, Mohsen M, Fateme G, Hamidreza GS. Prevalence of dementia in Boyerahmad county of Iran. Life Science Journal-Acta Zhengzhou University Overseas Edition. 2012; 9(3):1312-4. 22. Mostofsky E, Maclure M, Tofler GH, Muller JE, Mittleman MA. Relation of outbursts of anger and risk of acute myocardial infarction. The American journal of cardiology. 2013; 112(3):343-8. https://doi.org/10.1016/j.amjcard.2013.03.035 PMid:23642509 PMCid:PMC3753402 39. Brosschot JF, Aarsse HR. Restricted emotional processing and somatic attribution in fibromyalgia. The International Journal of Psychiatry in Medicine. 2001; 31(2):127-46. https://doi.org/10.2190/K7AU-9UX9-W8BW-TETL PMid:11760858 23. Pimple P, Shah A, Rooks C, Bremner JD, Nye J, Ibeanu I, Murrah N, Shallenberger L, Kelley M, Raggi P, Vaccarino V. Association between anger and mental stress–induced myocardial ischemia. American heart journal. 2015; 169(1):115-21. https://doi.org/10.1016/j.ahj.2014.07.031 PMid:25497256 PMCid:PMC4268485 24. Vaccarino V, Goldberg J, Rooks C, Shah AJ, Veledar E, Faber TL, Votaw JR, Forsberg CW, Bremner JD. Post-traumatic stress disorder and incidence of coronary heart disease: a twin study. Journal of the American College of Cardiology. 2013; 62(11):970-8. https://doi.org/10.1016/j.jacc.2013.04.085 PMid:23810885 PMCid:PMC3823367 25. Roest AM, Martens EJ, de Jonge P, Denollet J. Anxiety and risk of incident coronary heart disease: a meta-analysis. Journal of the American College of Cardiology. 2010; 56(1):38-46. https://doi.org/10.1016/j.jacc.2010.03.034 PMid:20620715 26. Nabavizadeh SH, Malekzadeh M, Mousavizadeh A, Shirazi HR, Ghaffari P, Karshenas N, Malekzadeh T, Zoladl M. Retrospective study of factors related to preterm labor in Yasuj, Iran. International journal of general medicine. 2012; 5:1013. PMid:23271920 PMCid:PMC3526874 40. Brooks SK, Chalder T, Rimes KA. Chronic Fatigue Syndrome: Cognitive, Behavioural and Emotional Processing Vulnerability Factors. Behav Cogn Psychother. 2017; 45(2):156-169. https://doi.org/10.1017/S1352465816000631 PMid:28098051 41. Mayall C, Esteves J. Emotional processing and its contribution to chronic lower back pain –a pilot study. Platform Presentation at International Conference on Advances in Osteopathic Research. Italian College of Osteopathic Medicine, 2010. PMCid:PMC2976618 42. Verissimo R, Mota-Cardoso R, Taylor G. Relationships between alexithymia, emotional control, and quality of life in patients with inflammatory bowel disease. Psychotherapy and psychosomatics. 1998; 67(2):75-80. https://doi.org/10.1159/000012263 PMid:9556198 43. Mazaheri M, Afshar H, Weinland S, Mohammadi N, Adibi P. Alexithymia and functional gastrointestinal disorders (FGID). Med Arh. 2012; 66(1):28-32. https://doi.org/10.5455/medarh.2012.66.28-32 PMid:22482339 44. Weihs KL, Enright TM, Simmens SJ. Close relationships and emotional processing predict decreased mortality in women with breast cancer: preliminary evidence. Psychosom Med. 2008; 70(1):117-24. https://doi.org/10.1097/PSY.0b013e31815c25cf _______________________________________________________________________________________________________________________________ Open Access Maced J Med Sci. 5 Clinical Science _______________________________________________________________________________________________________________________________ PMid:18158376 45. Gremigni P, Santanastaso M. The emotional processing scale in Italy. In: Denollet J, Gidron Y, Nyklíček I, Vingerhoets A, editors. Proceedings of the Fourth International Conference on the (Non)Expression of Emotions in Health and Disease. the Netherlands: Tilburg, 2007; 131. 46. Greenberg LS, Pascual-Leone A. Emotion in psychotherapy: A practice-friendly research review.Journal of Clinical Psychology: In Session. 2006; 62:611–630. https://doi.org/10.1002/jclp.20252 PMid:16523500 47. Gay M-C, Bungener C, Thomas S, Vrignaud P, Thomas PW, Baker R, Montel S, Heinzlef O, Papeix C, Assouad R, Montreuil M. Anxiety, motional processing and depression in people with multiple sclerosis. BMC Neurology. 2017; 17:43-5. https://doi.org/10.1186/s12883-017-0803-8 PMid:28231828 PMCid:PMC5324294 48. Low CA, Stanton AL, Bower JE. Effects of acceptance-oriented versus evaluative emotional processing on heart rate recovery and habituation. Emotion. 2008; 8(3):419. https://doi.org/10.1037/15283542.8.3.419 PMid:18540758 49. Baker R, Thomas S, Thomas PW, Owens M. Development of an emotional processing scale. Journal of Psychosomatic Research. 2007; 62(2):167-78. https://doi.org/10.1016/j.jpsychores.2006.09.005 PMid:17270575 50. Baker R, Thomas S, Thomas PW, Gower P, Santonastaso M, Whittlesea A. The Emotional Processing Scale: scale refinement and abridgement (EPS-25). Journal of psychosomatic research. 2010; 68(1):83-8. https://doi.org/10.1016/j.jpsychores.2009.07.007 PMid:20004304 clinical trial. Clinical pharmacology: advances and applications. 2012; 4:1. PMid:22359466 PMCid:PMC3284259 52. Field A. Discovering statistics using SPSS. Sage publications; 2009. 53. Isasi CR, Ostrovsky NW, Wills TA. The association of emotion regulation with lifestyle behaviors in inner-city adolescents. Eat Behav 2013; 14:518–21. https://doi.org/10.1016/j.eatbeh.2013.07.009 PMid:24183148 PMCid:PMC3817414 54. Pressman SD, Cohen S. Does positive affect influence health? Psychol Bull. 2005; 131(6):925-971. https://doi.org/10.1037/00332909.131.6.925 PMid:16351329 55. Steptoe A, Wardle J, Marmot M. Positive affect and healthrelated neuroendocrine, cardiovascular, and inflammatory processes. Proc Natl Acad Sci U S A. 2005; 102(18):6508-6512. https://doi.org/10.1073/pnas.0409174102 PMid:15840727 PMCid:PMC1088362 56. Steptoe A, Wardle J. Positive affect and biological function in everyday life. Neurobiol Aging. 2005; 26(1):108-112. https://doi.org/10.1016/j.neurobiolaging.2005.08.016 PMid:16213629 57. Gross JJ, John OP. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. Journal of personality and social psychology. 2003; 85(2):348. https://doi.org/10.1037/0022-3514.85.2.348 58. Haukkala A, Konttinen H, Laatikainen T, Kawachi I, Uutela A. Hostility, anger control, and anger expression as predictors of cardiovascular disease. Psychosom Med. 2010; 72:556–62. https://doi.org/10.1097/PSY.0b013e3181dbab87 PMid:20410251 51. Hashemi SN, Shirazi HG, Mohammadi A, Zadeh-Bagheri GH, Noorian KH, Malekzadeh M. Nortriptyline versus fluoxetine in the treatment of major depressive disorder: a six-month, double-blind _______________________________________________________________________________________________________________________________ 6 https://www.id-press.eu/mjms/index