Cardiovascular diseases (CVD) have been around since the second half of the 20th century. still the most common cause of mortality in the world, with up to 80% of premature deaths from CVD identified as preventable (WHO, 2009). For more than half a century, the relationship between psychological, social and behavioral variables and CVD risk factors has been studied in this context. From the beginning of the 80s of the 20th century. increasingly clear indications of the relationship between the level of burnout syndrome and the level of CVD risk factors began to appear in the world literature.

In one of the first works on this topic, a cross-sectional study conducted among a group of North American teachers (N = 181), a statistically significant relationship was found between burnout syndrome and subjective and medically diagnosed symptoms of CVD (Belcastro, 1982).

These and other findings (Appels, Otten, 1992; Melamed, Kushnir, Shirom, 1992; Toppinen-Tanner et al., 2005; Melamed et al., 2006; Shirom, 2007) point to a very likely relationship between burnout syndrome and acute myocardial infarction, ischemic heart disease, stroke, and sudden cardiac death, in in the vast majority of cases, with the assumption that burnout probably precedes CVD rather than arising as a result of it.

The first possible interpretation of the association between burnout syndrome and CVD risks is the negative influence of the hypothalamus-pituitary-adrenal cortex (HPA) axis, and thus the secretion of cortisol and other stress hormones, as well as some other influencing variables (Melamed et al., 1999).

The second possibility of interpretation of this relationship is based on the assumed influence of lipid metabolism. Melamed, Kushnir and Shirom (1992) found a relationship between the level of burnout score and the level of somatic cravings, cholesterol, glucose, triglycerides and uric acid in a group of 104 healthy men. A. Shirom et al. (1997) similarly found a relationship between SV levels of total cholesterol and triglycerides.

The third possible interpretation of this relationship is the use of the constructs of behavior type and personality type (Friedman, Rosenman, 1974; Denollet, 1991, 2005).

Following on from earlier research carried out in Czech conditions (Kebza, Šolcová, 2009), we decided to verify the validity of the above-mentioned aspects in an empirical investigation, carried out among the Czech adult population within the framework of the project GA ČR 406/06/0747 and the research plan AV 0Z 70250504.

Empirical research – design and methodology

Due to the well-known problems with determining the level of cortisol, we decided to use the possibility of relatively reliable biochemical diagnostics, which allows the determination of the level of total cholesterol and its fractions (HDL and LDL cholesterol), triglycerides in relation to blood pressure values, nutritional habits and psychological variables from the collected venous blood sample.

  • The study presents part of the results of a prospectively arranged two-phase investigation, the aim of which is to verify the potential connections between the burnout syndrome and the main known risks of cardiovascular diseases (CVD) on a group of economically active Czech men and women through:
  • data from personal and family history,
  • determining the level of cholesterol and its fractions,
  • triglyceride values,
  • determination of nutritional habits,
  • frequency of smoking,
  • blood pressure values and more
  • through a battery of methods to determine the level of psychosocial risks of CVD (type of behavior, irritability, hostility, tension, frustration, sensitivity to experienced life events, interpersonal sensitivity, D-type personality, burnout syndrome) and more general health risks (negative affectivity, daily life events, long-term life events, resilience in the sense of hardiness and perceived social support).

The project also included a comprehensive intervention aimed at reducing the incidence of CVD risk factors and burnout syndrome.

Another goal of the project was therefore also an effort to demonstrate the effect of education of the probands on reducing the risks of CVD (including burnout syndrome), as was previously proven abroad, e.g. in the Stanford Five Cities Project (Farquhar et al., 1990), but also in the Czech Republic as part of the joint Czech-American project Program for Reduction of Cardiovascular and Cerebrovascular Disease in the Czech Republic, implemented with the support of a US-AID (Agency for International Development) grant in the Czech Republic in the years 1992 - 1995.

The set of probands was obtained by approaching Czech and foreign companies, enterprises and institutions that previously used cooperation with the State Health Institute and other medical facilities to implement preventive programs that serve to protect and support the health of their employees.

At the beginning of the implementation of the project, in 2006, we obtained a set of 100 persons by contacting these institutions, during the second year of the implementation of the project we expanded it to 162 persons, but for the final examination carried out at the end of 2008, we obtained complete data from 78 persons (64 women, 14 men; average age 48.4; SD 11.6; min. age 22, max. age 67). These were subjectively healthy persons without CVD symptoms who participated from the beginning of all phases of the project implementation.

Examination of the probands always took place in the first (2006) and last (2008) years of the project according to a standard procedure, first in the morning between 7.30 and 8.00 fasting blood sampling and basic anthropometric and medical (internal) examination, followed by a psychological examination after a light snack. The total duration of the examination was about three and a half hours.

