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Sutar R, Lahiri A, Ali R, Solanki V, Majumdar A, Sharma M, Chaturvedi S. Development and Validation of Hospital Mental Health Screen to Detect Psychiatric Morbidity in Medically Ill Patients in India. Indian J Psychol Med 2025; 47:166-172. [PMID: 39564343 PMCID: PMC11572602 DOI: 10.1177/02537176241248061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2024] Open
Abstract
Background Psychiatric morbidities often go unnoticed in medically ill patients. It is essential to screen patients with medical morbidity so that they can be referred to psychiatrists for early interventions in general hospitals in India. There is a potential lacuna in terms of the availability of a scale that can aptly identify psychiatric symptoms in medically ill patients beyond depression or anxiety, especially in low-resource settings like India. The aim was to detect psychiatric morbidity in medically ill patients in India. Methods Items were generated using deductive and inductive approaches. Item-Content Validity Index (I-CVI) and Scale-Content Validity Index/Universal Agreement (S-CVI/UA) were computed by involving eight subject matter specialists. The tool was circulated to 397 medically ill patients for computing The exploratory factor analysis (EFA). Domain-wise reliability using Cronbach's alpha was calculated for six factors. The concurrent criterion validity of the Hospital Mental Health Screen (HMHS) tool was calculated by the receiver operating curve (ROC) against the gold standard of any psychiatric morbidity diagnosed by two psychiatrists in 397 medically ill patients. We used IBM SPSS version 23. Results Initially, 34 items were generated. At the I-CVI threshold of 79%, seven items were discarded. The S-CVI/UA of the scale was 85.1%. The Kaiser-Meier-Olkin Measure of Sampling Adequacy (KMO MSA) was found to be 0.916. At a factor loading threshold of 0.4 and an eigenvalue above 1, a six-factor structure was extracted using principal component analysis and varimax rotation. Domain-wise reliability was computed, which was between 0.657 and 0.840. The final tool consisted of 27 Likert items (0 = never to 4 = always). Using the ROC curve at the 19.5 threshold, 91.4% of the positive outcomes were correctly classified and 9.5% of the adverse outcomes were expected to be incorrectly identified by the HMHS screening tool. Conclusion HMHS is a valid and reliable tool with good screening properties, designed especially for the Indian setting. This scale can assist in identifying psychiatric morbidity in medically ill patients in low-resource settings. There is further scope for performing confirmatory factor analysis (CFA) to reinforce the factor structure of HMHS.
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Affiliation(s)
- Roshan Sutar
- Dept. of Psychiatry, AIIMS Bhopal, Madhya Pradesh, India
| | - Anuja Lahiri
- Dept. of Community and Family Medicine, AIIMS Bhopal, Madhya Pradesh, India
| | - Rashida Ali
- Dept. of Psychiatry, AIIMS Bhopal, Madhya Pradesh, India
| | | | - Anindo Majumdar
- Dept. of Community and Family Medicine, AIIMS Bhopal, Madhya Pradesh, India
| | - Manoj Sharma
- Dept. of Clinical Psychology, NIMHANS, Bangalore, Karnataka, India
| | - Santosh Chaturvedi
- Jagadguru Kripalu Chikitsalaya, Vrindavan and Barsana, Uttar Pradesh, India
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Muacevic A, Adler JR. Understanding Patient-Provider Interaction, Treatment Acceptance, and Outcomes in Medically Unexplained Symptoms. Cureus 2022; 14:e32915. [PMID: 36699771 PMCID: PMC9871694 DOI: 10.7759/cureus.32915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Medically unexplained symptoms (MUS) is an umbrella term used for chronic and often disabling health symptoms and conditions that remain unexplained after standard medical examinations, testing, and/or appropriate workup. Patients with MUS tend to receive little to no treatment but remain distressed, stigmatized, and disabled by symptoms and iatrogenic factors. METHODS A qualitative phenomenological study was conducted to explore daily challenges and psychosocial and iatrogenic factors affecting the management of MUS. RESULTS The analysis of the interviews revealed that MUS could cause significant distress to patients, impairing their functioning and leading to permanent disability. Conventional healthcare cannot meet the medical needs of these patients and might be a potential source of harm to them. It should be noted that confirmation of conditions associated with clinically significant psychiatric premorbidity was not provided. CONCLUSION Inconsistent diagnostic criteria, lack of proper training and research, diagnostic overshadowing, and implicit bias in healthcare professionals can lead to negative patient outcomes and the overuse of alternative or non-evidence-based services. Guidance, practice-based improvement ideas, and suggestions specific to improving patient-provider relationships can be applied to generate positive health effects.
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van der Feltz-Cornelis CM, Sweetman J, Edwards M, Gall N, Gilligan J, Hayle S, Kaul A, Moriarty AS, Perros P, Sampford J, Smith N, Elfeddali I, Varley D, Gower J. Identifying the top research priorities in medically not yet explained symptoms (MNYES): a James Lind Alliance priority setting partnership. BMJ Open 2022; 12:e061263. [PMID: 35777869 PMCID: PMC9252198 DOI: 10.1136/bmjopen-2022-061263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/14/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study establishes research priorities for medically not yet explained symptoms (MNYES), also known as persistent physical symptoms or medically unexplained symptoms, from the perspective of patients, caregivers and clinicians, in a priority setting partnership (PSP) following the James Lind Alliance (JLA) approach. Research into such symptoms in general has been poorly funded over the years and so far has been primarily researcher-led with minimal input from patients, caregivers and clinicians; and sometimes has been controversial. DESIGN JLA PSP method. The PSP termed these symptoms MNYES. METHODS The study was conducted according to the JLA's detailed methodology for conducting priority setting exercises. It involved five key stages: defining the appropriate term for the conditions under study by the PSP Steering Group; gathering questions on MNYES from patients, caregivers and clinicians in a publicly accessible survey; checking these research questions against existing evidence; interim prioritisation in a second survey; and a final multi-stakeholder consensus meeting to determine the top 10 unanswered research questions using the modified nominal group methodology. RESULTS Over 700 responses from UK patients, caregivers and clinicians were identified in the two surveys and charities contributed from a broad range of medical specialties and primary care. The final top 10 unanswered research questions cover, among others: treatment strategies, personalisation of treatment, collaborative care pathways, training for clinicians and outcomes that matter to patients. INTERPRETATION The top 10 unanswered research questions are expected to generate much needed, relevant and impactful research into MNYES.
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Affiliation(s)
- Christina Maria van der Feltz-Cornelis
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
- York Biomedical Research Institute, University of York, York, UK
- R&D Department, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
- Institute of Health Informatics, University College London, London, UK
| | | | - Mark Edwards
- St George's University of London, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Nicholas Gall
- Department of Cardiology, University of London Kings College Hospital, London, UK
| | | | | | - Arvind Kaul
- St George's University of London, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Andrew Stephen Moriarty
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - James Sampford
- Liaison team, Tees Esk and Wear Valleys Foundation Trust, York, UK
| | - Natalie Smith
- Department of Health Sciences, University of York, York, UK
| | - Iman Elfeddali
- Tranzo Department, Tilburg University, Tilburg, Netherlands
- Centre of Excellence for Body Mind and Health, GGz Breburg, Tilburg, The Netherlands
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Kube T, Rozenkrantz L, Rief W, Barsky A. Understanding persistent physical symptoms: Conceptual integration of psychological expectation models and predictive processing accounts. Clin Psychol Rev 2020; 76:101829. [PMID: 32062101 DOI: 10.1016/j.cpr.2020.101829] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 01/11/2023]
Abstract
Persistent physical symptoms (PPS) are distressing, difficult to treat, and pose a major challenge to health care providers and systems. In this article, we review two disparate bodies of literature on PPS to provide a novel integrative model of this elusive condition. First, we draw on the clinical-psychological literature on the role of expectations to suggest that people with PPS develop dysfunctional expectations about health and disease that become increasingly immune to disconfirmatory information (such as medical reassurance) through cognitive reappraisal. Second, we invoke neuroscientific predictive processing accounts and propose that the psychological process of 'cognitive immunization' against disconfirmatory evidence corresponds, at the neurobiological and computational level, to too much confidence (i.e. precision) afforded to prior predictions. This can lead to an attenuation of disconfirming sensory information so that strong priors override benign bodily signals and make people believe that something serious is wrong with the body. Combining these distinct accounts provides a unifying framework for persistent physical symptoms and shifts the focus away from their causes to the sustaining mechanisms that prevent symptoms from subsiding spontaneously. Based on this integrative model, we derive new avenues for future research and discuss implications for treating people with PPS in clinical practice.
