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Papers by Ad Appels

Current Opinion in Psychiatry, 2002

... Correspondence to Rob van Diest, Department of Psychiatry and Neuropsychology, Maastricht Uni... more ... Correspondence to Rob van Diest, Department of Psychiatry and Neuropsychology, Maastricht University, Box 616, 6200 MD, Maastricht, the Netherlands. Tel: +31 (0)43 3685337; fax: +31 (0)43 3685331; e-mail: rob.vandiest@pn.unimaas.nl. ... Cited Here... 16 Libby PL. ...

Journal of Human Stress, 1984

Unstable angina pectoris and feelings of fatigue and general malaise are often mentioned as premo... more Unstable angina pectoris and feelings of fatigue and general malaise are often mentioned as premonitory symptoms of myocardial infarction. From a psychological point of view these feelings of fatigue and malaise reflect a syndrome of vital exhaustion and depression (VED). A questionnaire which measures this syndrome was given to 3,571 males who participated in a voluntary health check up. It was found that the prevalence of "imminent myocardial infarction," defined as unstable angina pectoris plus electrocardiographic signs of ischaemia, was more than four times higher among exhausted and depressive persons, than among persons not so affected.

Psychology & Health, 2000

The main purpose of this research was to study the reliability and conceptual validity of two Spa... more The main purpose of this research was to study the reliability and conceptual validity of two Spanish language measures of Vital Exhaustion (VE), a short-term risk factor for coronary artery disease (CAD). The English version of the Maastricht Questionnaire for Vital Exhaustion was used to make a Spanish language questionnaire (VEQ) and a Spanish language interview (VEI) whose scoring systems

Patient Education and Counseling, 2004

This paper describes the development of the concept "vital exhaustion", the epidemiological evide... more This paper describes the development of the concept "vital exhaustion", the epidemiological evidence that this state belongs to the precursors of different manifestations of coronary artery disease, and the biological plausibility of the association between exhaustion and coronary artery disease. It further describes the main results of a randomized, controlled trial designed to determine whether a behavioural intervention reduces the risk of a new coronary event.

Journal of Psychosomatic Research, 1997

The evidence that depressive symptomatology precedes the onset of the acute coronary syndromes an... more The evidence that depressive symptomatology precedes the onset of the acute coronary syndromes and influences the course of disease after their manifestation is accumulating. However, we still are far short of proof that depression has a causal role in the etiology and pathogenesis of coronary heart disease (CHD). Some unsolved questions concern the causes and the nature of the depression preceding a first or recurrent cardiac event, the biological mechanisms relating depression and CHD, the time window of the exposure-disease association, and the power of therapy programs for depression to reduce the risk of a first or recurrent cardiac event.

Current Opinion in Psychiatry, 2002

The British Journal of Psychiatry, 1990

Both cardiologists and psychiatrists have observed that the onset of myocardial infarction is oft... more Both cardiologists and psychiatrists have observed that the onset of myocardial infarction is often preceded by feelings of decreasing energy, general malaise, and minor depression. This paper describes these observations and tries to integrate the findings. It is proposed that the mental state preceding myocardial infarction can be best described as 'vital exhaustion'.

