Top

Journal of Behavioral Medicine

Tip

Swipe om te navigeren naar een ander artikel

Gepubliceerd in:

24-10-2017

Attachment and telomere length: more evidence for psychobiological connections between close relationships, health, and aging

Auteurs: Kyle W. Murdock, Samuele Zilioli, Khadija Ziauddin, Cobi J. Heijnen, Christopher P. Fagundes

Gepubliceerd in: Journal of Behavioral Medicine | Uitgave 3/2018

Abstract

Individuals with a history of poor interpersonal relationships are more likely to demonstrate negative health outcomes than those who have had high quality relationships. We sought to evaluate how attachment orientations, stress-induced respiratory sinus arrhythmia (RSA), and self-reported stress were associated with length of telomeres measured from peripheral blood mononuclear cells. Participants (N = 213) completed self-report measures of attachment and stress. Measurement of RSA was conducted before and after a stressful task and a blood draw was completed for analysis of telomere length. Attachment orientations were not directly associated with telomere length; however, we found that high attachment anxiety was associated with shorter length of telomeres via high self-reported stress. Attachment avoidance was also associated with telomere length via self-reported stress, but only among those with high stress-induced RSA. Exploratory analyses of T cell subsets indicated that stress was most strongly associated with telomeres from CD8CD28+ cells in comparison to CD8CD28− and CD4 cells. Study findings indicate that attachment orientations are associated with telomere length via stress, providing novel insights into the mechanisms through which close relationships can impact health and aging.

vorige artikel Combining risk communication strategies to simultaneously convey the risks of four diseases associated with physical inactivity to socio-demographically diverse populations

volgende artikel Lower life satisfaction, active coping and cardiovascular disease risk factors in older African Americans: outcomes of a longitudinal church-based intervention

Barrett, J. H., Iles, M. M., Dunning, A. M., & Pooley, K. A. (2015). Telomere length and common disease: Study design and analytical challenges. Human Genetics, 134, 679–689. doi: 10.1007/s00439-015-1563-4 CrossRefPubMedPubMedCentral

Baumeister, R. F., & Heatherton, T. F. (1996). Self-regulation failure: An overview. Psychological Inquiry, 7, 1–15. CrossRef

Beauchaine, T. P. (2001). Vagal tone, development, and Gray’s motivational theory: Toward an integrated model of autonomic nervous system functioning in psychopathology. Development and Psychopathology, 13, 183–214. doi: 10.1017/S0954579401002012 CrossRefPubMed

Bentler, P. M. (2004). EQS (Version 6.1). Encino, CA: Multivariate Software.

Bilsland, A. E., Cairney, C. J., & Keith, W. N. (2011). Targeting the telomere and shelterin complex for cancer therapy: Current views and future perspectives. Journal of Cellular and Molecular Medicine, 15, 179–186. doi: 10.1111/j.1582-4934.2010.01253.x CrossRefPubMedPubMedCentral

Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-reported measurement of adult attachment: An integrative overview. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships (pp. 46–76). New York: Guilford Press.

Brody, G. H., Yu, T., Beach, S. R. H., & Philibert, R. A. (2015). Prevention effects ameliorate the prospective association between nonsupportive parenting and diminished telomere length. Prevention Science, 16, 171–180. doi: 10.1007/s11121-014-0474-2 CrossRefPubMedPubMedCentral

Brummett, B. H., Barefoot, J. C., Siegler, I. C., Clapp-Channing, N. E., Lytle, B. L., Bosworth, H. B., et al. (2001). Characteristics of socially isolated patients with coronary artery disease who are at elevated risk for mortality. Psychosomatic Medicine, 63, 267–272. CrossRefPubMed

Carroll, J. E., Diez Roux, A. V., Fitzpatrick, A. L., & Seeman, T. (2013). Low social support is associated with shorter leukocyte telomere length in late life: Multi-Ethnic Study of Atherosclerosis (MESA). Psychosomatic Medicine, 75, 171–177. doi: 10.1097/PSY.0b013e31828233bf CrossRefPubMed