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Affiliation(s)
- Tobias Kube
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Gutenbergstr. 18, 35032 Marburg, Germany; Pain and Psychotherapy Research Lab, University of Koblenz-Landau, Ostbahnstr. 10, 76829 Landau, Germany.
| | - Liron Rozenkrantz
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Gutenbergstr. 18, 35032 Marburg, Germany
| | - Arthur Barsky
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Psychiatry, Harvard Medical School, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
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Chutko LS, Surushkina SY, Yakovenko EA, Anisimova TI, Prokopenko SM. [Efficiency of cytoflavin in the treatment of somatoform disorders]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 117:21-24. [PMID: 28252599 DOI: 10.17116/jnevro20171171121-24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To study the efficacy of cytoflavin in patients with somatoform disorders (SD). MATERIAL AND METHODS The study included 60 patients with SD, aged from 27 to 43 years. The efficacy was assessed by the results of psychological and neurophysiological examinations. RESULTS AND CONCLUSION The higher efficacy of cytoflavin (the improvement of patient's condition in 63,3% of cases) compared to that of ethylmethylhydroxypyridine succinate (56,7% of cases) was found. Patient's state was more stable after treatment with cytoflavin.
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Affiliation(s)
- L S Chutko
- Institute of Human Brain Russian Academy of Sciences, St. Petersburg
| | - S Y Surushkina
- Institute of Human Brain Russian Academy of Sciences, St. Petersburg
| | - E A Yakovenko
- Institute of Human Brain Russian Academy of Sciences, St. Petersburg
| | - T I Anisimova
- Institute of Human Brain Russian Academy of Sciences, St. Petersburg
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Carlier IVE, Andree Wiltens DH, van Rood YR, van Veen T, Dekker J, van Hemert AM. Treatment course and its predictors in patients with somatoform disorders: A routine outcome monitoring study in secondary psychiatric care. Clin Psychol Psychother 2018; 25:550-564. [PMID: 29573030 DOI: 10.1002/cpp.2191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 02/14/2018] [Accepted: 02/14/2018] [Indexed: 12/27/2022]
Abstract
AIM Somatoform disorders are common and often chronic. It would be helpful to distinguish those patients who are likely to have a positive treatment course from those who are likely to follow a negative course. Such studies of different somatoform disorders are scarce, especially in secondary psychiatric care. This study examined the 6-month treatment course of psychological, physical symptoms, and functioning, and its predictors in a naturalistic sample of secondary psychiatric care outpatients with somatoform disorders. METHOD The present study used routine outcome monitoring data of patients with somatoform disorders regarding their 6-month treatment course of psychological and physical symptoms as well as functioning. The following patient groups were included: total group of somatoform disorders (N = 435), and undifferentiated somatoform disorder (N = 242), pain disorder (N = 102), body dysmorphic disorder (N = 51), and hypochondriasis (N = 40). Measures were Mini-International Neuropsychiatric Interview plus, Brief Symptom Inventory, Montgomery-Ǻsberg Depression Rating Scale, Brief Anxiety Scale, Short Form Health Survey 36, and Physical Symptom Checklist (PSC). RESULTS The study population generally showed high co-morbidity, especially with anxiety and mood disorders. The PSC total score, body dysmorphic disorder, and hypochondriasis were significant predictors for the treatment course of symptoms (Brief Symptom Inventory), whereas the PSC total score was the only significant predictor for the course of functioning (Short Form Health Survey 36). CONCLUSION Secondary psychiatric care outpatients with somatoform disorders showed high co-morbidity with anxiety and mood disorders, and an unfavourable 6-month course of both symptoms and functioning. Clinical implications are discussed, such as additional treatment of co-morbidity in somatoform disorders.
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Affiliation(s)
- I V E Carlier
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Y R van Rood
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
| | - T van Veen
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
| | - J Dekker
- Department of Psychiatry and Department of Rehabilitation Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - A M van Hemert
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
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Page LA, Wessely S. Medically Unexplained Symptoms: Exacerbating Factors in the Doctor-Patient Encounter. J R Soc Med 2017; 96:223-7. [PMID: 12724431 PMCID: PMC539474 DOI: 10.1177/014107680309600505] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- L A Page
- Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK.
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Payne H. The body speaks its mind: The BodyMind Approach® for patients with medically unexplained symptoms in primary care in England. ARTS IN PSYCHOTHERAPY 2015. [DOI: 10.1016/j.aip.2014.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lo studio internazionale multicentrico dell'Organizzazione Mondiale della Sanità sui disturbi psichici nella medicina generale: risultati relativi all'area di Verona. ACTA ACUST UNITED AC 2014. [DOI: 10.1017/s1121189x0001023x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
SummaryObjectives - To present the results obtained from a cross-sectional evaluation of a sample of primary care attenders selected in Verona in the framework of the World Health Organization International Multicentre Study on Psychological Problems in Primary Care Settings. Methods - Among consecutive attenders at 16 primary care clinics in Verona during the period April 1991/February 1992, a random sample, stratified on the basis of GHQ-12 scores, was selected for a thorough evaluation of psychological status, physical status and disability in occupational and other daily activities. All patients with psychopathological symptoms at baseline assessment and a 20% random sample of those without psychopathological symptoms were interviewed again after 3 and 12 months (data not presented here). Results - Overall, 1,656 subjects were approached at the primary care clinics and 1,625 met inclusion criteria. The screening procedure was completed by 1,558 subjects and the second-stage evaluation by 250. Psychiatric disorders according to ICD-10 criteria were diagnosed in 12.4% of consecutive primary care attenders; of these, about one-third (4.5% of consecutive primary care attenders) satisfied ICD-10 diagnostic criteria for two or more disorders. Current Depressive Episode (4.7%) and Generalized Anxiety Disorder (3.7%) were the most common diagnoses. In addition, 11.2% of consecutive primary care attenders had ‘sub-threshold’ psychiatric disorders (i.e., they suffered from symptoms in at least two different areas among those listed in ICD-10, but they did not satisfy diagnostic criteria for well-defined disorders). Psychiatric disorders were more common among females and those aged 24-44 years. Only 20.6% of the subjects with psychiatric disorders contacted the general practitioner for their psychological symptoms, 5.7% complained of symptoms which might have had a psychological origin, whereas in about 70% of the cases the psychiatric disorder was concealed behind the presentation of somatic symptoms, pains in various parts of the body or chronic physical illness. Sixty-two percent of the subjects with psychiatric disorders rated their health status as fair or poor, as compared to 52.0% of those with chronic physical illness and 31.3% of those without such disorders. According to the general practitioner, 40.1% of the subjects with psychiatric disorders and 45.3% of those with chronic physical illness had a fair or poor health status, compared to 14.4% of those without such disorders. Disability in occupational and other daily activities was reported by 52.5% of the subjects with psychiatric disorders (in 40.1% of the cases disability was moderate or severe), 44.4% of those with chronic physical illness (in 26.8% of the cases disability was moderate or severe), and 15.0% of the subjects without such disorders (in 9.1% of the cases disability was moderate or severe). According to the interviewer, disability was identified in 48.4% of the subjects with psychiatric disorders, 39.0% of those with chronic physical illness, and 27.6% of the subjects without such disorders. Sixty per cent of the subjects with psychiatric disorders suffered from concurrent chronic physical illness; these subjects had a poorer health status and higher disability levels than those with psychiatric disorders only. Conclusions - Psychiatric disorders among primary care attenders are frequent and represents a major public health problem, since they entail severe functional limitations for the patients and high costs for the society. Thus, appropriate programs for their recognition and treatment are needed.