Psychosomatic Medicine, 2007

Macrophage migration inhibitory factor (MIF), a protein secreted by immune cells and the pituitar... more Macrophage migration inhibitory factor (MIF), a protein secreted by immune cells and the pituitary gland, may be associated with coronary artery disease (CAD) and the mental state of coronary patients. The first origin of MIF suggests positive, the second negative associations. The aim of this study was to explore the direction of the association of MIF with CAD and of MIF with exhaustion, if any. Participants were 194 patients who had been recently treated by percutaneous coronary intervention (PCI) and who were exhausted at the start of the study. Half entered a behavioral intervention program. MIF, C-reactive protein, interleukin (IL)-6, IL-1 receptor antagonist, and neopterin were measured in blood collected 6 weeks after PCI (baseline) and 6 and 18 months after baseline. A single measurement of MIF was also available for 129 age- and sex-matched healthy individuals (reference group). At baseline, MIF in patients undergoing PCI was significantly lower than in the reference group (p < .01). New cardiac events occurred twice as often in the lowest quartile than in the highest quartile of MIF concentrations. However, the association was not significant (chi(2) = 2.27; df = 3; p = .52). During follow up, MIF concentrations increased significantly in patients undergoing PCI (p < .001). At 18 months, MIF concentrations were significantly lower in the exhausted patients than in the nonexhausted patients (p = .02). hsCRP, IL-1ra, IL-6, and neopter in concentrations did not change over this time period. The data are suggestive of a negative association of MIF with CAD and of MIF with exhaustion. The observation that those patients who remained exhausted had lower concentrations of MIF fits into earlier observations that suggested that exhausted coronary patients may be characterized by a hypoactivity of the hypothalamic-pituitary-adrenocortical axis.

Psychosomatic Medicine, 1998

Acute physical and psychological stressors affect blood coagulation and fibrinolysis, but little ... more Acute physical and psychological stressors affect blood coagulation and fibrinolysis, but little is known about hemostatic factors associated with chronic psychological stress. Prolonged psychological stress may end in a state of vital exhaustion, which has been shown to be a risk factor for first myocardial infarction and recurrent events after coronary angioplasty. The present study tested the hypothesis that vital exhaustion resulting from chronic psychological stress is associated with impaired fibrinolytic capacity and increased coagulation factors. On the basis of a validated questionnaire and subsequent structured interview, a well-defined group of otherwise healthy exhausted men was recruited (N = 15) and compared with age-matched not-exhausted controls (N = 15). Fibrinolytic measures included tissue plasminogen activator (TPA) antigen and plasminogen activator inhibitor (PAI-1) activity, and as coagulation factors we examined factors VIIc, factor VIIIc, and fibrinogen. Control variables were: blood pressure, smoking status, triglycerides, cholesterol, and standard hematological measures. Samples were collected twice to correct for intraindividual fluctuations. Statistical analyses were performed using 2 x 2 mixed model analysis of variance with subsequent univariate testing. Vital exhaustion was associated with significantly elevated levels of PAI-1 activity (p = .023). The higher PAI-1 activity in exhausted subjects (median = 13.0 U/ml vs. 6.0 U/ml) was not accounted for by smoking status or serum lipids. No significant differences were observed in TPA antigen, factor VIIc, factor VIIIc, and fibrinogen. The groups did not differ in blood pressure, smoking status, triglycerides, cholesterol, or standard hematological measures. These data suggest a reduced fibrinolytic capacity in exhausted individuals. Therefore, the relationship between vital exhaustion and risk of myocardial infarction may be mediated in part by an imbalance between blood coagulation and fibrinolysis.

Psychosomatic Medicine, 2003

Infections with herpes viruses have been implicated in the pathogenesis of atherosclerosis. We te... more Infections with herpes viruses have been implicated in the pathogenesis of atherosclerosis. We tested the hypothesis that vital exhaustion (VE) is associated with multiple herpesvirus infections, such as herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, and cytomegalovirus, and with an increase in pathogen burden (ie, the aggregated seropositivity to immunoglobulin G antibodies for herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, and cytomegalovirus). In addition, we examined the association of VE and pathogen burden with measures of hemostasis and inflammation. Blood samples were drawn from 29 men with VE and 30 male control subjects, all healthy and nonsmokers, to assess serological evidence of infection and measures of hemostasis and inflammation. VE is associated with a relatively high pathogen burden, altered hemostasis, and higher levels of cytokines, such as interleukin-6. Across all subjects, a relatively high pathogen burden was also associated with altered hemostasis but not with increased cytokine levels. The interaction of VE with pathogen burden revealed significant linear increases in measures of hemostasis and inflammation. Finally, immunoglobulin G antibody titer levels of individual herpesvirus infections were not associated with hemostatic measures or with cytokines. We conclude that stress-related alterations in hemostasis and inflammation are not necessarily linked to one particular herpesvirus infection but rather to an increase in aggregated seropositivity to herpesvirus infections.

