Psychological factors associated with acute and chronic central serous chorioretinopathy
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Theresa Lahousen, Annamaria Painold, Wolfgang Luxenberger, Anne Schienle, Hans-Peter Kapfhammer, Rottraut Ille
Lahousen T, Painold A, Luxenberger W, Schienle A, Kapfhammer HP, Ille R, Psychological factors associated with acute and chronic central serous chorioretinopathy. Nord J Psychiatry 2015; Early Online:1–7. Background: Central serous chorioretinopathy (CSC) has been associated with several psychological factors. But previous psychological data are limited and mainly restricted to male patients and small sample size. In this study we investigated psychosomatic complaints, personality factors, life events, and stress coping in acute and chronic recurrent CSC patients. Methods: Ninety-five patients (71 men, 24 women) with either acute or chronic CSC were evaluated regarding critical life events before diagnosis, psychosomatic complaints, personality traits and coping style. The characteristics of CSC patients were compared with a control group comprising 75 patients (46 men, 29 women) suffering from acute or chronic ophthalmic disorders other than CSC. Results: Compared with patients of the control group, CSC patients reported more psychosomatic problems, unfavourable stress coping strategies and critical life events as well as elevated tension, aggression, strain, emotional instability and achievement orientation. Except for aggression the observed characteristics were more pronounced in acute than in chronic CSC patients. Conclusions: The appearance of CSC may be associated with an accumulation of stressful life events with an unfavourable coping style and distinctive personality factors. Acute CSC is related to more unfavourable stress coping and more physical complaints compared to its chronic course. Elevated aggression may imply one potential risk factor for CSC manifestation and also may have an adverse effect with its chronification. • Acute and chronic central serous chorioretinopathy, Aggression, Life events, Psychological factors, Stress. Theresa Lahousen, MD, Department of Psychiatry, Medical University of Graz, Auenbruggerplatz 31, A-8036 Graz, Austria. E-mail: [email protected]; Accepted 10 April 2015.
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or many years physicians have been showing scientific interest in central serous chorioretinopathy (CSC). In the late 1920s Horniker identified psychological stress and behavioural traits as potentially influencing factors in the development of this ophthalmic disorder (1). Since then several study groups have tried to clarify the relationship between psychological aspects and CSC (2–9). CSC is characterized by localized detachment of the neurosensory retina and/or retinal pigment epithelium (RPE) in the posterior pole of the eye. While the acute form of CSC is commonly associated with a transient decrease of vision, the chronic form may result in a permanent vision loss (10, 11). Acute episodes resolve spontaneously in the majority of patients within 2–6 months, while permanent visual deficits may result from recurrent or persistent episodes leading to permanent retinal changes (4, 12). In contrast to several other retinal diseases CSC appears biographically early, being diagnosed
between 20 and 50 years of age. Men are disproportionally more commonly affected than women (2, 11–13). Several predisposing factors have been reported to induce or aggravate CSC, including psychological stress (2–4, 14), type A personality (15), pregnancy (16), lupus erythematosus (17), organ transplantation (because of the use of steroids) (18), increased levels of endogenous corticosteroids (19), as well as corticosteroid treatment (20, 21). Recently published, Bujarborua et al. (22) discuss possible interactions of the eye with the cerebral cortex which could lead to disease. Although exact information about the underlying biological mechanisms of CSC pathogenesis and interactions of triggering factors are still missing, CSC is considered a disorder where psychological factors play a major role in its appearance, course of disease, and progression (2–8, 22). Werry and Arends (5) found an association between appearance of CSC and neurotic personality structure.
© 2015 Informa Healthcare DOI: 10.3109/08039488.2015.1041156
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Bahrke et al. (2) reported more pronounced nervousness and less sociability in CSC patients but they could not identify a typical CSC personality profile. In a study by Conrad et al. (3) CSC patients reported more non-specific somatic complaints compared to controls, which is argued by the authors to be associated with inadequate stress coping (see also Tittl et al. (23)). In a more recent report by Conrad et al. (7), the authors found increased emotional distress and elevated scores for somatisation, depression and hostility in the CSC group, pointing to difficulties in emotion regulation. A study by Spahn et al. (6) suggests elevated psychic stress a few weeks after the onset of the ailment but results did not clearly show that psychosocial factors have a definite role in the aetiology of CSC. Some published studies indicate that CSC patients report higher emotional distress compared to controls despite a comparable number of critical life events (2, 3, 7). The literature further indicates associations between the appearance of CSC and type A behavioural characteristics (12, 15, 24). Type A behaviour implies elevated competitiveness, aggression and hostility (25) and typically occurs in employed young men. Furthermore, young employed men are also preferentially affected by CSC. Currently, hostility is regarded as the most critical component of type A behaviour in the development of CSC, making individuals more responsive to stressors (6, 7). Moreover, clinical as well as experimental data suggest a potential association between increased levels of stress hormones and CSC appearance (19–21, 26). Yannuzzi et al. (15) suggested that the eye as an organ system and the macula as ultimate target area can be adversely stimulated by type A behaviour and its physiological consequences. These findings were supported by Conrad et al. (27), displaying the existence of specific aspects of type A behaviour as well as emotional distress in CSC patients. Type A behaviour as well as CSC is associated with elevated levels of catecholamines (12, 28). Furthermore, hyperadrenal activity with persistent high levels of glucocorticoids could cause type A behaviour patterns as well as CSC (29). In summary, roles of critical personality features, of stressful life events and stress coping as well as predisposition to somatization in the development of CSC seems still heterogeneous and poorly understood. It is striking that several studies on this topic are outdated (5, 15, 24) and findings are limited by small sample size, mainly consisting of male patients (2, 3, 6). Furthermore, previous studies did not differentiate between acute and chronic states of CSC (2, 3, 6, 7). Nonetheless, there seems to be a link: both exposure to stressful events and specific personality characters such as aggression/hostility or neuroticism are associated with elevated corticosteroid hormone and catecholamine levels (12, 30, 31), and high levels of glucocorticoids and catecholamines can cause CSC (11, 29).