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Abstract
In medically ill patients the term 'somatic symptoms' is used to understand those symptoms which cannot be fully understood in the light of existing medical illness(es). These include a number of physical symptoms and also certain clinical syndromes such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome among others. However, it is increasingly recognized that such patients have larger degrees of psychological morbidities, especially depressive and anxiety disorders, and have disproportionately elevated rates of medical care utilization, including outpatient visits, hospitalizations and total healthcare costs. In view of this psychological morbidity, significant distress and functional impairment, the role of the consultation-liaison psychiatrist is prominent in the management of these patients. A consultation-liaison (CL) psychiatrist is expected to be part of the primary care team to manage patient with unexplained SS, and at the same time is expected to guide colleagues to practice a patient-centred approach to improve the outcome of patients with such symptoms. The clinical work of a CL psychiatrist involves evaluation of patients with medically unexplained symptoms for probable psychiatric disorders and treatment of psychiatric morbidity and also management of patients without psychiatric morbidity. Management strategies include reattribution, cognitive behaviour therapy and antidepressants, with each strategy showing varying degrees of success.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Zonneveld LNL, van Rood YR, Timman R, Kooiman CG, Van't Spijker A, Busschbach JJV. Effective group training for patients with unexplained physical symptoms: a randomized controlled trial with a non-randomized one-year follow-up. PLoS One 2012; 7:e42629. [PMID: 22880056 PMCID: PMC3413637 DOI: 10.1371/journal.pone.0042629] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Accepted: 07/09/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although cognitive-behavioral therapy for Unexplained Physical Symptoms (UPS) is effective in secondary care, studies done in primary care produced implementation problems and conflicting results. We evaluated the effectiveness of a cognitive-behavioral group training tailored to primary care patients and provided by a secondary community mental-health service reaching out into primary care. METHODOLOGY/PRINCIPAL FINDINGS The effectiveness of this training was explored in a randomized controlled trial. In this trial, 162 patients with UPS classified as undifferentiated somatoform disorder or as chronic pain disorder were randomized either to the training or a waiting list. Both lasted 13 weeks. The preservation of the training's effect was analyzed in non-randomized follow-ups, for which the waiting group started the training after the waiting period. All patients attended the training were followed-up after three months and again after one year. The primary outcomes were the physical and the mental summary scales of the SF-36. Secondary outcomes were the other SF-36-scales and the SCL-90-R. The courses of the training's effects in the randomized controlled trial and the follow-ups were analyzed with linear mixed modeling. In the randomized controlled trial, the training had a significantly positive effect on the quality of life in the physical domain (Cohen's d = 0.38;p = .002), but this overall effect was not found in the mental domain. Regarding the secondary outcomes, the training resulted in reporting an improved physical (Cohen's d = 0.43;p = 0.01), emotional (Cohen's d = 0.44;p = 0.01), and social (Cohen's d = 0.36;p = 0.01) functioning, less pain and better functioning despite pain (Cohen's d = 0.51;p = <0.001), less physical symptoms (Cohen's d = -.23;p = 0.05) and less sleep difficulties (Cohen's d = -0.25;p = 0.04) than time in the waiting group. During the non-randomized follow-ups, there were no relapses. CONCLUSIONS/SIGNIFICANCE The cognitive-behavioral group training tailored for UPS in primary care and provided by an outreaching secondary mental-health service appears to be effective and to broaden the accessibility of treatment for UPS. TRIAL REGISTRATION TrialRegister.nl NTR1609
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Affiliation(s)
- Lyonne N L Zonneveld
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Wong WS, Fielding R. The co-morbidity of chronic pain, insomnia, and fatigue in the general adult population of Hong Kong: Prevalence and associated factors. J Psychosom Res 2012; 73:28-34. [PMID: 22691556 DOI: 10.1016/j.jpsychores.2012.04.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 04/24/2012] [Accepted: 04/24/2012] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Although research suggests there is considerable overlap among chronic pain, fatigue, and sleep disturbances, no research to date has concurrently examined their interrelationships. This study estimates the co-occurrence of these three conditions in terms of prevalence and associated factors in the general adult population. METHODS In a population-based, cross-sectional telephone survey, 5001 adults aged ≥18 years drawn from the Hong Kong general population completed the Chronic Pain Grade (CPG) questionnaire, the Pittsburgh Sleep Quality Index (PSQI), the Chronic Fatigue Scale (CFS), Hospital Anxiety and Depression Scale (HADS), and socio-demographic questions. RESULTS The overall prevalence of reporting all three chronic conditions was 5.6% (95% CI: 4.9-6.4) and increased with age, being higher in women, and those in lower income and education level groups. Individuals with multiple symptoms also reported poorer mental health, and self-perceived health. Results of multi-ordinal regression analyses identified female, divorced/separated, having part time employment, retirees, unemployment, housewives, existing long-term health problems, higher HADS scores, and low self-perceived health to be significantly associated with reporting all three symptoms. CONCLUSION This study has shown that the co-occurrence of chronic pain, fatigue, and sleep disturbances was common in the general adult population. Multiple symptoms are comorbid of psychological distress.
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Affiliation(s)
- Wing S Wong
- Department of Psychological Studies, The Hong Kong Institute of Education, 10 Lo Ping Road, Tai Po, Hong Kong.
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Quinti I, Di Pietro C, Martini H, Pesce AM, Lombardi F, Baumghartner M, Colantuono S, Milito C, Tabolli S. Health related quality of life in common variable immunodeficiency. Yonsei Med J 2012; 53:603-10. [PMID: 22477006 PMCID: PMC3343431 DOI: 10.3349/ymj.2012.53.3.603] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To quantify the health related quality of life in primary immunodeficiency patients. MATERIALS AND METHODS We used generic health status and general psychological health questionnaires to determine the range of issues that needed to be considered in examining the burden of common variable immunodeficiency (CVID). RESULTS The health status of patients with CVID was lower than that observed in normal subjects. Overall, Role-Physical and General Health scales correlated with a poorer clinical status. Surprisingly, the duration of disease did not influence health status. Being female, older, General Health Questionnaire-positive and alexithymic proved to be major risk factors associated with a poor health status. Patients with chronic lung disease and chronic diarrhea had the lowest values on the Medical Outcome Study, Short Form SF-36 (SF-36) scales. Disease severity perception was associated with the General Health Questionnaire and alexithymia status. Limitations in daily activities as a result of lower physical health were the major problems facing common variable immunodeficiency patients. CONCLUSION Our data underlined the importance of conducting a periodical health related quality of life assessment on patients with primary antibody deficiencies and, moreover, stressed the necessity of providing psychological support to at risk patients.