Medical Hypotheses, 1997

An enduring state of exhaustion as opposed to chronic hostility-a long-term risk factor-has been ... more An enduring state of exhaustion as opposed to chronic hostility-a long-term risk factor-has been found to be a more proximal precursor of myocardial infarction. The strength of the association with exhaustion suggests that this behavioral factor reflects not only a breakdown in adaptation to chronic stressors but also the disease process itself. Recent research on the pathogenesis of myocardial infarction lends credence to a role for immunological factors. herein, we outline a two-stage theoretical model, postulating a feedback relationship between behavior, associated neuroendocrine changes, immunological responses, and the pathogenesis of this disease. We propose a long-term first stage consisting of chronic hostility, prolonged occupational over-exertion, and exposure to other life stressors, terminating eventually in a much shorter second stage of 'vital exhaustion'. Stressor-associated neuroendocrine changes result in immunosuppression leading to reactivation of latent, systemic infections (such as cytomegalovirus) and potentially to autoimmune reactions as well. The consequent release of pro-inflammatory cytokines exacerbates fatigue and induces a stimulus for cytokine production in brain. This cytokine production stimulates a chronically activated, over-compensated limbic-hypothalamic-pituitary-adrenal axis, resulting in a dampened response, continued exhaustion, and a potential 'reverberating circuit' between behavior, neuroendocrine change, cytokine release and coronary artery occlusion, culminating in myocardial infarction.

Behavioral Medicine, 2000

Little is known about the nature of the depressive symptomatology preceding myocardial infarction... more Little is known about the nature of the depressive symptomatology preceding myocardial infarction (MI). Specification of the depressive symptomatology is important for the development of hypotheses about the biological mechanisms relating depressive symptoms to MI. To test the hypothesis that feelings of fatigue and loss of energy have the strongest predictive power of all depressive symptoms, the authors reanalyzed data from a prospective study of 3877 healthy men aged 40 to 65 years. The men's mental state was assessed using the Maastricht Questionnaire, a scale that measures vital exhaustion, which is characterized by unusual fatigue and lack of energy, increased irritability, and depressive symptoms, including demoralization. Oblique factor analysis was used to validate these dimensions. Results of Cox's regression analyses showed that the fatigue subscale has the strongest predictive power for incident MI and that depression and irritability subscales lose their predictive power when controlled for fatigue.

Behavioral Medicine, 1991

During the preparation of a prospective study of exhaustion as a precursor of myocardial infarcti... more During the preparation of a prospective study of exhaustion as a precursor of myocardial infarction (MI), the authors found that many coronary patients said that they had been burned out at some time in their lives. Therefore, the question, "Have you ever been burned out?" was included in the study. The cohort was formed by 3,877 men, aged 39 to 65, and was followed up on for 4.2 years. Among the men who were free of coronary heart disease (CHD) at screening, 59 subjects experienced a fatal or nonfatal myocardial infarction during follow-up. Those who endorsed the above question when they entered the study were found to be at increased risk for myocardial infarction when the authors controlled for age, blood pressure, smoking, and cholesterol; RR (relative risk) = 2.13; p less than .01. About one third of those who were exhausted before myocardial infarction had been burned out at some time in their lives, chi 2 = 7.09, p less than .01. The data indicate that a state of exhaustion before myocardial infarction is often a reactivation of earlier periods of breakdown in adaptation to stress.