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The primary aim of the present study was to determine whether CSC is associated with specific personality factors (e.g. characteristics signifying for type A personality), more stressful life events associated with unfavourable stress coping mechanisms and increased predisposition to somatization indicated by more psychosomatic complaints (e.g. heart complaints without organic malfunction). Since young employed men are considered a “target group” regarding the disease, we analysed the potential influence of gender and occupational engagement on CSC appearance. Additionally, we compared patients with acute and chronic CSC. We expected that chronic recurrent CSC would be more closely associated with certain personality factors such as hostility or neuroticism, whereas previous stressful life events should rather initiate the acute form of CSC. This would be supported by the fact that personality factors have enduring effects on corticosteroid and catecholamine levels while stressful life events are normally limited in time. To answer the questions above we studied personality factors, psychosomatic complaints, previous burden of stressful life events and stress coping in acute and chronic recurrent CSC patients compared to patients with acute and chronic eye illnesses other than CSC. Ophthalmic patients as controls have been chosen to investigate whether associations between psychological factors are CSC specific.
Methods
Participants We studied 95 patients diagnosed with CSC (71 men, 24 women, mean age 47.4 years, SD 9.8) at the Department of Ophthalmology at the Medical University of Graz. Diagnosis was obtained on the basis of typical symptoms (decrease of visual acuity, metamorphopsia), as well as clinical evidence (serous retinal elevation), and was confirmed by fluorescence angiography (leaking point). As a control group, 75 patients suffering from ophthalmic disorders other than CSC (46 men, 29 women; mean age 43.8 years, SD 14.2) were included in the analyses (Table 1). Selecting control subjects with ophthalmic disorders provided the possibility of comparing groups with acute and chronic visual impairment with and without CSC.
Inclusion criteria Research group: verified diagnosis of CSC by an ophthalmologist, aged between 18 and 65 years, no manifest psychiatric or neurological symptomatology. Control group: verified diagnosis of an ophthalmic disease other than CSC by an ophthalmologist, aged between 18 and 65 years, no manifest psychiatric or neurological symptomatology. NORD J PSYCHIATRY·EARLY ONLINE·2015
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Research and control group: age less than 18 years and over 65 years, manifest psychiatric or neurological symptomatology, persons incapable of consent. At the time of inclusion into our study all patients underwent an evaluation, comprising a complete medical history and physical examination. The investigation was carried out in accordance with the Helsinki Declaration 2008. The Ethics Committee of the Medical University of Graz, Austria has approved the study.
negative coping skills (five subscales). Cronbach’s alphas of these subscales range between 0.84 and 0.94. For estimation of the participants’ coping skills we calculated the ratio between positive and negative coping strategies, which is provided as one evaluation tool by the test authors. The Freiburger Complaint List (FBL-R) (33) is a selfreport questionnaire which includes 80 psychosomatic complaints (e.g. “Do you have headache?”). It consists of eight subscales (General complaints, Tiredness, Cardiovascular complaints, Head-neck syndrome, Tension, Emotional reactivity, Pain, and Sensory perception) and is applied as a five-point scale (1 almost never, 5 almost every day). Additionally, a constraint sum is calculated. Cronbach’s alphas of the subscales range between 0.66 and 0.92. We only calculated group differences of the sum score. Subjects with high sum scores report frequent and intensive constraints in a variety of somatic functions. Emotions are felt physically by those individuals. As consultation with the general practitioner has been shown to be associated with psychosomatic complaints (34) we assessed its frequency during the past year (FBLR, 5-point scale: 1 never; 5 about once a week). Moreover, patients completed the Freiburg Personality Inventory (FPI-R) (35), assessing 12 personal traits with “yes/ no” responses (e.g. “I am rather lively”; “I often muse about my previous life”). It consists of 10 primary scales (Life satisfaction, Social orientation, Achievement orientation, Social inhibition, Impulsiveness, Aggressiveness, Strain, Somatic complaints, Health concerns, and Frankness) and two secondary scales (Extraversion, Emotionality). Cronbach’s alphas of the subscales range between 0.70 and 0.96.
Psychometric instruments
Clinical analyses
Table 1. Diagnoses of ophthalmic diseases in central serous chorioretinopathy (CSC) patients and controls. CSC patients
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Diagnosis Myopia Amotio Glaucoma Cataract Violation Diabetic retinopathy Implant Strabismus surgery Ulcus corneae Herpes uveitis Ocular hypertension Basal cell carcinoma Keratoconus Astigmatism Lid lifting Conjunctivitis Hypermetropia
Controls
n
%
n
%
10
10.5
1 10
1.1 10.5
1
1.1
1 1 5 5
1.1 1.1 5.3 5.3
23 6 6 6 5 4 4 4 4 3 3 2 2 2 1
30.7 8.0 8.0 8.0 6.7 5.3 5.3 5.3 5.3 4 4 2.7 2.7 2.7 1.3
Exclusion criteria
For frequency of critical life events during the 6-month period before initial manifestation of acute CSC, diagnosis of chronic state was assessed by a self-report questionnaire. The Questionnaire to Critical Life Events (Bahrke et al. (2000); Authors; R.Fuchs, University of Freiburg, Germany and R. Schwarzer, University of Berlin, Germany) enquires into the frequency of burdens of critical life events during the past 6 months using 15 questions including the following domains: employment, partnership, family (children/relatives), friends/social activities, bereavement, health (personal), health (others), finances and housing. With an additional open question, subjects can point to critical life events that had not been considered by these questions. Subjects are asked to report only events which they had experienced as a burden of stress. The frequency of critical life events is evaluated. For the assessment of patients’ stress coping, the Coping with Stress Questionnaire Stressverarbeitungsfragebogen (SVF 78) (32) was utilized, enquiring about 13 positive and negative coping skills (e.g. Rumination: “If I have been upset by something or someone I cannot think of anything else for a long time”). We only report group differences for NORD J PSYCHIATRY·EARLY ONLINE·2015
For CSC patients we differentiated between an acute (serous retinal and/or RPE detachment with duration shorter than 6 months) and a chronic (serous retinal and/ or RPE detachment with duration longer than 6 months and/or decompensation of the RPE) form of CSC, and whether the detachment concerned one or both eyes.
Statistical analyses Group comparisons of descriptive variables were calculated using Student t-tests and Chi2 tests. Group comparisons of “critical life events” and “consultations with the general practitioner” were calculated with the Mann-Whitney test because distribution was skewed to the right. Group comparisons for psychometric tests were calculated by a multivariate (MANOVA) analysis of variance, with the factors group (CSC/control), sex and employment.