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Affiliation(s)
- Isabella Quinti
- Department of Molecular Medicine, Sapienza University of Rome and Fondazione Eleonora Lorillard Spencer Cenci, Rome, Italy
| | - Cristina Di Pietro
- Health Services Research Unit, Istituto Dermopatico Dell'Immacolata IDI-IRCCS, Rome, Italy
| | - Helene Martini
- Department of Molecular Medicine, Sapienza University of Rome and Fondazione Eleonora Lorillard Spencer Cenci, Rome, Italy
| | - Anna Maria Pesce
- Department of Clinical Immunology, Sapienza University of Rome, Rome, Italy
| | - Francesca Lombardi
- Department of Clinical Immunology, Sapienza University of Rome, Rome, Italy
| | | | | | - Cinzia Milito
- Department of Molecular Medicine, Sapienza University of Rome and Fondazione Eleonora Lorillard Spencer Cenci, Rome, Italy
| | - Stefano Tabolli
- Health Services Research Unit, Istituto Dermopatico Dell'Immacolata IDI-IRCCS, Rome, Italy
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Sahai-Srivastava S, Zheng L. Undiagnosed depression and its correlates in a predominantly immigrant Hispanic neurology clinic. Clin Neurol Neurosurg 2011; 113:623-5. [PMID: 21680085 DOI: 10.1016/j.clineuro.2011.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 04/04/2011] [Accepted: 04/22/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Previous studies have reported a high incidence of depression in neurology clinics, however areas where there are predominantly underserved immigrants have not been studied. METHODS Retrospective cohort study in an academic outpatient neurology clinic in Los Angeles, California. Newly referred patients (N=318) were assessed consecutively for depression using a PHQ-9 questionnaire, accompanied by review of the assessment of the depressive disorder. RESULTS The patient cohort consisted of 190 females (59%) and 130 males (41%), primarily of Hispanic descent (72%), with 8% Asian 11% white, and 5% African-American. Sixty-eight percent (68%) had depression, with 40% exhibiting moderate to severe depression. Patients who had moderate to severe depression (based on PHQ-9) were more likely to be unemployed (75.2% vs. 60.7%, p=0.008), dependent on government income (29.5% vs. 20.4%, p=0.06), and have headache or pain as the reason for referral (42.4% vs. 28.5%, p=0.03). Severity of depression also significantly correlated with current treatment by psychiatrist, current antidepressant use, and less independent living. Patients with moderate to severe depression were more likely to have made ER visits in the last 12 months (0.9 vs. 0.7, p=0.01) and were taking more medications (3.3 vs. 2.5, p=0.03), compared to patient with mild or no depression. CONCLUSION The presence of moderate to severe depression significantly correlated with socioeconomic status, use of emergency room, and presence of headache/pain. Neurology clinics with predominantly underserved immigrant patients have a disproportionate amount of depression, which may be related to socioeconomic factors resulting in overutilization of scarce healthcare resources.
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Affiliation(s)
- Soma Sahai-Srivastava
- Department of Neurology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA.
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Rayner L, Price A, Evans A, Valsraj K, Higginson IJ, Hotopf M. Antidepressants for depression in physically ill people. Cochrane Database Syst Rev 2010:CD007503. [PMID: 20238354 DOI: 10.1002/14651858.cd007503.pub2] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND There is an increased risk of depression in people with a physical illness. Depression is associated with reduced treatment adherence, poor prognosis, increased disability and higher mortality in many physical illnesses. Antidepressants are effective in the treatment of depression in physically healthy populations, but there is less clarity regarding their use in physically ill patients. This review updates Gill's Cochrane review (2000), which found that antidepressants were effective for depression in physical illness. Since Gill there have been a number of larger trials assessing the efficacy of antidepressants in this context. OBJECTIVES To determine the efficacy of antidepressants in the treatment of depression in patients with a physical illness. SEARCH STRATEGY Electronic searches of the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) trial registers were conducted together with supplementary searches of The Cochrane Central Register of Controlled Trials (CENTRAL) and the standard bibliographic databases, MEDLINE, EMBASE and PsycINFO. Reference lists of included studies were scanned and trials registers were searched to identify additional unpublished data. Last searches were run in December 2009. SELECTION CRITERIA Randomised controlled trials comparing the efficacy of antidepressants and placebo in the treatment of depression in adults with a physical illness. Depression included diagnoses of Major Depression, Adjustment Disorder and Dysthymia based on standardised criteria. DATA COLLECTION AND ANALYSIS The primary outcome was efficacy 6-8 weeks after randomisation. Data were also extracted at three additional time-points (4-5 weeks, 9-18 weeks, >18 weeks). Acceptability and tolerability were assessed by comparing the number of drop-outs and adverse events. Odds ratios with 95% confidence intervals were calculated for dichotomous data (response to treatment). Standardised mean differences with 95% CI were calculated for continuous data (mean depression score). Data were pooled using a random effects model. MAIN RESULTS Fifty-one studies including 3603 participants were included in the review. Forty-four studies including 3372 participants contributed data towards the efficacy analyses. Pooled efficacy data for the primary outcome provided an OR of 2.33, CI 1.80-3.00, p<0.00001 (25 studies, 1674 patients) favouring antidepressants. Antidepressants were also more efficacious than placebo at the other time-points. At 6-8 weeks, fewer patients receiving placebo dropped out compared to patients treated with an antidepressant. Dry mouth and sexual dysfunction were more common in patients treated with an antidepressant. AUTHORS' CONCLUSIONS This review provides evidence that antidepressants are superior to placebo in treating depression in physical illness. However, it is likely that publication and reporting biases exaggerated the effect sizes obtained. Further research is required to determine the comparative efficacy and acceptability of particular antidepressants in this population.
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Affiliation(s)
- Lauren Rayner
- Department of Palliative Care, Policy and Rehabilitation, King's College London, Bessemer Road, Denmark Hill, London, UK, SE5 9PJ
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16
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Evaluation on the psychosocial status of orthognathic surgery patients. ACTA ACUST UNITED AC 2009; 108:828-32. [DOI: 10.1016/j.tripleo.2009.07.044] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 07/18/2009] [Accepted: 07/23/2009] [Indexed: 11/23/2022]
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Stress coping, distress, and health perceptions in inflammatory bowel disease and community controls. Am J Gastroenterol 2009; 104:2959-69. [PMID: 19755973 DOI: 10.1038/ajg.2009.529] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study compares a community inflammatory bowel disease (IBD) sample of individuals with a matched non-IBD community sample of individuals on psychological functioning and health perceptions. METHODS Participants in the population-based Manitoba IBD Cohort Study (n=388) were directly compared with sex-, age-, and region-matched controls from a national random-sample health survey on the aspects of psychological health, coping, and perceived general health. RESULTS Overall, the IBD sample had lower psychological well-being and mastery, as well as higher distress than did the non-IBD controls (P<or=0.02). Those with IBD used avoidant coping significantly more often, and active coping modestly more often than did the non-IBD sample; both had similar levels of "self-soothing" behaviors. Patients with Crohn's disease and ulcerative colitis had similarly poor levels of functioning along these dimensions compared with the non-IBD sample, as did those with active disease (P<0.01). However, those with inactive disease were similar to the non-IBD sample, and had modestly higher mastery levels. Whereas nearly half of the non-IBD group reported chronic health conditions, those with IBD were threefold more likely to report poorer health (odds ratio 3.07, 95% confidence interval: 2.10-4.47). Psychological factors explained a greater amount of variance in perceived health for the IBD than for the non-IBD sample. CONCLUSIONS Those with IBD have significantly poorer psychological health than do those without IBD and view their general health status more negatively, although adaptive stress-coping strategies were similar. However, when disease is quiescent there is little detriment to functioning. Active disease should be a flag to consider psychological needs in the care of an IBD patient.