The American Journal of Cardiology, 1991

The American Journal of Cardiology, 1996

This study examines the effect of anger and vital exhaustion on recurrent evenk after translumina... more This study examines the effect of anger and vital exhaustion on recurrent evenk after transluminal coronary angioplasty (PTC Ape rcutaneous . Data came from 149 patients (123 men and 26 *omen) who underwent successful PTCA. During 18 months of followup, there were 37 recurrent events (25%) for which there was objective evidence of new or progression of coronary disease. The 123 male patients with high anger were si sel disease lx! nificantly more likely to have multivesore PTCA (odds ratio 2.42; p = 0.04), after controlling for standard heart disease risk factors. High-anger male patients also had a *reefold increased risk for recurrent events after PTCA (RR 2.94; p = O.Ol), which remained marginally significant after accounting for other heart disease risk factors and residual stenosis after PTCA (RR 2.33; p = 0.09). Amon female patients, these relations were much weaker an 1 not statistically significant. Among male 9"

Emotion, 2006

The EXhaustion Intervention Trial investigated the effect of a behavioural intervention programme... more The EXhaustion Intervention Trial investigated the effect of a behavioural intervention programme on exhaustion, health-related quality of life (HRQL), depression, anxiety, hostility, and anginal complaints in angioplasty patients who felt exhausted after percutaneous coronary intervention (PCI). Seven hundred ten patients were randomized into an intervention group and a usual care control group. The group intervention focused on stressors leading to exhaustion and on support of recovery. HRQL (measured by the MacNew questionnaire), exhaustion [measured by the Maastricht Questionnaire and the Maastricht Interview Vital Exhaustion (MIVE)], anxiety (measured by the State-Trait Inventory), and depression (measured by the structured clinical interview for DSM-IV) were assessed at intake and at 6 and 18 months. Presence of anginal complaints was assessed at 18 months. The intervention had a significant beneficial effect on all psychological factors except hostility and on the presence of anginal complaints. The effect of the intervention on exhaustion, as assessed by the MIVE, was modified by a previous history of coronary artery disease (CAD). Gender modified the effect of the intervention on exhaustion and on anxiety, the strongest effect being observed in women. The behavioural intervention improved HRQL and related psychological factors. Somatic comorbidity and a history of CAD limited the effect of the intervention.

Journal of chronic diseases, 1987

Type A behavior was assessed in Rotterdam in 3171 males, aged 45-59 years, by the Jenkins Activit... more Type A behavior was assessed in Rotterdam in 3171 males, aged 45-59 years, by the Jenkins Activity Survey (JAS) as part of the Kaunas-Rotterdam Intervention Study (KRIS). During a follow-up period of 9 1/2 years, 112 fatal and 157 non-fatal cases of myocardial infarction occurred. The JAS did not predict future cases of fatal or non-fatal myocardial infarction. Persons scoring highest on the hard-driving scale or the Dutch adaptation of the JAS tended to have higher incidences of angina pectoris. However, overall the validity of this test as a predictor of CHD was not substantiated in this population.

Psychotherapy and psychosomatics

Various definitions of both group cohesion and working alliance are used in theories on group psy... more Various definitions of both group cohesion and working alliance are used in theories on group psychotherapy, making the study of their relative contribution to the treatment outcome difficult. In this study, two different, nonoverlapping questionnaires were used to explore the relationship between group cohesion, working alliance and treatment outcome in a time-limited, structured cognitive behavioral group psychotherapy aiming at the reduction of coronary risk factors. After having undergone percutaneous transluminal coronary angioplasty, 42 patients were treated with the aim to reduce exhaustion, anxiety, hostility and depression. The newly developed Group Cohesion Questionnaire (GCQ) and the Helping Alliance Questionnaire (HAQ-II, measuring the bond between individual patients and the group psychotherapist) were administered after the fifth and tenth treatment session. Exhaustion, quality of life, anxiety, blood pressure and heart rate were measured before and after treatment. To...