Results
Participants’ characteristics For 37 CSC patients an acute state of the disease was diagnosed; in 49 patients CSC was already chronic
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recurrent, and in nine patients a reliable classification was not possible. In 36% of CSC patients additional ophthalmic diseases were diagnosed (see Table 1). In 43% of CSC patients the right eye was affected by the disease, in 43% the left eye and in 14% of CSC patients both eyes were affected. In total, 36% (27 patients) of the control group had an acute ophthalmic illness, 60% (45 patients) had a chronic eye disease and for 4% no allocation could be made. At the time of the investigation 71% of CSC patients and 43% of controls were employed. Further socio-demographic details of the participants are specified in Table 2. Of CSC patients, 26% suffered from arterial hypertension, 26.7% were smokers, and 14.3% had been treated with corticosteroids. In the control group 11.8% suffered from arterial hypertension, 35.3% were smokers and 7.4% had received a treatment with corticosteroids. Groups did not differ in gender distribution (Chi2 3.51, p 0.061), age (t125.6 1.83, p 0.069), employment (Chi2 0.01, p 0.984), and years of education (CSC patients: mean 11.6 years, SD 4.3; controls: 11.9 years, SD 4.2; t168 0.4, p 0.690). CSC patients and controls did not differ in distribution of acute versus chronic state of ophthalmic disease (Chi2 0.50, p 0.481). Groups did not differ for steroid exposure (Chi2 4.52, p 0.104) and nicotine abuse (Chi2 1.31, p 0.253), but CSC patients showed arterial hypertension more frequently (Chi2 4.62, p 0.032).
to controls patients with CSC reported higher impulsiveness (t166 3.07, p 0.002), aggressiveness (t166 3.19, p 0.002), strain (t166 3.58, p p0.001), frankness (t166 3.33, p 0.001) and higher emotionality (t166 2.84, p 0.005) (Table 3). For psychosomatic complaints (FBL-R, sum-score) we found an effect of group (F(1,162) 8.79, p 0.003) and sex (F(1,162) 18.54, p0.001). CSC patients reported a higher rate of psychosomatic complaints than controls (t166 2.80, p 0.006) and women scored higher than men (t166 4.25 p0.001). Patients with CSC also reported more consultations with the general practitioner in the past year (Mann-Whitney test: Z 2.52, p 0.012) than controls. For negative stress coping (SVF-78) we found significant effects for group (F(5,158) 3.78, p 0.003) and profession (F(5,158) 3.86, p 0.003). Compared to controls CSC patients reported more frequent rumination (t166 2.67, p 0.008) and participants who were not in employment displayed more avoidance behaviour than employed individuals (t166 3.15, p 0.002). Furthermore, comparison of the relation between total use of positive and negative coping strategies showed a group x sex interaction (F(1,162) 4.27, p 0.040). Women with Table 3. Means (standard deviations) of psychometric parameters in central serous chorioretinopathy (CSC) patients and controls.
Psychometric analyses CSC patients versus controls Compared to controls, CSC patients reported more burdening life events for the 6-month period before the diagnosis of the disease (Mann-Whitney test: Z 6.55, p 0.001) (Table 3). Moreover, CSC patients reported more frequently that the last critical life event before manifestation of the disease was related to their profession (Chi2 21.95, p 0.001). Some personality traits assessed by the FPI-R differed between groups (F(12,144) 2.48, p 0.006). Compared Table 2. Sociodemographic data of participants. CSC patients N 95
Single Married Widowed Divorced Existing partnership Primary school Apprenticeship Grammar school University
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Controls N 75
n
%
n
%
13 66 1 9 6 43 4 30 17
13.7 69.5 1.1 9.5 6.3 45.3 4.2 31.6 17.9
20 47 1 2 4 29 9 21 13
26.7 62.7 1.3 2.7 5.3 38.7 12 28 17.3
Total of Critical Life Events FPI-R Life satisfaction Social orientation Achievement orientation Social inhibition Impulsiveness Aggressiveness Strain Somatic complaints Health concern Frankness Extraversion Emotionality FBL-R Total of somatic complaints Consultations with general practitioner SVF 78 Avoidance Escape Rumination Resignation Self-accusation Negative strategies (total) Relation between positive and negative strategies
CSC Patients N 95
Controls N 75
p
1.65 (1.26)
0.57 (0.79)
0.001
5.04 (2.08) 6.13 (1.82) 4.83 (1.73) 5.54 (2.17) 5.92 (2.02) 4.81 (1.80) 5.72 (1.88) 5.63 (1.73) 4.94 (2.08) 5.01 (2.03) 4.34 (2.05) 5.51 (1.98)
4.87 (1.78) 5.80 (1.79) 4.36 (1.81) 5.14 (1.80) 5.01 (1.71) 3.89 (1.86) 4.70 (1.73) 4.66 (1.46) 4.59 (1.52) 4.00 (1.79) 4.80 (2.18) 4.64 (1.96)
0.250 0.237 0.093 0.196 0.002 0.001 0.001 0.001 0.236 0.001 0.173 0.005
5.61 (1.66) 1.88 (1.05)
4.87 (1.78) 1.45 (0.92)
0.006 0.012
51.41 47.67 49.23 48.55 48.36 50.16 1.73
(9.59) (12.05) (11.73) (11.76) (10.32) (11.71) (16.41)
50.61 47.85 44.61 45.53 47.23 47.08 3.68
(9.38) (10.00) (10.50) (9.68) (12.47) (11.12) (15.12)
0.588 0.917 0.008 0.075 0.518 0.084 0.426
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CSC showed a more unfavourable relation between positive and negative coping strategies than men with CSC (t93 2.89, p 0.005), while there was no gender difference in controls (t73 0.54, p 0.594).
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Acute versus chronic state of CSC In chronic CSC patients bilaterality of disease was observed more frequently than in acute patients (Chi2 3.95, p 0.047). Patients with acute CSC did not differ from chronic subjects in the number of critical life events before diagnosis (Mann Whitney U-test: Z 0.68, p 0.500). Acute CSC patients reported more psychosomatic complaints (t84 2.15, p 0.035), a more frequent negative stress coping (t84 2.88, p 0.005), and a more unfavourable relation between positive and negative coping strategies (t84 2.11, p 0.038). Personality traits differed only marginally between acute and chronic CSC patients (F(12,73) 1.75, p 0.077), but we found higher aggression in chronic CSC patients (t84 2.03, p 0.045). Acute and chronic patients of the control group (other ophthalmic disorders) did not differ in personality, frequency of psychosomatic complaints and stress coping (all p0.231).