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18
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[Drug treatment of psychological alterations in inflammatory bowel disease: application by the gastroenterologist]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32 Suppl 2:19-24. [PMID: 19900624 DOI: 10.1016/s0210-5705(09)72601-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
As in other chronic diseases, in inflammatory bowel disease (IBD) there is a high prevalence of emotional disorders. Patients' quality of life and wellbeing are closely related to symptoms of anxiety and depression - hence the importance of a comprehensive approach to this disease. Among the available pharmacological options, anxiolytics and selective serotonin reuptake inhibitors (SSRI) are considered to be effective drugs that are easily administered and show excellent safety and tolerability. The present article provides a practical description of the characteristics of these compounds to indicate when, how and for how long a pharmacological approach should be used. In general, benzodiazepines are the drugs of choice in short-term treatments. SSRI are preferred in long-term treatments, whether for anxiety of depression, with the recommendation that treatment be maintained for at least 1 year.
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Psicología y enfermedad inflamatoria intestinal. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32 Suppl 2:1-2. [DOI: 10.1016/s0210-5705(09)72597-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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20
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Cognitive Behavioural Therapy for Unexplained Physical Symptoms: Process and Prognostic Factors. Behav Cogn Psychother 2009. [DOI: 10.1017/s1352465800018580] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The aims of this study were to examine the construct validity of a cognitive behavioural treatment model for medically unexplained physical symptoms and to examine potential predictors of treatment outcome. In concordance with the treatment model we used, the extent of hypochondriacal cognitions and psychological distress at baseline appeared to be associated. Change in hypochondriacal cognitions was related to change in psychological distress. The extent of hypochondriacal cognitions after treatment was predictive of the level of psychological distress at one year follow-up. The only baseline variable that predicted a negative treatment outcome was illness behaviour.
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Cognitive Behavioural Therapy for Medically Unexplained Physical Symptoms: A Pilot Study. Behav Cogn Psychother 2009. [DOI: 10.1017/s1352465800016799] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of the study was to develop a cognitive behavioural treatment model for medically unexplained physical symptoms and assess its feasibility and effect in a small sample of patients. This study was the first step in the realization of a randomized controlled trial. The study population consisted of consecutive patients presenting at a general medical outpatient clinic, whose symptoms could not be explained by objective abnormal findings. The treatment was based on a general model of the disorder, consisting of the physical symptoms, the patient's attribution and perceived control and the cognitive, behavioural, physical and social consequences. It incorporated record keeping concerning physical symptoms and emotions, identification of cognitions about the symptoms, challenging dysfunctional thoughts and behavioural experiments. At 6–months follow-up, four of the five treated patients were improved with regard to frequency and intensity of the symptoms, psychological distress and functional impairment. The improvement was sustained at 1–year follow-up.
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Medical Psychology Services in Dutch General Hospitals: State of the Art Developments and Recommendations for the Future. J Clin Psychol Med Settings 2009; 16:161-8. [DOI: 10.1007/s10880-009-9158-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Accepted: 02/10/2009] [Indexed: 10/21/2022]
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Seignourel PJ, Miller K, Kellison I, Rodriguez R, Fernandez HH, Bauer RM, Bowers D, Okun MS. Abnormal affective startle modulation in individuals with psychogenic [corrected] movement disorder. Mov Disord 2008; 22:1265-71. [PMID: 17486611 DOI: 10.1002/mds.21451] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Despite recent advances, psychogenic movement disorder (PMD) remains a poorly understood phenomenon. Emotional functioning and responsiveness to stress are believed to play a role in the development of psychogenic symptoms, but empirical studies examining emotional responsiveness in PMD and other conversion disorders are lacking. We investigated modulation of the startle eyeblink reflex by affective pictures in 12 patients with PMD and 12 age- and education-matched control participants. Participants viewed positive, neutral, and negative pictures, while eyeblink responses to white noise bursts were recorded. Control participants showed the expected pattern of startle modulation, with significant potentiation by negative pictures and slight (nonsignificant) inhibition by positive pictures. In the PMD group, however, both positive and negative pictures yielded significantly greater startle responses than neutral pictures. Depression and anxiety symptomatology did not correlate with startle modulation, and the two groups did not differ in self-reported emotional reactions to the pictures. Our findings suggest that individuals with PMD show aversive physiological reactions to positive as well as negative stimuli. Abnormal affective startle modulation may be used to help distinguish between malingering and PMD. Future studies using larger samples are needed to better understand the role of emotions in conversion disorder.
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Affiliation(s)
- Paul J Seignourel
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA.
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North CS, Hong BA, Alpers DH. Relationship of functional gastrointestinal disorders and psychiatric disorders: Implications for treatment. World J Gastroenterol 2007; 13:2020-7. [PMID: 17465442 PMCID: PMC4319119 DOI: 10.3748/wjg.v13.i14.2020] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This article revisits the links between psychopathology and functional gastrointestinal disorders such as irritable bowel syndrome (IBS), discusses the rational use of antidepressants as well as non-pharmacological approaches to the management of IBS, and suggests guidelines for the treatment of IBS based on an interdisciplinary perspective from the present state of knowledge. Relevant published literature on psychiatric disorders, especially somatization disorder, in the context of IBS, and literature providing direction for management is reviewed, and new directions are provided from findings in the literature. IBS is a heterogeneous syndrome with various potential mechanisms responsible for its clinical presentations. IBS is typically complicated with psychiatric issues, unexplained symptoms, and functional syndromes in other organ systems. Most IBS patients have multiple complaints without demonstrated cause, and that these symptoms can involve systems other than the intestine, e.g. bones and joints (fibromyalgia, temporomandibular joint syndrome), heart (non-cardiac chest pain), vascular (post-menopausal syndrome), and brain (anxiety, depression). Most IBS patients do not have psychiatric illness per se, but a range of psychoform (psychological complaints in the absence of psychiatric disorder) symptoms that accompany their somatoform (physical symptoms in the absence of medical disorder) complaints. It is not correct to label IBS patients as psychiatric patients (except those more difficult patients with true somatization disorder). One mode of treatment is unlikely to be universally effective or to resolve most symptoms. The techniques of psychotherapy or cognitive-behavioral therapy can allow IBS patients to cope more readily with their illness. Specific episodes of depressive or anxiety disorders can be managed as appropriate for those conditions. Medications designed to improve anxiety or depression are not uniformly useful for psychiatric complaints in IBS, because the psychoform symptoms that sound similar to those seen in psychiatric disorders may not have the same significance in patients with IBS.
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Abstract
PURPOSE OF REVIEW In this article we summarize recent investigations into the influence of illness perceptions on outcomes in patients with medical conditions. RECENT FINDINGS Developments in assessment include the publishing of a new brief scale to assess illness perceptions and the examination of the relationship between patient drawings of their illness and outcomes. Recent studies in primary care highlight the importance of patients' beliefs and emotional responses to their illness as being important in influencing their satisfaction with the consultation, reassurance following negative medical testing and future healthcare use. Recent research shows illness perceptions to have associations with a number of outcomes in chronic illness including self-management behaviours and quality of life. As yet, however, few interventions have been developed designed to change illness perceptions and improve illness outcomes. Emerging areas of research include the application of illness perceptions to mental illness and genetic and risk factor testing. SUMMARY Research on illness perceptions has confirmed that patients' beliefs are associated with important outcomes in a broadening range of illnesses and risk factor testing. New interventions based on this model have the potential to improve patient outcomes but have yet to be widely developed and applied.
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Affiliation(s)
- Keith J Petrie
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.
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Arnold IA, de Waal MWM, Eekhof JAH, van Hemert AM. Somatoform Disorder in Primary Care: Course and the Need for Cognitive-Behavioral Treatment. PSYCHOSOMATICS 2006; 47:498-503. [PMID: 17116951 DOI: 10.1176/appi.psy.47.6.498] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medically unexplained physical symptoms are prevalent in primary care. Of all patients attending the family physician, 16% have a somatoform disorder as described by DSM-IV. Cognitive-behavioral treatment has been demonstrated to be effective in secondary care. However, the course of somatoform disorders and their need for treatment have not yet been established in primary care. In this study, data from 1,046 attendees in family practice were analyzed for prevalence, course, and eligibility for treatment. Over a 6-month follow-up, the prevalence of somatoform disorder decreased from 16.1% to 12.3%. After assessment of eligibility, about 5% of patients demonstrated a need for treatment.