Czech versions of the following methods were used from psychological questionnaires: 1. The extended Bortner scale (Horváth et al., 1983) contains 22 items to determine the type of behavior, evaluated on a visual analog scale with a length of 35 mm.; items are grouped into 6 scales - irritability, tension, hostility, interpersonal sensitivity, sensitivity to life events, frustration. The total score – type A behavior level was calculated both from this 22-item scale (A1) and from the original ten-item Bortner scale (A2). 2. The Survey of Recent Life Experiences (SRLE; Kohn, Macdonald, 1992) is a structured interview that uses 51 items, assessed on a four-point scale, to determine the impact of daily events over the past 30 days. 3. Personal Views Survey (PVS; Kobasa, 1985) – is a questionnaire aimed at determining resistance in the sense of hardiness through 50 items evaluated on a four-point scale (Šolcová, Kebza, 1996). 4. Social Readjustment Rating Scale (Holmes, Rahe, 1967) - an inventory of 43 items, determining through point expression the scores of life events for the last 12 months. 5. Perceived Social Support Scale (PSSS; Blumenthal et al., 1987) – a questionnaire that assesses the perceived level of social support on a seven-point scale through 12 basic and 4 additional items. 6. Shirom–Melamed-Burnout-Measure - a questionnaire aimed at determining the level of risk of burnout syndrome through 14 items, evaluated on a seven-point assessment scale (Shirom, Melamed, 2006). 7. Denollet's questionnaire to determine the D-type of personality (DS 14; Denollet, 2005); D stands for distressed. It is a combination of two personality characteristics, the tendency to experience negative emotions and the tendency to social inhibition, operationalized in 14 items, evaluated on a five-point scale (see Šolcová, Kebza, 2006 for details). 8. Scales for measuring anger and anger (ŠHAN, form X – 2; Psychodiagnostika Bratislava, 1990). The questionnaire, including 15 basic items, evaluated on a four-point scale and 1 additional item, evaluated on a seven-point scale, serves to determine the level of negative affectivity.

Blood pressure was measured in accordance with the methodology established within the WHO-MONICA program (MONItoring of trends and determinants in Cardiovascular Disease, 1988).

From the venous blood sample taken, the levels of total cholesterol, HDL and LDL cholesterol and triglycerides were determined by the standard laboratory procedure in the FNKV laboratory.

The intervention activities were started already in the first year of the project in cooperation with the staff of ZÚ based in Prague (3 doctors, 1 nutrition specialist and 1 nurse) and were conceived comprehensively, i.e. j.: 1. in the field of nutrition and physical activity, aimed at ensuring an adequate balance between energy intake and output, reducing the volume of fat (especially in the form of "red", i.e. pork and beef and meat products (sausages), fatty dairy products, saturated fatty acids and reducing salt intake and increasing the consumption of "light" meat (fish and chicken), and vegetables and fruits. 2. another area of intervention was the area of addictions with a special focus on prevention, or smoking cessation, 3. intervention in the field of load and stress management was focused on practicing relaxation methods, stress management, reducing tension, irritability, hostility, frustration, moderating the occurrence of life events and supporting and creating faith in one's own abilities, the meaning of life, increasing social support.

Results - statistical processing

Biological variables are dependent variables in this study, psychological variables are independent variables. We determined the effect of the intervention on individual variables using a paired t-test.

Due to the large number of psychological variables, we performed factor analyzes of input data, output data and differences between input and output data to make the data clearer.

The biological variables detected during the final examination were then related to the values of the factor scores by regression linear analysis both for the initial psychological values and for the "output" (after the intervention) psychological values.

Determining the effect of the intervention on the development of CVD risk factors

Within the monitored biochemical variables, there was a decrease in the level of total cholesterol and LDL cholesterol.

Within the monitored biochemical variables, no statistically significant changes were detected in the case of HDL cholesterol, triglycerides and both blood pressure values (see table no. 1).

Determining the effect of the intervention on the development of psychological variables

For the monitored psychological variables, there was a statistically significant decrease in the values of the A1 and A2 scales, representing the level of type A behavior (non-negotiable striving for something), as well as a decrease in the level of tension, frustration and hostility, sensitivity to experienced life events, the level of daily events (SRLE) and life events (LE), negative affectivity (ŠHAN), and a statistically significant increase in the level of social support (PSSS). On the contrary, there were no statistically significant changes in the case of irritability, interpersonal sensitivity, level of burnout syndrome (Shirom-Melamed scale), D-type personality and level of psychological resistance in the sense of hardiness (PVS questionnaire, see table no. 2).

Factor analysis

The results of the factor analysis (principal component method, Varimax rotation with Kaiser normalization) divided the psychological variables into three input and four "output" factors. The initial three-factor solution explained 73.1% of the total variance, the four-factor solution exhausted 71.9% of the total variance.

The first input factor is filled with variables that represent a composite variable that can be characterized as general risk factors for health (level of "big" life events, social support, negative affectivity, psychological resistance-hardiness, everyday "small" events, D-type personality and burnout syndrome).