Discussion Our data corroborate previous studies that CSC is associated with different psychological factors (2-8, 22). CSC patients of our study cohort showed a predisposition to somatization, reporting more psychosomatic complaints compared to subjects of the control group who were affected by ophthalmic diseases other than CSC. Interestingly, CSC patients of our study cohort also reported more consultations with the general practitioner than controls during the past 12-month period. This finding seems conclusive since psychosomatic patients are known for frequent general practice consultations (36, 37). Previous findings have also displayed associations between CSC and psychopathological symptoms. Conrad et al. (7) have reported higher depression scores in CSC patients. Fok and associates could show that a history of psychiatric illness, e.g. depression is associated with an increased risk of recurrence for CSC (8). Psychosomatic complaints, meaning somatic symptoms without evidence of an organic malfunction, are often considered to be a consequence of work-related stress (38) and had also been shown in CSC patients Bahrke et al. (2); Conrad et al. (27). Moreover, previous studies have reported associations between job strain and arterial hypertension (39). Our CSC patients showed arterial hypertension more frequently than controls and reported not only more burdening life events for the 6-month period before diagnosis of the disease but additionally the last critical life event before CSC manifestaNORD J PSYCHIATRY·EARLY ONLINE·2015
tion was related to their profession more frequently than in controls. In regard to personality profiles, we found certain personality differences between CSC patients and controls. CSC patients reported more pronounced excitability, more stress, frankness (meaning admitting minor weaknesses and common violation of norms), a higher level of aggressiveness and higher emotional instability. These findings underline that some of the characteristics of type A personality might be associated with CSC. However, despite showing medium effect sizes, CSC patients’ characteristics were still within the non-clinical range of the inventories used. Distinctive personal characteristics of CSC patients might also influence their coping with negative life events in an unfavourable way. Compared to controls, CSC patients reported more frequent rumination about negative experiences, an adverse stress coping that leads to prolonged stress experience. Several previous studies reported young and middleaged employed men as a primary risk group concerning the development of CSC (2, 11–13). In our study cohort, none of the psychological risk factors investigated were found to be more pronounced in male than in female CSC patients. On the contrary, women with CSC showed more unfavourable stress coping than men. Zakir et al. (26) emphasize a possible role of interaction between steroid hormones and testosterone levels. This is supported by data from previous studies which consistently show that increased levels of corticosteroids as well as other stress hormones are strongly associated with the appearance of CSC (10, 19). Furthermore, stressful life events and certain personality traits such as aggression have been shown to be associated with increased levels of both catecholamines and corticosteroids (30, 40, 41). These findings give rise to speculation that an increased male vulnerability for developing CSC might be a consequence of gender-specific factors. In our study cohort, employed CSC patients did not differ from unemployed individuals with regard to frequency of psychosomatic complaints and personality characteristics. Unemployed participants even reported more avoidance behaviour, thus showing more unfavourable stress coping than employed persons. This finding seems indicative for CSC development as a response to a more unspecific burden of critical life events. Chronic CSC resulted in more strongly affected vision compared to acute CSC, as a bilateral involvement was observed more frequently. Patients with acute or chronic CSC did not differ in the number of critical life events before diagnosis, but acute subjects reported more psychosomatic complaints and more unfavourable stress coping than chronic CSC patients. This finding points to a stress overload at the time of CSC manifestation. By contrast, in chronic patients a higher level of aggression
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was found. This may indicate that aggression is a personality factor which implies a risk for manifestation of CSC and may have an adverse effect also with its chronification. Elevated aggression has been reported as a characteristic feature of Type A personality (25), and could also interact with stressors such as chronic recurrent visual impairment. Physiological factors such as steroid exposure, hypertension or nicotine use did not differ between acute and chronic CSC states. In conclusion, our results obtained from a large number of acute and chronic CSC patients confirm previous findings that CSC is associated with several psychological factors. Patients affected with CSC reported more critical life events before diagnosis than patients with other ophthalmic diseases. Furthermore, higher frequency of psychosomatic complaints points to vulnerability for physiological manifestation of psychological stress in inividuals affected by CSC. Several personality traits auch as elevated aggressiveness or emotional instability and adverse stress coping intensify the negative effect of stressful situations. We assume that the appearance of CSC may be associated with an accumulation of unfavourable psychic factors, which might also adversely affect stress hormone levels. Moreover, our findings give rise to speculation that occupational stress is only one factor in CSC pathogenesis and due to investigating mainly employed men in the past its role might have been overestimated so far. CSC manifestation seems to be triggered by burden of critical life events, associated by adverse personality characteristics and accompanied by an unfavourable coping style. Nevertheless, because of the cross-sectional nature of the study, causal inferences cannot be drawn. When relating to individual stress, it is not clear if CSC is the consequence or a prerequisite of it, and manifestation of CSC may lead to further stress-related responses. However, critical personality characteristics as represented in Type A personality are rather a precondition than a consequence of CSC. Extended knowledge about this burdening disease may improve diagnostic, therapeutic and preventive strategies. For further analyses of the associations between CSC and psychological and biological factors a prospective approach would be necessary, including patients of both sexes. Acknowledgement—The authors thank Dietmar Mattes, Beate Langer-Wegscheider, Anton Haas and Martin Weger from the Department of Ophthalmology, Graz for their valuable assistance. Disclosure of interests: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. The authors alone are responsible for the content and writing of the paper.
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in central serous chorioretinopathy. ScientificWorldJournal 2014;2014:631687. Gallacher JE, Sweetnam PM, Yaenell JW, Elwood PC, Stansfeld SA. Is type A behavior really a trigger for coronary heart disease events? Psychosom Med 2003;65:339–46. Roberts D. Glucocorticoids and secondary stress as combined causes of chronic central serous chorioretinopathy. MD Support. Available at http://www.mdsupport.org/stresstheory.pdf; 2000. Alfarez DN, Wiegert O, Krugers HJ. Stress, corticosteroid hormones and hippocampal synaptic function. CNS Neurol Disord Drug Targets 2006;5:521–9. Volavka J, Bilder R, Nolan K. Catecholamines and aggression: the role of COMT and MAO polymorphisms. Ann N Y Acad Sci 2004;1036:393–8. Janke W, Erdmann G, Kallus W. Stressverarbeitungsbogen SVF 78, (Stress Coping Style Questionnaire SVF 78). Göttingen: Hogrefe; 2002. Fahrenberg J. Die Freiburger Beschwerdenliste (FBL). (The Freiburg Complaint List). Form FBL-G und revidierte Form FBL-R. Handanweisung. Göttingen: Hogrefe; 1994. Perkins SL, Kim JE, Pollack JS, Merrill PT. Clinical characteristics of central serous chorioretinopathy in women. Ophthalmology 2002;109:262–6. Fahrenberg J, Hampel R, Selg H. Das Freiburger Persönlichkeitsinventar FPI. Revidierte Fassung. (Freiburg Personality Inventory). Göttingen: Hogrefe; 2001. Fazekas C, Matzer F, Greimel ER, Moser G, Stelzig M, Langewitz W et al. Psychosomatic medicine in primary care: influence of training. Wien Klin Wochenschr 2009;121:446–53.