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Affiliation(s)
- Ingrid A Arnold
- Department of General Practice and Nursing Home Medicine, Leiden University Medical Center, 2301 CB, The Netherlands.
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Abstract
BACKGROUND Somatizing patients have maladaptive and increased rates of medical care utilization. If there were a way of routinely identifying such patients, one that did not require intensive, case-by-case review, they could be targeted for specific interventions to improve their use of medical care. OBJECTIVE We sought to identify patterns of medical care utilization that would distinguish somatizing and nonsomatizing medical outpatients with acceptable sensitivity and specificity. DESIGN Subjects completed questionnaires assessing somatization and sociodemographic characteristics. Their medical care utilization was obtained for the 12 months preceding the index visit. We then used multivariable logistic regression and recursive partitioning to identify patients with a provisional diagnosis of somatoform disorder. These exploratory models used various patterns of medical care utilization and sociodemographic characteristics as the independent variables. SUBJECTS We studied consecutive adults attending 2 primary care practices on randomly chosen days. MEASURES The provisional diagnosis of a somatoform disorder was assessed with a 15-item self-report questionnaire. The number of primary care visits, specialty visits, mental health visits, emergency visits, and inpatient and outpatient costs were obtained for the 12 months preceding the index visit from our hospital's automated medical records, which also provided a rating of aggregate medical morbidity. Self-reported utilization outside our hospital system was obtained from a subsample of patients. RESULTS Complete data were obtained on 1440 patients. Somatizing patients had more specialty care than primary care visits, higher outpatient than inpatient costs, and more emergency visits than nonsomatizing patients. A regression model containing 7 measures of utilization and 4 sociodemographic characteristics distinguished somatizing and nonsomatizing patients with a c-statistic = 0.73. Recursive partitioning identified 10 terminal nodes with a very high specificity (99%) but a very low sensitivity (15%). CONCLUSIONS We identified 7 discrete patterns of medical care utilization that distinguished somatizing and nonsomatizing patients. However, they did so with only modest specificity and sensitivity. This algorithm might be used effectively as the first step in a 2-step screening procedure whose second step would entail more intensive screening or individual, case-by-case review to identify somatizing patients in primary care practice.
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Affiliation(s)
- Arthur J Barsky
- Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.
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Rief W, Heitmüller AM, Reisberg K, Rüddel H. Why reassurance fails in patients with unexplained symptoms--an experimental investigation of remembered probabilities. PLoS Med 2006; 3:e269. [PMID: 16866576 PMCID: PMC1523375 DOI: 10.1371/journal.pmed.0030269] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Accepted: 04/19/2006] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Providing reassurance is one of physicians' most frequently used verbal interventions. However, medical reassurance can fail or even have negative effects. This is frequently the case in patients with medically unexplained symptoms. It is hypothesized that these patients are more likely than patients from other groups to incorrectly recall the likelihoods of medical explanations provided by doctors. METHODS AND FINDINGS Thirty-three patients with medically unexplained symptoms, 22 patients with major depression, and 30 healthy controls listened to an audiotaped medical report, as well as to two control reports. After listening to the reports, participants were asked to rate what the doctor thinks the likelihood is that the complaints are caused by a specific medical condition. Although the doctor rejected most of the medical explanations for the symptoms in his verbal report, the patients with medically unexplained complaints remembered a higher likelihood for medical explanations for their symptoms. No differences were found between patients in the other groups, and for the control conditions. When asked to imagine that the reports were applicable to themselves, patients with multiple medical complaints reported more concerns about their health state than individuals in the other groups. CONCLUSIONS Physicians should be aware that patients with medically unexplained symptoms recall the likelihood of medical causes for their complaints incorrectly. Therefore, physicians should verify correct understanding by using check-back questions and asking for summaries, to improve the effect of reassurance.
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Affiliation(s)
- Winfried Rief
- Department of Clinical Psychology, University of Marburg, Marburg, Germany.
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Thomas T, Booth S, Earl H, Lennox G. Somatization disorder and cancer: a case history and review. Palliat Support Care 2006; 2:409-13. [PMID: 16594404 DOI: 10.1017/s1478951504040556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Cancer pain generally has a physical cause exacerbated to varying degrees by psychological, social, and spiritual factors. This article describes the case history of a cancer patient with severe pain for which no physical cause could be found, who was subsequently found to have a history of somatization disorder. There follows a review of the literature, with specific reference to the difficulties of managing somatization in the context of cancer.
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Page LA, Petrie KJ, Wessely SC. Psychosocial responses to environmental incidents: a review and a proposed typology. J Psychosom Res 2006; 60:413-22. [PMID: 16581367 DOI: 10.1016/j.jpsychores.2005.11.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this review was to propose a typology for understanding the diversity of psychosocial reactions to environmental incidents. METHODOLOGY The first section provides an introduction and background to the topic; we then attempt to provide a typology of psychosocial responses to environmental incidents. RESULTS Response to an environmental incident can be usefully considered in terms of the exposure, the response of the individual, the action of professionals, the response of the community, and the influence of the society in which the incident occurs. We reviewed each of these factors. CONCLUSIONS By examining incidents in an ordered framework, we suggest that a more comprehensive understanding is possible. We also suggest some basic ways in which the psychosocial management of such difficult and diverse incidents could be improved.
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Affiliation(s)
- Lisa A Page
- Department of Psychological Medicine, Institute of Psychiatry, King's College, London, UK
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Killgore WDS, Stetz MC, Castro CA, Hoge CW. The effects of prior combat experience on the expression of somatic and affective symptoms in deploying soldiers. J Psychosom Res 2006; 60:379-85. [PMID: 16581362 DOI: 10.1016/j.jpsychores.2006.02.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Deployment to a combat zone is undoubtedly an extremely stressful experience. It was hypothesized that, when faced with an impending wartime deployment, soldiers with prior combat experience would report minimal emotional problems accompanied by high rates of somatic complaints compared with combat-naive soldiers. METHODS Self-reports of posttraumatic stress disorder (PTSD) and affective and somatic complaints were collected from 2068 U.S. soldiers just prior to combat deployment during Operation Iraqi Freedom. RESULTS Although the percentage of soldiers scoring positive for PTSD was nearly identical for the experienced and inexperienced groups, scores on the Affective and Somatic scales differed as a function of prior combat history. Previous combat experience was associated with lower affective and greater somatic complaints relative to combat-naive soldiers. CONCLUSIONS Consistent with theories of stress reaction, repression, and somatic amplification, combat-experienced soldiers reported limited affective complaints but greater somatic complaints relative to soldiers without combat experience.
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Affiliation(s)
- William D S Killgore
- Department of Psychiatry and Behavioral Sciences, Walter Reed Army Institute of Research, Silver Spring, MD, USA.