East-West Life Expectancy Gap in Europe, 1996

Psychosomatic Medicine, 1998

ABSTRACT

Current Opinion in Psychiatry, 2002

... Correspondence to Rob van Diest, Department of Psychiatry and Neuropsychology, Maastricht Uni... more ... Correspondence to Rob van Diest, Department of Psychiatry and Neuropsychology, Maastricht University, Box 616, 6200 MD, Maastricht, the Netherlands. Tel: +31 (0)43 3685337; fax: +31 (0)43 3685331; e-mail: rob.vandiest@pn.unimaas.nl. ... Cited Here... 16 Libby PL. ...

Journal of Human Stress, 1984

Unstable angina pectoris and feelings of fatigue and general malaise are often mentioned as premo... more Unstable angina pectoris and feelings of fatigue and general malaise are often mentioned as premonitory symptoms of myocardial infarction. From a psychological point of view these feelings of fatigue and malaise reflect a syndrome of vital exhaustion and depression (VED). A questionnaire which measures this syndrome was given to 3,571 males who participated in a voluntary health check up. It was found that the prevalence of "imminent myocardial infarction," defined as unstable angina pectoris plus electrocardiographic signs of ischaemia, was more than four times higher among exhausted and depressive persons, than among persons not so affected.

Psychology & Health, 2000

The main purpose of this research was to study the reliability and conceptual validity of two Spa... more The main purpose of this research was to study the reliability and conceptual validity of two Spanish language measures of Vital Exhaustion (VE), a short-term risk factor for coronary artery disease (CAD). The English version of the Maastricht Questionnaire for Vital Exhaustion was used to make a Spanish language questionnaire (VEQ) and a Spanish language interview (VEI) whose scoring systems

Patient Education and Counseling, 2004

This paper describes the development of the concept "vital exhaustion", the epidemiological evide... more This paper describes the development of the concept "vital exhaustion", the epidemiological evidence that this state belongs to the precursors of different manifestations of coronary artery disease, and the biological plausibility of the association between exhaustion and coronary artery disease. It further describes the main results of a randomized, controlled trial designed to determine whether a behavioural intervention reduces the risk of a new coronary event.

Journal of Psychosomatic Research, 1997

The evidence that depressive symptomatology precedes the onset of the acute coronary syndromes an... more The evidence that depressive symptomatology precedes the onset of the acute coronary syndromes and influences the course of disease after their manifestation is accumulating. However, we still are far short of proof that depression has a causal role in the etiology and pathogenesis of coronary heart disease (CHD). Some unsolved questions concern the causes and the nature of the depression preceding a first or recurrent cardiac event, the biological mechanisms relating depression and CHD, the time window of the exposure-disease association, and the power of therapy programs for depression to reduce the risk of a first or recurrent cardiac event.

Current Opinion in Psychiatry, 2002

The British Journal of Psychiatry, 1990

Both cardiologists and psychiatrists have observed that the onset of myocardial infarction is oft... more Both cardiologists and psychiatrists have observed that the onset of myocardial infarction is often preceded by feelings of decreasing energy, general malaise, and minor depression. This paper describes these observations and tries to integrate the findings. It is proposed that the mental state preceding myocardial infarction can be best described as 'vital exhaustion'.