Chen, W., Kimura, M., Kim, S., Cao, X., Srinivasan, S. R., Berenson, G. S., et al. (2011). Longitudinal versus cross-sectional evaluations of leukocyte telomere length dynamics: Age-dependent telomere shortening is the rule. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 66a, 312–319. doi: 10.1093/gerona/glq223 CrossRefPubMedCentral

Cohen, S., Janicki-Deverts, D., Turner, R. B., Casselbrant, M. L., Li-Korotky, H. S., Epel, E. S., et al. (2013). Association between telomere length and experimentally induced upper respiratory viral infection in healthy adults. JAMA, 309, 699–705. doi: 10.1001/jama.2013.613 CrossRefPubMedPubMedCentral

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396. doi: 10.2307/2136404 CrossRefPubMed

Dewitte, M., De Houwer, J., Goubert, L., & Buysse, A. (2010). A multi-modal approach to the study of attachment related distress. Biological Psychiatry, 85, 149–162. doi: 10.1016/j.biopsycho.2010.06.006 CrossRef

Ditzen, B., Schmidt, S., Strauss, B., Nater, U. M., Ehlert, U., & Heinrichs, M. (2008). Adult attachment and social support interact to reduce psychological but not cortisol responses to stress. Journal of Psychosomatic Research, 64, 479–486. doi: 10.1016/j.jpsychores.2007.11.011 CrossRefPubMed

Dowd, J. B., Zajacova, A., & Aiello, A. E. (2010). Predictors of inflammation in U.S. children aged 3–16 years. American Journal of Preventative Medicine, 39, 314–320. doi: 10.1016/j.amepre.2010.05.014 CrossRef

Duhamel, P., & Vetterli, M. (1990). Fast Fourier transforms: A tutorial review and state of the art. Signal Process, 19, 259–299. doi: 10.1016/0165-1684(90)90158-U CrossRef

Effros, R. B., Allsopp, R., Chiu, C. P., Hausner, M. A., Hirji, K., Wang, L., et al. (1996). Shortened telomeres in the expanded CD28–CD8+ cell subset in HIV disease implicate replicative senescence in HIV pathogenesis. AIDS, 10, 17–22. CrossRef

El-Sheikh, M. (2004). Stability of respiratory sinus arrhythmia in children and young adolescents: A longitudinal investigation. Developmental Psychobiology, 46, 66–74. doi: 10.1002/dev.20036 CrossRef

Epel, E. S., Blackburn, E. H., Lin, J., Dhabhar, F. S., Adler, N. E., Morrow, J. D., et al. (2004). Accelerated telomere shortening in response to life stress. Proceedings of the National Academy of Sciences of the United States of America, 101, 17312–17315. doi: 10.1073/pnas.0407162101 CrossRefPubMedPubMedCentral

Epel, E. S., Lin, J., Willhelm, F. H., Wolkowitz, O. M., Cawthon, R., Adler, N. E., et al. (2006). Cell aging in relation to stress arousal and cardiovascular disease risk factors. Psychoneuroendocrinology, 31, 277–287. doi: 10.1016/j.psyneuen.2005.08.011 CrossRefPubMed

Fagundes, C. P., Diamond, L. M., & Allen, K. P. (2012). Adolescent attachment insecurity and parasympathetic functioning predict future loss adjustment. Personality and Social Psychology Bulletin, 38, 821–832. doi: 10.1177/0146167212437429 CrossRefPubMed

Fagundes, C. P., Jaremka, L. M., Glaser, R., Alfano, C. M., Povoski, S. P., Lipari, A. M., et al. (2014a). Attachment anxiety is related to Epstein–Barr virus latency. Brain, Behavior, and Immunity, 41, 232–238. doi: 10.1016/j.bbi.2014.04.002 CrossRefPubMedPubMedCentral

Fagundes, C. P., Jaremka, L. M., Malarkey, W. B., & Kiecolt-Glaser, J. K. (2014b). Attachment style and respiratory sinus arrhythmia predict post-treatment quality of life in breast cancer survivors. Psycho-Oncology, 23, 820–826. doi: 10.1002/pon.3492 CrossRefPubMedPubMedCentral

Ford, J. L., & Stowe, R. P. (2013). Racial-ethnic differences in Epstein–Barr virus antibody titers among U.S. children and adolescents. Annals of Epidemiology, 23, 275–280. doi: 10.1016/j.annepidem.2013.02.008 CrossRefPubMed