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37. Verhaak PF,Tij huis MA. The somatizing patient in general practice. Int J Psychiatry Med 1994;24:157–77. 38. Zwerenz R, Knickenberg RJ, Schattenburg L, Beutel ME.Workrelated stress and resources of psychosomatic patients compared to the general population. Rehabilitation 2004;43:10–16. 39. Ducher M, Cerutti C, Chatellier G, Fauvel JP. Is high job strain associated with hypertension genesis? Am J Hypertens 2006;19:694–700. 40. Carre JM, Putnam SK, McCormick CM. Testosterone responses to competition predict future aggressive behaviour at a cost to reward in men. Psychoneuroendocrinology 2009;34:561–70. 41. Izawa S, Hirata U, Kodama M, Nomura S. Effect of hostility on salivary cortisol levels in university students. Shinrigaku Kenkyu 2007;78:277–83. Theresa Lahousen, Department of Psychiatry, Medical University of Graz, Austria. Annamaria Painold, Department of Psychiatry, Medical University of Graz, Austria. Wolfgang Luxenberger, Department of Psychiatry, Medical University of Graz, Austria. Anne Schienle, Department of Psychology, Karl-Franzens-University of Graz, Austria. Hans-Peter Kapfhammer, Department of Psychiatry, Medical University of Graz, Austria. Rottraut Ille, Department of Psychology, Karl-Franzens-University of Graz, Austria.
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Theresa Lahousen, Annamaria Painold, Wolfgang Luxenberger, Anne Schienle, Hans-Peter Kapfhammer, Rottraut Ille
Lahousen T, Painold A, Luxenberger W, Schienle A, Kapfhammer HP, Ille R, Psychological factors associated with acute and chronic central serous chorioretinopathy. Nord J Psychiatry 2015; Early Online:1–7. Background: Central serous chorioretinopathy (CSC) has been associated with several psychological factors. But previous psychological data are limited and mainly restricted to male patients and small sample size. In this study we investigated psychosomatic complaints, personality factors, life events, and stress coping in acute and chronic recurrent CSC patients. Methods: Ninety-five patients (71 men, 24 women) with either acute or chronic CSC were evaluated regarding critical life events before diagnosis, psychosomatic complaints, personality traits and coping style. The characteristics of CSC patients were compared with a control group comprising 75 patients (46 men, 29 women) suffering from acute or chronic ophthalmic disorders other than CSC. Results: Compared with patients of the control group, CSC patients reported more psychosomatic problems, unfavourable stress coping strategies and critical life events as well as elevated tension, aggression, strain, emotional instability and achievement orientation. Except for aggression the observed characteristics were more pronounced in acute than in chronic CSC patients. Conclusions: The appearance of CSC may be associated with an accumulation of stressful life events with an unfavourable coping style and distinctive personality factors. Acute CSC is related to more unfavourable stress coping and more physical complaints compared to its chronic course. Elevated aggression may imply one potential risk factor for CSC manifestation and also may have an adverse effect with its chronification. • Acute and chronic central serous chorioretinopathy, Aggression, Life events, Psychological factors, Stress. Theresa Lahousen, MD, Department of Psychiatry, Medical University of Graz, Auenbruggerplatz 31, A-8036 Graz, Austria. E-mail: [email protected]; Accepted 10 April 2015.
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or many years physicians have been showing scientific interest in central serous chorioretinopathy (CSC). In the late 1920s Horniker identified psychological stress and behavioural traits as potentially influencing factors in the development of this ophthalmic disorder (1). Since then several study groups have tried to clarify the relationship between psychological aspects and CSC (2–9). CSC is characterized by localized detachment of the neurosensory retina and/or retinal pigment epithelium (RPE) in the posterior pole of the eye. While the acute form of CSC is commonly associated with a transient decrease of vision, the chronic form may result in a permanent vision loss (10, 11). Acute episodes resolve spontaneously in the majority of patients within 2–6 months, while permanent visual deficits may result from recurrent or persistent episodes leading to permanent retinal changes (4, 12). In contrast to several other retinal diseases CSC appears biographically early, being diagnosed
between 20 and 50 years of age. Men are disproportionally more commonly affected than women (2, 11–13). Several predisposing factors have been reported to induce or aggravate CSC, including psychological stress (2–4, 14), type A personality (15), pregnancy (16), lupus erythematosus (17), organ transplantation (because of the use of steroids) (18), increased levels of endogenous corticosteroids (19), as well as corticosteroid treatment (20, 21). Recently published, Bujarborua et al. (22) discuss possible interactions of the eye with the cerebral cortex which could lead to disease. Although exact information about the underlying biological mechanisms of CSC pathogenesis and interactions of triggering factors are still missing, CSC is considered a disorder where psychological factors play a major role in its appearance, course of disease, and progression (2–8, 22). Werry and Arends (5) found an association between appearance of CSC and neurotic personality structure.
© 2015 Informa Healthcare DOI: 10.3109/08039488.2015.1041156
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Bahrke et al. (2) reported more pronounced nervousness and less sociability in CSC patients but they could not identify a typical CSC personality profile. In a study by Conrad et al. (3) CSC patients reported more non-specific somatic complaints compared to controls, which is argued by the authors to be associated with inadequate stress coping (see also Tittl et al. (23)). In a more recent report by Conrad et al. (7), the authors found increased emotional distress and elevated scores for somatisation, depression and hostility in the CSC group, pointing to difficulties in emotion regulation. A study by Spahn et al. (6) suggests elevated psychic stress a few weeks after the onset of the ailment but results did not clearly show that psychosocial factors have a definite role in the aetiology of CSC. Some published studies indicate that CSC patients report higher emotional distress compared to controls despite a comparable number of critical life events (2, 3, 7). The literature further indicates associations between the appearance of CSC and type A behavioural characteristics (12, 15, 24). Type A behaviour implies elevated competitiveness, aggression and hostility (25) and typically occurs in employed young men. Furthermore, young employed men are also preferentially affected by CSC. Currently, hostility is regarded as the most critical component of type A behaviour in the development of CSC, making individuals more responsive to stressors (6, 7). Moreover, clinical as well as experimental data suggest a potential association between increased levels of stress hormones and CSC appearance (19–21, 26). Yannuzzi et al. (15) suggested that the eye as an organ system and the macula as ultimate target area can be adversely stimulated by type A behaviour and its physiological consequences. These findings were supported by Conrad et al. (27), displaying the existence of specific aspects of type A behaviour as well as emotional distress in CSC patients. Type A behaviour as well as CSC is associated with elevated levels of catecholamines (12, 28). Furthermore, hyperadrenal activity with persistent high levels of glucocorticoids could cause type A behaviour patterns as well as CSC (29). In summary, roles of critical personality features, of stressful life events and stress coping as well as predisposition to somatization in the development of CSC seems still heterogeneous and poorly understood. It is striking that several studies on this topic are outdated (5, 15, 24) and findings are limited by small sample size, mainly consisting of male patients (2, 3, 6). Furthermore, previous studies did not differentiate between acute and chronic states of CSC (2, 3, 6, 7). Nonetheless, there seems to be a link: both exposure to stressful events and specific personality characters such as aggression/hostility or neuroticism are associated with elevated corticosteroid hormone and catecholamine levels (12, 30, 31), and high levels of glucocorticoids and catecholamines can cause CSC (11, 29).