Psychosomatic Medicine, 2007

Macrophage migration inhibitory factor (MIF), a protein secreted by immune cells and the pituitar... more Macrophage migration inhibitory factor (MIF), a protein secreted by immune cells and the pituitary gland, may be associated with coronary artery disease (CAD) and the mental state of coronary patients. The first origin of MIF suggests positive, the second negative associations. The aim of this study was to explore the direction of the association of MIF with CAD and of MIF with exhaustion, if any. Participants were 194 patients who had been recently treated by percutaneous coronary intervention (PCI) and who were exhausted at the start of the study. Half entered a behavioral intervention program. MIF, C-reactive protein, interleukin (IL)-6, IL-1 receptor antagonist, and neopterin were measured in blood collected 6 weeks after PCI (baseline) and 6 and 18 months after baseline. A single measurement of MIF was also available for 129 age- and sex-matched healthy individuals (reference group). At baseline, MIF in patients undergoing PCI was significantly lower than in the reference group (p < .01). New cardiac events occurred twice as often in the lowest quartile than in the highest quartile of MIF concentrations. However, the association was not significant (chi(2) = 2.27; df = 3; p = .52). During follow up, MIF concentrations increased significantly in patients undergoing PCI (p < .001). At 18 months, MIF concentrations were significantly lower in the exhausted patients than in the nonexhausted patients (p = .02). hsCRP, IL-1ra, IL-6, and neopter in concentrations did not change over this time period. The data are suggestive of a negative association of MIF with CAD and of MIF with exhaustion. The observation that those patients who remained exhausted had lower concentrations of MIF fits into earlier observations that suggested that exhausted coronary patients may be characterized by a hypoactivity of the hypothalamic-pituitary-adrenocortical axis.

Psychosomatic Medicine, 1998

Acute physical and psychological stressors affect blood coagulation and fibrinolysis, but little ... more Acute physical and psychological stressors affect blood coagulation and fibrinolysis, but little is known about hemostatic factors associated with chronic psychological stress. Prolonged psychological stress may end in a state of vital exhaustion, which has been shown to be a risk factor for first myocardial infarction and recurrent events after coronary angioplasty. The present study tested the hypothesis that vital exhaustion resulting from chronic psychological stress is associated with impaired fibrinolytic capacity and increased coagulation factors. On the basis of a validated questionnaire and subsequent structured interview, a well-defined group of otherwise healthy exhausted men was recruited (N = 15) and compared with age-matched not-exhausted controls (N = 15). Fibrinolytic measures included tissue plasminogen activator (TPA) antigen and plasminogen activator inhibitor (PAI-1) activity, and as coagulation factors we examined factors VIIc, factor VIIIc, and fibrinogen. Control variables were: blood pressure, smoking status, triglycerides, cholesterol, and standard hematological measures. Samples were collected twice to correct for intraindividual fluctuations. Statistical analyses were performed using 2 x 2 mixed model analysis of variance with subsequent univariate testing. Vital exhaustion was associated with significantly elevated levels of PAI-1 activity (p = .023). The higher PAI-1 activity in exhausted subjects (median = 13.0 U/ml vs. 6.0 U/ml) was not accounted for by smoking status or serum lipids. No significant differences were observed in TPA antigen, factor VIIc, factor VIIIc, and fibrinogen. The groups did not differ in blood pressure, smoking status, triglycerides, cholesterol, or standard hematological measures. These data suggest a reduced fibrinolytic capacity in exhausted individuals. Therefore, the relationship between vital exhaustion and risk of myocardial infarction may be mediated in part by an imbalance between blood coagulation and fibrinolysis.

Psychosomatic Medicine, 2003

Infections with herpes viruses have been implicated in the pathogenesis of atherosclerosis. We te... more Infections with herpes viruses have been implicated in the pathogenesis of atherosclerosis. We tested the hypothesis that vital exhaustion (VE) is associated with multiple herpesvirus infections, such as herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, and cytomegalovirus, and with an increase in pathogen burden (ie, the aggregated seropositivity to immunoglobulin G antibodies for herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, and cytomegalovirus). In addition, we examined the association of VE and pathogen burden with measures of hemostasis and inflammation. Blood samples were drawn from 29 men with VE and 30 male control subjects, all healthy and nonsmokers, to assess serological evidence of infection and measures of hemostasis and inflammation. VE is associated with a relatively high pathogen burden, altered hemostasis, and higher levels of cytokines, such as interleukin-6. Across all subjects, a relatively high pathogen burden was also associated with altered hemostasis but not with increased cytokine levels. The interaction of VE with pathogen burden revealed significant linear increases in measures of hemostasis and inflammation. Finally, immunoglobulin G antibody titer levels of individual herpesvirus infections were not associated with hemostatic measures or with cytokines. We conclude that stress-related alterations in hemostasis and inflammation are not necessarily linked to one particular herpesvirus infection but rather to an increase in aggregated seropositivity to herpesvirus infections.