Fraley, R. C., & Shaver, P. R. (2000). Adult romantic attachment: Theoretical developments, emerging controversies, and unanswered questions. Review of General Psychology, 4, 132–154. doi: 10.1037//1089-2680.4.2.132 CrossRef

Gentzler, A. L., Santucci, A. K., Kovacs, M., & Fox, N. A. (2009). Respiratory sinus arrhythmia reactivity predicts emotion regulation and depressive symptoms in at-risk and control children. Biological Psychology, 82, 156–163. doi: 10.1016/j.biopsycho.2009.07.002 CrossRefPubMedPubMedCentral

Gilley, D., Herbert, B. S., Huda, N., Tanaka, H., & Reed, T. (2008). Factors impacting human telomere homeostasis and age-related disease. Mechanisms of Ageing and Development, 129, 27–37. doi: 10.1016/j.mad.2007.10.010 CrossRefPubMed

Gouin, J. P., Glaser, R., Loving, T. J., Malarkey, W. B., Stowell, J., Houts, C., et al. (2009). Attachment avoidance predicts inflammatory responses to marital conflict. Brain, Behavior, and Immunity, 23, 898–904. doi: 10.1016/j.bbi.2008.09.016 CrossRefPubMed

Grossman, P., & Svebak, S. (1987). Respiratory sinus arrhythmia as an index of parasympathetic cardiac control during active coping. Psychophysiology, 24, 228–235. doi: 10.1111/j.1469-8986.1987.tb00284.x CrossRefPubMed

Haycock, P. C., Heydon, E. E., Kaptoge, S., Butterworth, A. S., Thompson, A., & Willeit, P. (2014). Leukocyte telomere length and risk of cardiovascular disease: Systematic Review and meta-analysis. British Medical Journal, 349, g4227. doi: 10.1136/bmj.g4227 CrossRefPubMedPubMedCentral

Hayes, A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Communication Monographs, 76, 408–420. doi: 10.1080/03637750903310360 CrossRef

Heidinger, B. J., Blount, J. D., Boner, W., Griffiths, K., Metcalfe, N., & Monaghan, P. (2012). Telomere length in early life predicts lifespan. Proceedings of the National Academy of Sciences in the United States of America, 109, 1743–1748. doi: 10.1073/pnas.1113306109 CrossRef

IBM. (2012). IBM SPSS statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.

Kirschbaum, C., Pirke, K., & Hellhammer, D. H. (1993). The ‘Trier Social Stress Test’: A tool for investigating psychobiological stress responses in a laboratory setting. Neuropsychobiology, 28, 76–81. doi: 10.1159/000119004 CrossRefPubMed

Kroenke, C. H., Epel, E., Adler, N., Bush, N. R., Obradovic, J., Lin, J., et al. (2011). Autonomic and adrenocortical reactivity and buccal cell telomere length in kindergarten children. Psychosomatic Medicine, 73, 533–540. doi: 10.1097/PSY.0b013e318229acfc CrossRefPubMedPubMedCentral

Laboratory for the Study of Stress, Immunity, and Disease. (2016). Common Cold Project. Retrieved from http://www.commoncoldproject.com

Lehrer, P. M., & Gevirtz, R. (2014). Heart rate variability biofeedback: How and why does it work? Frontiers in Psychology, 5, 756. doi: 10.3389/fpsyg.2014.00756 CrossRefPubMedPubMedCentral

Lo, C., Walsh, A., Mikulincer, M., Gagliese, L., Zimmermann, C., & Rodin, G. (2009). Measuring attachment security in patients with advanced cancer: Psychometric properties of a modified and brief Experiences in close Relationships scale. Psycho-Oncology, 18, 490–499. doi: 10.1002/pon.1417 CrossRefPubMed

Maciejowski, J., & de Lange, T. (2017). Telomeres in cancer: Tumour suppression and genome instability. Nature Reviews Molecular Biology, 18, 175–186. doi: 10.1038/nrm.2016.171 CrossRef