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van den Berg B, Grievink L, Yzermans J, Lebret E. Medically unexplained physical symptoms in the aftermath of disasters. Epidemiol Rev 2005; 27:92-106. [PMID: 15958430 DOI: 10.1093/epirev/mxi001] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bellis van den Berg
- National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
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Reuber M, Mitchell AJ, Howlett SJ, Crimlisk HL, Grünewald RA. Functional symptoms in neurology: questions and answers. J Neurol Neurosurg Psychiatry 2005; 76:307-14. [PMID: 15716517 PMCID: PMC1739564 DOI: 10.1136/jnnp.2004.048280] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Between 10 and 30% of patients seen by neurologists have symptoms for which there is no current pathophysiological explanation. The objective of this review is to answer questions many neurologists have about disorders characterised by unexplained symptoms (functional disorders) by conducting a multidisciplinary review based on published reports and clinical experience. Current concepts explain functional symptoms as resulting from auto-suggestion, innate coping styles, disorders of volition or attention. Predisposing, precipitating, and perpetuating aetiological factors can be identified and contribute to a therapeutic formulation. The sympathetic communication of the diagnosis by the neurologist is important and all patients should be screened for psychiatric or psychological symptoms because up to two thirds have symptomatic psychiatric comorbidity. Treatment programmes are likely to be most successful if there is close collaboration between neurologists, (liaison) psychiatrists, psychologists, and general practitioners. Long term, symptoms persist in over 50% of patients and many patients remain dependent on financial help from the government. Neurologists can acquire the skills needed to engage patients in psychological treatment but would benefit from closer working relationships with liaison psychiatry or psychology.
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Affiliation(s)
- M Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK.
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Anxiety and depressive disorders in an emergency department ward of a general hospital: a control study. Emerg Med J 2005; 21:175-9. [PMID: 14988342 DOI: 10.1136/emj.2003.006957] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE In this study anxiety and depressive disorders were evaluated in patients admitted to an emergency department (ED) or to a medical department (MD). METHODS The General Health Questionnaire-30 (GHQ-30) was administered to screen all patients (n = 719) consecutively admitted to an ED (n = 556) and to MD (n = 163) in a 120 day period. All GHQ-30 positive (score>4) underwent the Mini International Neuropsychiatric Interview, a structured interview to diagnose mental disorders according to DSM-IV criteria. RESULTS Subjects positive to GHQ-30 were 264 (47%) in ED and 88 (54%) in MD. A mental disorder was diagnosed in 233 ED patients (42%) and in 77 MD patients (47%) (p = 0.70). The most frequent disorders were anxiety disorders in ED patients (18.1%) and depressive disorders in MD patients (21%) (p = 0.04). CONCLUSIONS Anxious patients more frequently seek attention at ED, whereas patients with depressive disorders are more often observed in medical units. The improvement of quality of care, the waste of healthcare resources through unnecessary medical care, and the well known efficacy of appropriate treatments in patients with anxiety and depressive disorders make the diagnosis of these patients particularly important.
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Arnold IA, Speckens AEM, van Hemert AM. Medically unexplained physical symptoms: the feasibility of group cognitive-behavioural therapy in primary care. J Psychosom Res 2004; 57:517-20. [PMID: 15596157 DOI: 10.1016/j.jpsychores.2004.04.369] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2003] [Accepted: 04/20/2004] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to estimate the number of patients with medically unexplained physical symptoms (MUPS) that could be eligible for group cognitive-behavioural treatment (CBT) and to assess the acceptability of this treatment. METHODS For 3 months, all consultations of one general practitioner (GP) were screened for MUPS. Patients with MUPS who were considered eligible for group CBT were interviewed and offered treatment. RESULTS From January to March 1999, 1084 consultations of 796 patients were screened. The GP classified the symptoms of 104 patients aged 25-79 as unexplained. Of these, 71 patients were not considered to be eligible for treatment, mainly due to a psychological attribution of the symptoms. The research interview was offered to 33 patients, 16 of them declined and 12 were interviewed. Seven out of the 12 eligible patients accepted treatment. CONCLUSION In primary care, 18% of patients aged 25-79 years was estimated to have MUPS. For only a minority of these patients, group CBT was considered suitable and acceptable.
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Affiliation(s)
- I A Arnold
- Department of General Practice and Nursing Home, Leiden University Medical Center, P.O. Box 2088, Leiden 23101 CB, The Netherlands.
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Dammen T, Arnesen H, Ekeberg O, Friis S. Psychological factors, pain attribution and medical morbidity in chest-pain patients with and without coronary artery disease. Gen Hosp Psychiatry 2004; 26:463-9. [PMID: 15567212 DOI: 10.1016/j.genhosppsych.2004.08.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2004] [Accepted: 08/05/2004] [Indexed: 01/04/2023]
Abstract
This cross-sectional psychiatric and cardiological study compared patients with and without coronary artery disease (CAD) with respect to psychiatric morbidity, psychological factors, pain characteristics, medical morbidity and the prevalence of coronary risk factors. The 199 participants had been referred to cardiological outpatient clinics for the investigation of chest pain and had no history of heart disease. Current panic disorder occurred significantly more often in non-CAD patients (41% vs. 22%). No significant differences were found for other psychiatric disorders and psychological variables. Non-CAD patients reported significantly longer histories of pain and a higher prevalence of atypical chest pain. In other respects, there were surprisingly few differences between the groups. High morbidity of both psychiatric disease (pain disorder, 19%; any current psychiatric disorder, 72%) and somatic conditions (musculoskeletal disease, 33%; dyspepsia, 23%) was found with no significant differences between the groups. In these patients, multifactorial complaints may explain chest pain in both patient groups. The physicians should attend to psychiatric disorders in non-CAD as well as in CAD patients.
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Affiliation(s)
- Toril Dammen
- Department of Psychiatry, Ullevål University Hospital, N-0407 Oslo, Norway.
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Husain N, Chaudhry I, Afsar S, Creed F. Psychological distress among patients attending a general medical outpatient clinic in Pakistan. Gen Hosp Psychiatry 2004; 26:277-81. [PMID: 15234822 DOI: 10.1016/j.genhosppsych.2004.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2003] [Accepted: 03/09/2004] [Indexed: 01/10/2023]
Abstract
It is not known whether the pattern of psychiatric disorders in medical outpatients in Pakistan is similar to that observed in the West. Consecutive medical outpatients completed the Self-Report Questionnaire (SRQ) to detect probable psychiatric disorder. The usual cut-off score of 8/9 was used. One-thousand and sixty-nine patients completed the SRQ (84% response rate) at four half-day clinics. Sixteen percent of men and 58% of women presented with medically unexplained symptoms. In men, 80% of patients with medically unexplained symptoms had an SRQ score of 9 or above (probable depressive disorder) compared to 40% of those with symptoms caused by recognized physical illness (P<.0005). In women, the respective proportions were 55.4% and 49.6% (P=.34). Depressive disorder is probably very common in medical outpatients in Pakistan, especially in men with medically unexplained symptoms. Systematic attempts to initiate antidepressant treatment in this setting should be attempted.
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Affiliation(s)
- Nusrat Husain
- Department of Psychiatry, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.
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de Waal MWM, Arnold IA, Eekhof JAH, van Hemert AM. Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br J Psychiatry 2004; 184:470-6. [PMID: 15172939 DOI: 10.1192/bjp.184.6.470] [Citation(s) in RCA: 332] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND General practitioners play a pivotal part in the recognition and treatment of psychiatric disorders. Identifying somatoform disorders is important for the choice of treatment. AIMS To quantify the prevalence of, and functional impairment associated with, somatoform disorders, and their comorbidity with anxiety/depressive disorders. METHOD Two-stage prevalence study: a set of questionnaires was completed by 1046 consecutive patients of general practitioners (aged 25-80 years), followed by a standardised diagnostic interview (SCAN 2.1). RESULTS The prevalence of somatoform disorders was 16.1% (95% CI 12.8-19.4). When disorders with only mild impairment were included, the prevalence increased to 21.9%. Comorbidity of somatoform disorders and anxiety/depressive disorders was 3.3 times more likely than expected by chance. In patients with comorbid disorders, physical symptoms, depressive symptoms and functional limitations were additive. CONCLUSIONS Our findings underline the importance of a comprehensive diagnostic approach to psychiatric disorders in general practice.