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The primary aim of the present study was to determine whether CSC is associated with specific personality factors (e.g. characteristics signifying for type A personality), more stressful life events associated with unfavourable stress coping mechanisms and increased predisposition to somatization indicated by more psychosomatic complaints (e.g. heart complaints without organic malfunction). Since young employed men are considered a “target group” regarding the disease, we analysed the potential influence of gender and occupational engagement on CSC appearance. Additionally, we compared patients with acute and chronic CSC. We expected that chronic recurrent CSC would be more closely associated with certain personality factors such as hostility or neuroticism, whereas previous stressful life events should rather initiate the acute form of CSC. This would be supported by the fact that personality factors have enduring effects on corticosteroid and catecholamine levels while stressful life events are normally limited in time. To answer the questions above we studied personality factors, psychosomatic complaints, previous burden of stressful life events and stress coping in acute and chronic recurrent CSC patients compared to patients with acute and chronic eye illnesses other than CSC. Ophthalmic patients as controls have been chosen to investigate whether associations between psychological factors are CSC specific.
Methods
Participants We studied 95 patients diagnosed with CSC (71 men, 24 women, mean age 47.4 years, SD 9.8) at the Department of Ophthalmology at the Medical University of Graz. Diagnosis was obtained on the basis of typical symptoms (decrease of visual acuity, metamorphopsia), as well as clinical evidence (serous retinal elevation), and was confirmed by fluorescence angiography (leaking point). As a control group, 75 patients suffering from ophthalmic disorders other than CSC (46 men, 29 women; mean age 43.8 years, SD 14.2) were included in the analyses (Table 1). Selecting control subjects with ophthalmic disorders provided the possibility of comparing groups with acute and chronic visual impairment with and without CSC.
Inclusion criteria Research group: verified diagnosis of CSC by an ophthalmologist, aged between 18 and 65 years, no manifest psychiatric or neurological symptomatology. Control group: verified diagnosis of an ophthalmic disease other than CSC by an ophthalmologist, aged between 18 and 65 years, no manifest psychiatric or neurological symptomatology. NORD J PSYCHIATRY·EARLY ONLINE·2015
Psychological factors in chorioretinopathy
Research and control group: age less than 18 years and over 65 years, manifest psychiatric or neurological symptomatology, persons incapable of consent. At the time of inclusion into our study all patients underwent an evaluation, comprising a complete medical history and physical examination. The investigation was carried out in accordance with the Helsinki Declaration 2008. The Ethics Committee of the Medical University of Graz, Austria has approved the study.
negative coping skills (five subscales). Cronbach’s alphas of these subscales range between 0.84 and 0.94. For estimation of the participants’ coping skills we calculated the ratio between positive and negative coping strategies, which is provided as one evaluation tool by the test authors. The Freiburger Complaint List (FBL-R) (33) is a selfreport questionnaire which includes 80 psychosomatic complaints (e.g. “Do you have headache?”). It consists of eight subscales (General complaints, Tiredness, Cardiovascular complaints, Head-neck syndrome, Tension, Emotional reactivity, Pain, and Sensory perception) and is applied as a five-point scale (1 almost never, 5 almost every day). Additionally, a constraint sum is calculated. Cronbach’s alphas of the subscales range between 0.66 and 0.92. We only calculated group differences of the sum score. Subjects with high sum scores report frequent and intensive constraints in a variety of somatic functions. Emotions are felt physically by those individuals. As consultation with the general practitioner has been shown to be associated with psychosomatic complaints (34) we assessed its frequency during the past year (FBLR, 5-point scale: 1 never; 5 about once a week). Moreover, patients completed the Freiburg Personality Inventory (FPI-R) (35), assessing 12 personal traits with “yes/ no” responses (e.g. “I am rather lively”; “I often muse about my previous life”). It consists of 10 primary scales (Life satisfaction, Social orientation, Achievement orientation, Social inhibition, Impulsiveness, Aggressiveness, Strain, Somatic complaints, Health concerns, and Frankness) and two secondary scales (Extraversion, Emotionality). Cronbach’s alphas of the subscales range between 0.70 and 0.96.
Psychometric instruments
Clinical analyses
Table 1. Diagnoses of ophthalmic diseases in central serous chorioretinopathy (CSC) patients and controls. CSC patients
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Diagnosis Myopia Amotio Glaucoma Cataract Violation Diabetic retinopathy Implant Strabismus surgery Ulcus corneae Herpes uveitis Ocular hypertension Basal cell carcinoma Keratoconus Astigmatism Lid lifting Conjunctivitis Hypermetropia
Controls
n
%
n
%
10
10.5
1 10
1.1 10.5
1
1.1
1 1 5 5
1.1 1.1 5.3 5.3
23 6 6 6 5 4 4 4 4 3 3 2 2 2 1
30.7 8.0 8.0 8.0 6.7 5.3 5.3 5.3 5.3 4 4 2.7 2.7 2.7 1.3
Exclusion criteria
For frequency of critical life events during the 6-month period before initial manifestation of acute CSC, diagnosis of chronic state was assessed by a self-report questionnaire. The Questionnaire to Critical Life Events (Bahrke et al. (2000); Authors; R.Fuchs, University of Freiburg, Germany and R. Schwarzer, University of Berlin, Germany) enquires into the frequency of burdens of critical life events during the past 6 months using 15 questions including the following domains: employment, partnership, family (children/relatives), friends/social activities, bereavement, health (personal), health (others), finances and housing. With an additional open question, subjects can point to critical life events that had not been considered by these questions. Subjects are asked to report only events which they had experienced as a burden of stress. The frequency of critical life events is evaluated. For the assessment of patients’ stress coping, the Coping with Stress Questionnaire Stressverarbeitungsfragebogen (SVF 78) (32) was utilized, enquiring about 13 positive and negative coping skills (e.g. Rumination: “If I have been upset by something or someone I cannot think of anything else for a long time”). We only report group differences for NORD J PSYCHIATRY·EARLY ONLINE·2015
For CSC patients we differentiated between an acute (serous retinal and/or RPE detachment with duration shorter than 6 months) and a chronic (serous retinal and/ or RPE detachment with duration longer than 6 months and/or decompensation of the RPE) form of CSC, and whether the detachment concerned one or both eyes.