Malik, M. (1996). Heart rate variability: Standards of measurement, physiological interpretation and clinical use. Task force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Circulation, 93, 1043–1065. doi: 10.1161/01.CIR.93.5.1043 CrossRef

Mathur, M. B., Epel, E., Kind, S., Desai, M., Parks, C. G., Sandler, D. P., et al. (2016). Perceived stress and telomere length: A systematic review, meta-analysis, and methodologic considerations for advancing the field. Brain, Behavior, and Immunity, 54, 158–169. doi: 10.1016/j.bbi.2016.02.002 CrossRefPubMedPubMedCentral

Maunder, R. G., & Hunter, J. J. (2008). Attachment relationships as determinants of physical health. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 36, 11–32. CrossRefPubMed

McWilliams, L. A., & Bailey, S. J. (2010). Associations between adult attachment ratings and health conditions: Evidence from the National Comorbidity Survey Replication. Health Psychology, 29, 446–4453. doi: 10.1037/a0020061 CrossRefPubMed

Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics, and change. New York, NY, US: Guilford Press.

Mikulincer, M., & Shaver, P. R. (2009). An attachment and behavioral systems perspective on social support. Journal of Social and Personal Relationships, 26, 7–19. doi: 10.1177/0265407509105518 CrossRef

Murdock, K. W., & Fagundes, C. P. (2017). Attachment orientations, respiratory sinus arrhythmia, and stress are important for understanding the link between childhood socioeconomic status and adult self-reported health. Annals of Behavioral Medicine, 51, 189–198. doi: 10.1007/s12160-016-9842-4 CrossRefPubMedPubMedCentral

O’Callaghan, N. J., Dhillon, V. S., Thomas, P., & Fenech, M. (2008). A quantitative real-time PCR method for absolute telomere length. BioTechniques, 44, 807–809. doi: 10.2144/000112761 CrossRefPubMed

Pietromonaco, P. R., Uchino, B., & Dunkel-Schetter, C. D. (2013). Close relationship processes and health: Implications of attachment theory for health and disease. Health Psychology, 32, 499–513. doi: 10.1037/a0029349 CrossRefPubMedPubMedCentral

Porges, S. W. (2001). The polyvagal theory: Phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42, 123–146. doi: 10.1016/S0167-8760(01)00162-3 CrossRefPubMed

Price, L. H., Kao, H. T., Burgers, D. E., Carpenter, L. L., & Tyrka, A. R. (2013). Telomeres and early-life stress: An overview. Biological Psychiatry, 73, 15–23. doi: 10.1016/j.biopsych.2012.06.025 CrossRefPubMed

Puig, J., Englund, M. M., Simpson, J. A., & Collins, W. A. (2012). Predicting adult physical illness from infant attachment: A prospective longitudinal study. Health Psychology, 32, 409–417. doi: 10.1037/a00288889 CrossRefPubMedPubMedCentral

Reblin, M., & Uchino, B. N. (2008). Social and emotional support and its implication for health. Current Opinion in Psychiatry, 21, 201–205. doi: 10.1097/YCO.0b013e3282f3ad89 CrossRefPubMedPubMedCentral

Repetti, R. L., Taylor, S. E., & Seeman, T. E. (2002). Risky families: Family social environments and the mental and physical health of offspring. Psychological Bulletin, 128, 330–366. doi: 10.1037//0033-2909.128.2.330 CrossRefPubMed

Révész, D., Verhoeven, J. E., Milaneschi, Y., de Geus, E. J. C. N., Wolkowitz, O. M., & Penninx, B. W. J. H. (2014). Dysregulated physiological stress systems and accelerated cellular aging. Neurobiology of Aging, 35, 1422–1430. doi: 10.1016/j.neurobiolaging.2013.12.027 CrossRefPubMed

Rottenberg, J., Salomon, K., Gross, J. J., & Gotlib, I. H. (2005). Vagal withdrawal to a sad film predicts subsequent recovery from depression. Psychophysiology, 42, 277–281. doi: 10.1111/j.1469-8986.2005.00289.x CrossRefPubMed

Routlege, F. S., Campbell, T. S., McFetridge-Durdle, J. A., & Bacon, S. L. (2010). Improvement in heart rate variability with exercise therapy. The Canadian Journal of Cardiology, 26, 303–312. doi: 10.1016/S0828-282X(10)70395-0 CrossRef