The second input factor is filled with variables from the Bortner scale, the composition of which is very close to the so-called AHA syndrome (Anger-Hostility-Aggression in the concept of C. Spielberger), i.e. j. level of meaning attributed to experienced life events, hostility, tension, frustration and irritability.

The third input factor contains scores A1 and A1, expressing the essence of type A behavior. In the four-factor solution at the final examination, the Bortner scale was divided into 3 factors, by separating interpersonal sensitivity from the AHA factor into a separate factor. The factor of general risk factors for health remained the same, which, among other things, it confirms both the reliability of the factor solution and the fact that we chose variables that, especially in combination, represent health risks. The type A behavior factor remained in the output four-factor solution.

Linear regression analysis

The next step was to find out the relationship between the biochemical variables found during the final examination and the psychological variables found during the initial and/or final examination.

The results of factor analyzes were used as input data for linear regression analyses. Physiological and biochemical variables detected during the exit examination were further related to the values ​​of factor scores (1) for input psychological values, (2) for output psychological values ​​by regression linear analysis. Factor scores were determined by the regression estimation method. These analyzes were performed by stepwise regression analysis, while in the first step all factor scores were included among the predictors, in the next steps the number of predictors was reduced by those that were the least significant and only those for which the level of significance p less than 0.100 was found were included in the final statistical set. This method was applicable in this case, because there is no risk of collinearity of the predictors, as the factor scores are uncorrelated.

The results for total cholesterol (M = 5.09; SD = 0.63) and LDL cholesterol (M = 2.99, SD = 0.65) found at the final examination are presented in tab. 3. The predictor of both biochemical variables is the factor of general health risks found during the initial examination.

The predictor of HDL cholesterol (M = 1.58, SD = 0.37) detected at the exit examination is the input factor of general health risks (negative relationship) and the input factor called AHA syndrome. The predictor of triglycerides (M = 1.15, SD = 0.59) is the input factor of general health risks. The predictor of diastolic blood pressure (M = 80.5, SD = 6.14) is the input factor, which we called the AHA syndrome.

Further analysis of the above results showed that as a predictor of total cholesterol, negative affectivity (ŠHAN) is used as a predictor of the general health risks factor, irritability and burnout syndrome are used as a predictor of the HDL cholesterol level (negative relationship), and hostility is a predictor of the diastolic blood pressure level (see tab. 4).

If we relate the final biological values to the output psychological factors, then no statistically significant predictor was applied for total cholesterol. A statistically significant predictor for HDL (M = 1.58, SD = 0.37) is the general health risks factor (negative relationship) and the type A behavior factor (Table 5). Diastolic pressure (M = 80.5, SD = 6.14) is predicted by the outcome factor AHA syndrome.

In a more detailed analysis of the above results, tension from the Bortner scale was found to be a predictor of diastolic blood pressure (B = 0.235, confidence interval > 0.029 < 0.440, p = 0.026).

Discussion

Regarding changes in biochemical variables, the reduction of total cholesterol and LDL cholesterol can be considered a very favorable finding. Changes in psychological variables can also be considered favorable: there was a reduction in a number of risk characteristics and an increase in the level of perceived social support, which is a protective factor. It is known from the literature that even if the perception of social support is considered a personality characteristic, it is amenable to intervention (see Šolcová, Kebza, 1999 for more details).

Changes in the type of behavior and its individual components confirm the findings of a number of authors that behavior is relatively easily accessible to psychological interventions (see, for example, Jenni, Wollersheim, 1979; Thoresen, Telch, Eagleston, 1981).

In the case of the burnout syndrome, its stability over time was confirmed, which was pointed out some time ago by A. Shirom (2005).

Of course, we would like to attribute the detected positive changes within psychological variables to the influence of a complex intervention, but for some of them (e.g. daily or life events) this cannot be clearly stated from a critical point of view - the development of life dynamics is influenced by a number of variables that cannot be controlled.

Conclusion

It can be stated that the central hypothesis of the project on the connection between burnout syndrome, selected psychological and social variables and psychophysiological and biochemical variables in the study of cardiovascular disease risk factors was partially confirmed: its validity is limited by only some combinations of the studied variables, and by the scope and characteristics of the group of probands participating in both examinations.

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The paper was presented at the 5th annual conference entitled ,,Psychology of health 2010", which took place on May 19, 2010 in Bratislava. The conference was organized by the health psychology section of the SPS at SAV in cooperation with the health section of the Ministry of Health of the Slovak Republic. The following participated in the preparation of the event: National Institute of Heart and Vascular Diseases in Bratislava, VŠZaSP St. Elizabeth in Bratislava, WHO Office in Slovakia, KISH Košice, Department of Psychology FF KU in Ružomberok and Department of Psychology FF TU in Trnava.

Proceedings from the 5th conference of health psychology, Bratislava, 2010 was published only in electronic form Availability: http://www.prohuman.sk/psychologia/zbornik-prispevkov-z-konferencie-psychologia-zdravia-2010