Medical Hypotheses, 1997

An enduring state of exhaustion as opposed to chronic hostility-a long-term risk factor-has been ... more An enduring state of exhaustion as opposed to chronic hostility-a long-term risk factor-has been found to be a more proximal precursor of myocardial infarction. The strength of the association with exhaustion suggests that this behavioral factor reflects not only a breakdown in adaptation to chronic stressors but also the disease process itself. Recent research on the pathogenesis of myocardial infarction lends credence to a role for immunological factors. herein, we outline a two-stage theoretical model, postulating a feedback relationship between behavior, associated neuroendocrine changes, immunological responses, and the pathogenesis of this disease. We propose a long-term first stage consisting of chronic hostility, prolonged occupational over-exertion, and exposure to other life stressors, terminating eventually in a much shorter second stage of 'vital exhaustion'. Stressor-associated neuroendocrine changes result in immunosuppression leading to reactivation of latent, systemic infections (such as cytomegalovirus) and potentially to autoimmune reactions as well. The consequent release of pro-inflammatory cytokines exacerbates fatigue and induces a stimulus for cytokine production in brain. This cytokine production stimulates a chronically activated, over-compensated limbic-hypothalamic-pituitary-adrenal axis, resulting in a dampened response, continued exhaustion, and a potential 'reverberating circuit' between behavior, neuroendocrine change, cytokine release and coronary artery occlusion, culminating in myocardial infarction.

Behavioral Medicine, 2000

Little is known about the nature of the depressive symptomatology preceding myocardial infarction... more Little is known about the nature of the depressive symptomatology preceding myocardial infarction (MI). Specification of the depressive symptomatology is important for the development of hypotheses about the biological mechanisms relating depressive symptoms to MI. To test the hypothesis that feelings of fatigue and loss of energy have the strongest predictive power of all depressive symptoms, the authors reanalyzed data from a prospective study of 3877 healthy men aged 40 to 65 years. The men's mental state was assessed using the Maastricht Questionnaire, a scale that measures vital exhaustion, which is characterized by unusual fatigue and lack of energy, increased irritability, and depressive symptoms, including demoralization. Oblique factor analysis was used to validate these dimensions. Results of Cox's regression analyses showed that the fatigue subscale has the strongest predictive power for incident MI and that depression and irritability subscales lose their predictive power when controlled for fatigue.

Behavioral Medicine, 1991

During the preparation of a prospective study of exhaustion as a precursor of myocardial infarcti... more During the preparation of a prospective study of exhaustion as a precursor of myocardial infarction (MI), the authors found that many coronary patients said that they had been burned out at some time in their lives. Therefore, the question, "Have you ever been burned out?" was included in the study. The cohort was formed by 3,877 men, aged 39 to 65, and was followed up on for 4.2 years. Among the men who were free of coronary heart disease (CHD) at screening, 59 subjects experienced a fatal or nonfatal myocardial infarction during follow-up. Those who endorsed the above question when they entered the study were found to be at increased risk for myocardial infarction when the authors controlled for age, blood pressure, smoking, and cholesterol; RR (relative risk) = 2.13; p less than .01. About one third of those who were exhausted before myocardial infarction had been burned out at some time in their lives, chi 2 = 7.09, p less than .01. The data indicate that a state of exhaustion before myocardial infarction is often a reactivation of earlier periods of breakdown in adaptation to stress.