Statistical analyses Group comparisons of descriptive variables were calculated using Student t-tests and Chi2 tests. Group comparisons of “critical life events” and “consultations with the general practitioner” were calculated with the Mann-Whitney test because distribution was skewed to the right. Group comparisons for psychometric tests were calculated by a multivariate (MANOVA) analysis of variance, with the factors group (CSC/control), sex and employment.
Results
Participants’ characteristics For 37 CSC patients an acute state of the disease was diagnosed; in 49 patients CSC was already chronic
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recurrent, and in nine patients a reliable classification was not possible. In 36% of CSC patients additional ophthalmic diseases were diagnosed (see Table 1). In 43% of CSC patients the right eye was affected by the disease, in 43% the left eye and in 14% of CSC patients both eyes were affected. In total, 36% (27 patients) of the control group had an acute ophthalmic illness, 60% (45 patients) had a chronic eye disease and for 4% no allocation could be made. At the time of the investigation 71% of CSC patients and 43% of controls were employed. Further socio-demographic details of the participants are specified in Table 2. Of CSC patients, 26% suffered from arterial hypertension, 26.7% were smokers, and 14.3% had been treated with corticosteroids. In the control group 11.8% suffered from arterial hypertension, 35.3% were smokers and 7.4% had received a treatment with corticosteroids. Groups did not differ in gender distribution (Chi2 3.51, p 0.061), age (t125.6 1.83, p 0.069), employment (Chi2 0.01, p 0.984), and years of education (CSC patients: mean 11.6 years, SD 4.3; controls: 11.9 years, SD 4.2; t168 0.4, p 0.690). CSC patients and controls did not differ in distribution of acute versus chronic state of ophthalmic disease (Chi2 0.50, p 0.481). Groups did not differ for steroid exposure (Chi2 4.52, p 0.104) and nicotine abuse (Chi2 1.31, p 0.253), but CSC patients showed arterial hypertension more frequently (Chi2 4.62, p 0.032).
to controls patients with CSC reported higher impulsiveness (t166 3.07, p 0.002), aggressiveness (t166 3.19, p 0.002), strain (t166 3.58, p p0.001), frankness (t166 3.33, p 0.001) and higher emotionality (t166 2.84, p 0.005) (Table 3). For psychosomatic complaints (FBL-R, sum-score) we found an effect of group (F(1,162) 8.79, p 0.003) and sex (F(1,162) 18.54, p0.001). CSC patients reported a higher rate of psychosomatic complaints than controls (t166 2.80, p 0.006) and women scored higher than men (t166 4.25 p0.001). Patients with CSC also reported more consultations with the general practitioner in the past year (Mann-Whitney test: Z 2.52, p 0.012) than controls. For negative stress coping (SVF-78) we found significant effects for group (F(5,158) 3.78, p 0.003) and profession (F(5,158) 3.86, p 0.003). Compared to controls CSC patients reported more frequent rumination (t166 2.67, p 0.008) and participants who were not in employment displayed more avoidance behaviour than employed individuals (t166 3.15, p 0.002). Furthermore, comparison of the relation between total use of positive and negative coping strategies showed a group x sex interaction (F(1,162) 4.27, p 0.040). Women with Table 3. Means (standard deviations) of psychometric parameters in central serous chorioretinopathy (CSC) patients and controls.
Psychometric analyses CSC patients versus controls Compared to controls, CSC patients reported more burdening life events for the 6-month period before the diagnosis of the disease (Mann-Whitney test: Z 6.55, p 0.001) (Table 3). Moreover, CSC patients reported more frequently that the last critical life event before manifestation of the disease was related to their profession (Chi2 21.95, p 0.001). Some personality traits assessed by the FPI-R differed between groups (F(12,144) 2.48, p 0.006). Compared Table 2. Sociodemographic data of participants. CSC patients N 95
Single Married Widowed Divorced Existing partnership Primary school Apprenticeship Grammar school University
4
Controls N 75
n
%
n
%
13 66 1 9 6 43 4 30 17
13.7 69.5 1.1 9.5 6.3 45.3 4.2 31.6 17.9
20 47 1 2 4 29 9 21 13
26.7 62.7 1.3 2.7 5.3 38.7 12 28 17.3
Total of Critical Life Events FPI-R Life satisfaction Social orientation Achievement orientation Social inhibition Impulsiveness Aggressiveness Strain Somatic complaints Health concern Frankness Extraversion Emotionality FBL-R Total of somatic complaints Consultations with general practitioner SVF 78 Avoidance Escape Rumination Resignation Self-accusation Negative strategies (total) Relation between positive and negative strategies
CSC Patients N 95
Controls N 75
p
1.65 (1.26)
0.57 (0.79)
0.001
5.04 (2.08) 6.13 (1.82) 4.83 (1.73) 5.54 (2.17) 5.92 (2.02) 4.81 (1.80) 5.72 (1.88) 5.63 (1.73) 4.94 (2.08) 5.01 (2.03) 4.34 (2.05) 5.51 (1.98)
4.87 (1.78) 5.80 (1.79) 4.36 (1.81) 5.14 (1.80) 5.01 (1.71) 3.89 (1.86) 4.70 (1.73) 4.66 (1.46) 4.59 (1.52) 4.00 (1.79) 4.80 (2.18) 4.64 (1.96)
0.250 0.237 0.093 0.196 0.002 0.001 0.001 0.001 0.236 0.001 0.173 0.005
5.61 (1.66) 1.88 (1.05)
4.87 (1.78) 1.45 (0.92)
0.006 0.012
51.41 47.67 49.23 48.55 48.36 50.16 1.73
(9.59) (12.05) (11.73) (11.76) (10.32) (11.71) (16.41)
50.61 47.85 44.61 45.53 47.23 47.08 3.68
(9.38) (10.00) (10.50) (9.68) (12.47) (11.12) (15.12)
0.588 0.917 0.008 0.075 0.518 0.084 0.426
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CSC showed a more unfavourable relation between positive and negative coping strategies than men with CSC (t93 2.89, p 0.005), while there was no gender difference in controls (t73 0.54, p 0.594).