Savage, S. A., & Bertuch, A. A. (2010). The genetics and clinical manifestations of telomere biology disorders. Genetics in Medicine, 12, 753–764. doi: 10.1097/GIM.0b013e3181f415b5 CrossRefPubMed

Sbarra, D. A., & Borelli, J. L. (2013). Heart rate variability moderates the association between attachment avoidance and self-concept reorganization following marital separation. International Journal of Psychophysiology, 88, 253–260. doi: 10.1016/j.ijpsycho.2012.04.004 CrossRefPubMed

Schaefer, C., Sciortino, S., Kvale, M., Lapham, K., Ranatunga, D., Rowell, S., et al. (2013). Demographic and behavioral influence on telomere length and relationship with all-cause mortality: Early results from the Kaiser Permanente Research Program on Genes, Environment, and Health (RPGEH). Clinical Medicine & Research, 11, 145. doi: 10.3121/cmr.2013.1176.b4-3

Schafer, J. L., & Olsen, M. K. (1998). Multiple imputation for multivariate missing-data problems: A data analyst’s perspective. Multivariate Behavioral Research, 33, 545–571. doi: 10.1207/s15327906mbr3304_5 CrossRefPubMed

Segerstrom, S. C., & Nes, L. S. (2007). Heart rate variability reflects self-regulatory strength, effort, and fatigue. Psychological Science, 18, 275–281. doi: 10.1111/j.1467-9280.2007.01888.x CrossRefPubMed

Shalev, I., Entringer, S., Wadhwa, P. D., Wolkowitz, O. M., Puterman, E., Lin, J., et al. (2013). Stress and telomere biology: A lifespan perspective. Psychoneuroendocrinology, 38, 1835–1842. doi: 10.1016/j.psyneuen.2013.03.010 CrossRefPubMedPubMedCentral

Shalev, I., Moffitt, T. E., Sugden, K., Williams, B., Houts, R. M., Danese, A., et al. (2012). Exposure to violence during childhood is associated with telomere erosion from 5 to 10 years of age: A longitudinal study. Molecular Psychiatry, 18, 576–581. CrossRefPubMedPubMedCentral

Shaver, P. R., & Mikulincer, M. (2005). Attachment theory and research: Resurrection of the psychodynamic approach to personality. Journal of Research in Personality, 39, 22–45. doi: 10.1016/j.jrp.2004.09.002 CrossRef

Shay, J. W., & Wright, W. E. (2000). Hayflick, his limit, and cellular ageing. Nature Reviews Molecular Cell Biology, 1, 72–76. doi: 10.1038/35036093 CrossRefPubMed

Shay, J. W., & Wright, W. E. (2005). Senescence and immortalization: The role of telomeres and telomerase. Carcinogenesis, 26, 867–874. doi: 10.1093/carcin/bgh296 CrossRefPubMed

Simpson, J. A., & Rholes, W. S. (2012). Adult attachment orientations, stress, and romantic relationships. Advances in Experimental Social Psychology, 45, 279–328. doi: 10.1016/B978-0-12-394289-9.00006-8 CrossRef

Strioga, M., Pasukoniene, V., & Characiejus, D. (2011). CD8+CD28− and CD8+CD57+T cells and their role in health and disease. Immunology, 134, 17–32. doi: 10.1111/j.1365-2567.2011.03470.x CrossRefPubMedPubMedCentral

Thayer, J. F., & Lane, R. D. (2000). A model of neurovisceral integration in emotion regulation and dysregulation. Journal of Affective Disorders, 61, 201–216. doi: 10.1016/S0165-0327(00)00338-4 CrossRefPubMed

Tyrka, A. R., Price, L. H., Kao, H. T., Porton, B., Marsella, S. A., & Carpenter, L. L. (2010). Childhood maltreatment and telomere shortening: Preliminary support for an effect of early stress on cellular aging. Biological Psychiatry, 67, 531–534. doi: 10.1016/j.biopsych.2009.08.014 CrossRefPubMed

