1. 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, PhD
Professor Emeritus, University of Pennsylvania
Professor, University of Groningen, University Medical
Center Groningen (UMCG), The Netherlands

2. 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.

3. We are witnessing the demise of Type
D personality as latest contender, but
more await promoting.

4. 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.

7. 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.

8. 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)

9. 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.
.

10. Key Distinction
Modifiable Risk Factor
Versus
Uninformative Risk Marker

11. 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.

12. 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.

13. AAllkkyyll NNiittrraattee PPooppppeerrss
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.

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

15. 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.

18. 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!

19. 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.

21. 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.

22. 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.

23. 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.

24. 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.…

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.”

31. 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.

32. 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.

33. “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?

34. 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

35. The effective end to confusing
scat with a bear?

36. 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.