The American Journal of Cardiology, 1991

The American Journal of Cardiology, 1996

This study examines the effect of anger and vital exhaustion on recurrent evenk after translumina... more This study examines the effect of anger and vital exhaustion on recurrent evenk after transluminal coronary angioplasty (PTC Ape rcutaneous . Data came from 149 patients (123 men and 26 *omen) who underwent successful PTCA. During 18 months of followup, there were 37 recurrent events (25%) for which there was objective evidence of new or progression of coronary disease. The 123 male patients with high anger were si sel disease lx! nificantly more likely to have multivesore PTCA (odds ratio 2.42; p = 0.04), after controlling for standard heart disease risk factors. High-anger male patients also had a *reefold increased risk for recurrent events after PTCA (RR 2.94; p = O.Ol), which remained marginally significant after accounting for other heart disease risk factors and residual stenosis after PTCA (RR 2.33; p = 0.09). Amon female patients, these relations were much weaker an 1 not statistically significant. Among male 9"

Emotion, 2006

The EXhaustion Intervention Trial investigated the effect of a behavioural intervention programme... more The EXhaustion Intervention Trial investigated the effect of a behavioural intervention programme on exhaustion, health-related quality of life (HRQL), depression, anxiety, hostility, and anginal complaints in angioplasty patients who felt exhausted after percutaneous coronary intervention (PCI). Seven hundred ten patients were randomized into an intervention group and a usual care control group. The group intervention focused on stressors leading to exhaustion and on support of recovery. HRQL (measured by the MacNew questionnaire), exhaustion [measured by the Maastricht Questionnaire and the Maastricht Interview Vital Exhaustion (MIVE)], anxiety (measured by the State-Trait Inventory), and depression (measured by the structured clinical interview for DSM-IV) were assessed at intake and at 6 and 18 months. Presence of anginal complaints was assessed at 18 months. The intervention had a significant beneficial effect on all psychological factors except hostility and on the presence of anginal complaints. The effect of the intervention on exhaustion, as assessed by the MIVE, was modified by a previous history of coronary artery disease (CAD). Gender modified the effect of the intervention on exhaustion and on anxiety, the strongest effect being observed in women. The behavioural intervention improved HRQL and related psychological factors. Somatic comorbidity and a history of CAD limited the effect of the intervention.

Journal of chronic diseases, 1987

Type A behavior was assessed in Rotterdam in 3171 males, aged 45-59 years, by the Jenkins Activit... more Type A behavior was assessed in Rotterdam in 3171 males, aged 45-59 years, by the Jenkins Activity Survey (JAS) as part of the Kaunas-Rotterdam Intervention Study (KRIS). During a follow-up period of 9 1/2 years, 112 fatal and 157 non-fatal cases of myocardial infarction occurred. The JAS did not predict future cases of fatal or non-fatal myocardial infarction. Persons scoring highest on the hard-driving scale or the Dutch adaptation of the JAS tended to have higher incidences of angina pectoris. However, overall the validity of this test as a predictor of CHD was not substantiated in this population.

Psychotherapy and psychosomatics

Various definitions of both group cohesion and working alliance are used in theories on group psy... more Various definitions of both group cohesion and working alliance are used in theories on group psychotherapy, making the study of their relative contribution to the treatment outcome difficult. In this study, two different, nonoverlapping questionnaires were used to explore the relationship between group cohesion, working alliance and treatment outcome in a time-limited, structured cognitive behavioral group psychotherapy aiming at the reduction of coronary risk factors. After having undergone percutaneous transluminal coronary angioplasty, 42 patients were treated with the aim to reduce exhaustion, anxiety, hostility and depression. The newly developed Group Cohesion Questionnaire (GCQ) and the Helping Alliance Questionnaire (HAQ-II, measuring the bond between individual patients and the group psychotherapist) were administered after the fifth and tenth treatment session. Exhaustion, quality of life, anxiety, blood pressure and heart rate were measured before and after treatment. To...

East-West Life Expectancy Gap in Europe, 1996

Psychosomatic Medicine, 1998

ABSTRACT