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Acute versus chronic state of CSC In chronic CSC patients bilaterality of disease was observed more frequently than in acute patients (Chi2 3.95, p 0.047). Patients with acute CSC did not differ from chronic subjects in the number of critical life events before diagnosis (Mann Whitney U-test: Z 0.68, p 0.500). Acute CSC patients reported more psychosomatic complaints (t84 2.15, p 0.035), a more frequent negative stress coping (t84 2.88, p 0.005), and a more unfavourable relation between positive and negative coping strategies (t84 2.11, p 0.038). Personality traits differed only marginally between acute and chronic CSC patients (F(12,73) 1.75, p 0.077), but we found higher aggression in chronic CSC patients (t84 2.03, p 0.045). Acute and chronic patients of the control group (other ophthalmic disorders) did not differ in personality, frequency of psychosomatic complaints and stress coping (all p0.231).
Discussion Our data corroborate previous studies that CSC is associated with different psychological factors (2-8, 22). CSC patients of our study cohort showed a predisposition to somatization, reporting more psychosomatic complaints compared to subjects of the control group who were affected by ophthalmic diseases other than CSC. Interestingly, CSC patients of our study cohort also reported more consultations with the general practitioner than controls during the past 12-month period. This finding seems conclusive since psychosomatic patients are known for frequent general practice consultations (36, 37). Previous findings have also displayed associations between CSC and psychopathological symptoms. Conrad et al. (7) have reported higher depression scores in CSC patients. Fok and associates could show that a history of psychiatric illness, e.g. depression is associated with an increased risk of recurrence for CSC (8). Psychosomatic complaints, meaning somatic symptoms without evidence of an organic malfunction, are often considered to be a consequence of work-related stress (38) and had also been shown in CSC patients Bahrke et al. (2); Conrad et al. (27). Moreover, previous studies have reported associations between job strain and arterial hypertension (39). Our CSC patients showed arterial hypertension more frequently than controls and reported not only more burdening life events for the 6-month period before diagnosis of the disease but additionally the last critical life event before CSC manifestaNORD J PSYCHIATRY·EARLY ONLINE·2015
tion was related to their profession more frequently than in controls. In regard to personality profiles, we found certain personality differences between CSC patients and controls. CSC patients reported more pronounced excitability, more stress, frankness (meaning admitting minor weaknesses and common violation of norms), a higher level of aggressiveness and higher emotional instability. These findings underline that some of the characteristics of type A personality might be associated with CSC. However, despite showing medium effect sizes, CSC patients’ characteristics were still within the non-clinical range of the inventories used. Distinctive personal characteristics of CSC patients might also influence their coping with negative life events in an unfavourable way. Compared to controls, CSC patients reported more frequent rumination about negative experiences, an adverse stress coping that leads to prolonged stress experience. Several previous studies reported young and middleaged employed men as a primary risk group concerning the development of CSC (2, 11–13). In our study cohort, none of the psychological risk factors investigated were found to be more pronounced in male than in female CSC patients. On the contrary, women with CSC showed more unfavourable stress coping than men. Zakir et al. (26) emphasize a possible role of interaction between steroid hormones and testosterone levels. This is supported by data from previous studies which consistently show that increased levels of corticosteroids as well as other stress hormones are strongly associated with the appearance of CSC (10, 19). Furthermore, stressful life events and certain personality traits such as aggression have been shown to be associated with increased levels of both catecholamines and corticosteroids (30, 40, 41). These findings give rise to speculation that an increased male vulnerability for developing CSC might be a consequence of gender-specific factors. In our study cohort, employed CSC patients did not differ from unemployed individuals with regard to frequency of psychosomatic complaints and personality characteristics. Unemployed participants even reported more avoidance behaviour, thus showing more unfavourable stress coping than employed persons. This finding seems indicative for CSC development as a response to a more unspecific burden of critical life events. Chronic CSC resulted in more strongly affected vision compared to acute CSC, as a bilateral involvement was observed more frequently. Patients with acute or chronic CSC did not differ in the number of critical life events before diagnosis, but acute subjects reported more psychosomatic complaints and more unfavourable stress coping than chronic CSC patients. This finding points to a stress overload at the time of CSC manifestation. By contrast, in chronic patients a higher level of aggression
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was found. This may indicate that aggression is a personality factor which implies a risk for manifestation of CSC and may have an adverse effect also with its chronification. Elevated aggression has been reported as a characteristic feature of Type A personality (25), and could also interact with stressors such as chronic recurrent visual impairment. Physiological factors such as steroid exposure, hypertension or nicotine use did not differ between acute and chronic CSC states. In conclusion, our results obtained from a large number of acute and chronic CSC patients confirm previous findings that CSC is associated with several psychological factors. Patients affected with CSC reported more critical life events before diagnosis than patients with other ophthalmic diseases. Furthermore, higher frequency of psychosomatic complaints points to vulnerability for physiological manifestation of psychological stress in inividuals affected by CSC. Several personality traits auch as elevated aggressiveness or emotional instability and adverse stress coping intensify the negative effect of stressful situations. We assume that the appearance of CSC may be associated with an accumulation of unfavourable psychic factors, which might also adversely affect stress hormone levels. Moreover, our findings give rise to speculation that occupational stress is only one factor in CSC pathogenesis and due to investigating mainly employed men in the past its role might have been overestimated so far. CSC manifestation seems to be triggered by burden of critical life events, associated by adverse personality characteristics and accompanied by an unfavourable coping style. Nevertheless, because of the cross-sectional nature of the study, causal inferences cannot be drawn. When relating to individual stress, it is not clear if CSC is the consequence or a prerequisite of it, and manifestation of CSC may lead to further stress-related responses. However, critical personality characteristics as represented in Type A personality are rather a precondition than a consequence of CSC. Extended knowledge about this burdening disease may improve diagnostic, therapeutic and preventive strategies. For further analyses of the associations between CSC and psychological and biological factors a prospective approach would be necessary, including patients of both sexes. Acknowledgement—The authors thank Dietmar Mattes, Beate Langer-Wegscheider, Anton Haas and Martin Weger from the Department of Ophthalmology, Graz for their valuable assistance. Disclosure of interests: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. The authors alone are responsible for the content and writing of the paper.
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