Uchino, B. N., Cacioppo, J. T., & Kiecolt-Glaser, J. K. (1996). The relationship between social support and physiological processes: A review with emphasis on underlying mechanisms and implications for health. Psychological Bulletin, 119, 488–531. doi: 10.1037/0033-2909.119.3.488 CrossRefPubMed

Uchino, B. N., Cawthon, R. M., Smith, T. W., Light, C. K., Mckenzie, J., Carlisle, M., et al. (2012). Social relationships and health: Is feeling positive, negative, or both (ambivalent) about your social ties related to telomeres. Health Psychology, 31, 789–796. doi: 10.1037/a0026836 CrossRefPubMedPubMedCentral

Uchino, B. N., Smith, T. W., & Berg, C. A. (2014). Spousal relationship quality and cardiovascular risk: Dyadic perceptions of relationship ambivalence are associated with coronary-artery calcification. Psychological Science, 25, 1037–1042. doi: 10.1177/0956797613520015 CrossRefPubMedPubMedCentral

Wagner, D. D., & Heatherton, T. F. (2014). Emotion and self-regulation failure. In J. J. Gross (Ed.), Handbook of emotion regulation (2nd ed., pp. 613–628). New York, NY: The Guilford Press.

Wei, M., Russell, D. W., Mallinckrodt, B., & Vogel, D. L. (2007). The Experiences in Close Relationship Scale (ECR)-short form: Reliability, validity, and factor structure. Journal of Personality Assessment, 88, 187–204. doi: 10.1080/00223890701268041 CrossRefPubMed

Wentzensen, I. M., Mirabello, L., Pfeiffer, R. M., & Savage, S. A. (2011). The association between telomere length and cancer: A meta-analysis. Cancer Epidemiology, Biomarkers and Prevention, 20, 1238–1250. doi: 10.1158/1055-9965.EPI-11-0005 CrossRefPubMedPubMedCentral

Xie, Z., Jay, K. A., Smith, D. L., Zhang, Y., Liu, Z., Zheng, J., et al. (2015). Early telomerase inactivation accelerates aging independently of telomere length. Cell, 160, 928–939. doi: 10.1016/j.cell.2015.02.002 CrossRefPubMedPubMedCentral

Zhao, J., Miao, K., Wang, H., Ding, H., & Wang, D. W. (2013). Association between telomere length and type 2 diabetes mellitus: A meta-analysis. PLoS ONE, 8, e79993. doi: 10.1371/journal.pone.0079993 CrossRefPubMedPubMedCentral

Zimmerman, P. (2004). Attachment representations and characteristics of friendship relations during adolescence. Journal of Experimental Child Psychology, 88, 83–101. doi: 10.1016/j.jecp.2004.02.002 CrossRef

Titel: Attachment and telomere length: more evidence for psychobiological connections between close relationships, health, and aging
Auteurs: Kyle W. Murdock
Samuele Zilioli
Khadija Ziauddin
Cobi J. Heijnen
Christopher P. Fagundes
Publicatiedatum: 24-10-2017
Uitgeverij: Springer US
Gepubliceerd in: Journal of Behavioral Medicine / Uitgave 3/2018
Print ISSN: 0160-7715
Elektronisch ISSN: 1573-3521
DOI: https://doi.org/10.1007/s10865-017-9895-2

Bohn Stafleu van Loghum

Tip

Swipe om te navigeren naar een ander artikel

Deel dit onderdeel of sectie (kopieer de link)

Abstract

Log in om toegang te krijgen

Andere artikelen Uitgave 3/2018

Demographic, clinical, dispositional, and social-environmental characteristics associated with psychological response to a false positive ovarian cancer screening test: a longitudinal study

Combining risk communication strategies to simultaneously convey the risks of four diseases associated with physical inactivity to socio-demographically diverse populations

Elevated inflammation in association with alcohol abuse among Blacks but not Whites: results from the MIDUS biomarker study

Lower life satisfaction, active coping and cardiovascular disease risk factors in older African Americans: outcomes of a longitudinal church-based intervention

Change in health-related quality of life and social cognitive outcomes in obese, older adults in a randomized controlled weight loss trial: Does physical activity behavior matter?

The role of perceived threat during emergency department cardiac evaluation and the age-posttraumatic stress disorder link