*2.2.2 Anxiety symptoms and syndromes*

In recent years, studies have identified anxiety as one of the risk factors for heart disease [22]. Many meta-analyses of community cohorts and patient cohorts have shown that anxiety symptoms increase the risk of heart disease [23]. Other studies have shown that patients with generalized anxiety disorder, panic attacks, and post-traumatic stress syndrome have an increased risk of heart disease events [24].

#### *2.2.3 Pessimism*

Mental outlook is also one of the determinants of health, with optimists being more positive, having enhanced social functioning and better recovery from

myocardial infarction or heart surgery [25]. Recent epidemiological data suggest that pessimism increases the risk of cardiac events, stroke, and/or all-cause mortality [26].

#### *2.2.4 Anger and hostility*

Anger and hostility have been extensively studied [27]. However, a meta-analysis of healthy people and patients with heart disease found that anger and/or hostility only increased the rate of cardiac events [28].

#### **2.3 Chronic stress**

So far, most studies on chronic stress have focused on situational stress [29], and work stress [30] is the most widely studied one. A recent meta-analysis showed that occupational stress was associated with increase in heart disease events [31]. Separation and divorce are two other common stressors that increase the risk of death [32], and independent epidemiological studies have also shown an association between marital stress and cardiovascular events [33].

It is worth mentioning that personal stress perception may also be one of the important factors affecting health [34]. A study that assessed levels of stress perception and perceptions of whether stress was harmful to health in 28,753 participants showed that stress increased mortality only in those who self-assessed risk harmful to health [35]. A complementary study showed that guiding individuals to understand stress as a positive effect improved cognitive and cardiovascular responses to stress. Combining the above two studies, we should further study the individual's perception of stress and the impact of its regulation on health.

#### **2.4 Social isolation and lack of social support**

Epidemiological studies consistently show that small social networks, lack of social support, loneliness, and/or feelings of lack of emotional support increase the risk of cardiac events [36]. Like other psychosocial risk factors, the likelihood of adverse cardiac events increases with the degree of lack of social support, and a positive social overall can nearly triple survival [37].

#### **2.5 Lack of sense of purpose**

Observational studies have shown that a strong sense of purpose in life is central to leading an active life, and that a lack of purpose in life can lead to boredom, increase risk of depression, and diminish resilience. Although only a few studies have assessed the pathophysiological outcomes of lack of purpose, a large number of recent studies have shown that lack of purpose increases the risk of death [38].

#### **2.6 Psychosocial functioning**

Negative psychosocial factors contribute to the development of disease by forming negative behaviors and direct pathophysiological effects. These effects vary by type of psychosocial stress, but as a whole include autonomic dysfunction, cardiovascular hyperresponsiveness, insulin resistance, central obesity, increased risk of hypertension, endothelial and platelet dysfunction, and brain adverse changes in adaptive and cognitive function, etc. [39].

Conversely, positive psychosocial factors favor healthy behaviors and promote beneficial physiological effects, including enhanced immune and endothelial and autonomic function. In addition, positive psychosocial functioning contributes to increased vitality, which in turn increases presence, purpose, and resistance [40].