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Affiliation(s)
- Margot W M de Waal
- Department of General Practice and Nursing Home Medicine, Leiden University Medical Centre, The Netherlands.
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Kooiman CG, Bolk JH, Rooijmans HGM, Trijsburg RW. Alexithymia does not predict the persistence of medically unexplained physical symptoms. Psychosom Med 2004; 66:224-32. [PMID: 15039507 DOI: 10.1097/01.psy.0000116714.38868.06] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alexithymia is thought to be associated with the development of medically unexplained physical symptoms (UPS). So far little research has been published on alexithymia as a risk factor for the persistence of UPS. OBJECTIVE To determine the clinical outcome in UPS patients and to study the relative importance of alexithymia in predicting that outcome. METHODS A follow-up study was conducted among general medical outpatients with UPS. Patients underwent extensive examinations at baseline and were reassessed after a mean 61-week interval. Outcome of the UPS and general health perception at follow-up were used as major outcome variables. RESULTS Outcome of the UPS and general health perception at follow-up were not strongly associated with each other. More than half (63%) of the patients reported improvement of their initial symptoms, but only 38% of the patients considered themselves at follow-up to be in good health. UPS outcome was predominantly predicted by the duration of the UPS and the number of additional physical symptoms at baseline. General health perception at follow-up was predominantly predicted by the general health perception at baseline and the number of additional physical symptoms and pain experience at baseline. The explained variance of the general health perception was three times as high as the explained variance for the UPS outcome. Alexithymia was not associated with any of the two outcome variables. CONCLUSIONS Outcome of the UPS and general health perception at follow-up are not strongly associated and are predicted by different variables. Alexithymia, however, is not an important predictor for the outcome in the majority of UPS patients.
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Affiliation(s)
- Cornelis G Kooiman
- Department of Psychiatry of the Leiden University Medical Center, Leiden, The Netherlands
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Mittermaier C, Dejaco C, Waldhoer T, Oefferlbauer-Ernst A, Miehsler W, Beier M, Tillinger W, Gangl A, Moser G. Impact of depressive mood on relapse in patients with inflammatory bowel disease: a prospective 18-month follow-up study. Psychosom Med 2004; 66:79-84. [PMID: 14747641 DOI: 10.1097/01.psy.0000106907.24881.f2] [Citation(s) in RCA: 371] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE There is evidence of an interaction between psychological factors and activity of inflammatory bowel disease (IBD). We examined the influence of depressive mood and associated anxiety on the course of IBD over a period of 18 months in a cohort of patients after an episode of active disease. METHODS In this prospective, longitudinal, observational study, 60 patients (37 women and 23 men) with clinically inactive IBD (Crohn disease, n = 47, 78%; ulcerative colitis, n = 13, 22%) were enrolled after a flare of disease. Psychological status, health-related quality of life (HRQOL), and disease activity were evaluated at baseline and then every 3 months for a period of 18 months by means of clinical and biological parameters, the Beck Depression Inventory (BDI), the Spielberger State-Trait Anxiety Inventory, the Inflammatory Bowel Disease Questionnaire, the Perceived Stress Questionnaire, and the Rating Form of Inflammatory Bowel Disease Patients Concerns. RESULTS At baseline, depression (BDI > or = 13 points) was found in 17 of 60 (28%) patients. Thirty-two patients (59%) experienced at least one relapse during the 18 months of follow-up. Regression analysis showed a significant correlation between BDI scores at baseline and the total number of relapses after 12 (p <.01) and 18 months (p <.01) of follow-up. Furthermore, depression scores at baseline correlated with the time until the first recurrence of the disease (p <.05). Anxiety and low HRQOL were also related with more frequent relapses during follow-up (p <.05 and p <.01, respectively). CONCLUSIONS Psychological factors such as a depressive mood associated with anxiety and impaired HRQOL may exert a negative influence on the course of IBD. Therefore, assessment and management of psychological distress should be included in clinical treatment of patients with IBD.
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Affiliation(s)
- Christian Mittermaier
- Department of Medicine IV, Division of Gastroenterology and Hepatology, University Hospital of Vienna, Vienna, Austria
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Smith RC, Korban E, Kanj M, Haddad R, Lyles JS, Lein C, Gardiner JC, Hodges A, Dwamena FC, Coffey J, Collins C. A method for rating charts to identify and classify patients with medically unexplained symptoms. PSYCHOTHERAPY AND PSYCHOSOMATICS 2004; 73:36-42. [PMID: 14665794 PMCID: PMC1993543 DOI: 10.1159/000074438] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND As part of conducting a randomized control trial (RCT) to treat chronically high utilizing patients with medically unexplained symptoms (MUS), we developed the chart rating method reported here to identify and classify MUS subjects. METHOD Intended at this point only as a research tool, the method is comprehensive, uses explicit guidelines, and requires clinician raters. It distinguishes primary organic disease patients from those with primary MUS, quantifies medical comorbidities in primary MUS patients, and also distinguishes subgroups among MUS patients that we call somatization (resembles DSM-IV somatoform disorders) and minor acute illness (MAI) which differs from DSM-IV somatoform definitions. Scoring rules are used to generate the diagnoses above. The rules may be set according to the investigator's needs, from highly sensitive to highly specific. RESULTS We found high levels of agreement with the gold standard for MUS vs. organic disease (97.6%) and among raters for the key individual chart elements rated (92-96%). The method identified 206 MUS subjects and the extent of their medical comorbidities for entry into a RCT. It also identified somatization and MAI; the latter supports the validity of this newly reported MAI syndrome. CONCLUSION We concluded that this method offered research potential for identifying MUS patients, for quantifying their medical comorbidities, and for classifying MUS subgroups.
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Affiliation(s)
- Robert C Smith
- Department of Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan, USA.
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Persoons P, Luyckx K, Desloovere C, Vandenberghe J, Fischler B. Anxiety and mood disorders in otorhinolaryngology outpatients presenting with dizziness: validation of the self-administered PRIME-MD Patient Health Questionnaire and epidemiology. Gen Hosp Psychiatry 2003; 25:316-23. [PMID: 12972222 DOI: 10.1016/s0163-8343(03)00072-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aims of the study were to: 1) assess the validity of the mood and anxiety modules of the PRIME-MD Patient Health Questionnaire (PHQ) in otorhinolaryngology outpatients consulting with dizziness; and, 2) the prevalence of anxiety and mood disorders in these patients and in 3 subgroups based on of the cause of dizziness (Functional group, with psychogenic or hyperventilation factor; Organic group with an organic cause; Unspecified group without indication of organic or psychogenic cause). The PRIME-MD PHQ was completed by 268 consecutive outpatients. In 97 patients a psychiatric interview was performed. Operating characteristics indicated good criterion validity for the assessed modules of the PRIME-MD PHQ. Thirty five percent of the patients were diagnosed with "Any Anxiety or Depressive Disorder". In the Functional group, the prevalence of "Any Anxiety or Depressive Disorder" was significantly higher than in the Organic group (P<.0001) and than in the Unspecified group (P<.0001). In the Unspecified group, the prevalence of "Any Anxiety or Depressive Disorder" was significantly lower than in the Organic group (P =.007). Our findings support the criterion validity of the PRIME-MD PHQ for anxiety and depressive disorders in otorhinolaryngology outpatients with dizziness. Psychiatric disorders were highly prevalent and differences in psychiatric status between the different subgroups were demonstrated.
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Affiliation(s)
- Phillippe Persoons
- Department of Neuroscience and Psychiatry, Liaison Psychiatry, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
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Abstract
OBJECTIVES Multiple relationships between anxiety, allergic symptoms, and treatment difficulties have been observed. The aim of the present study was to estimate the prevalence of anxiety disorders in outpatients with various allergic diseases, to identify diagnostic cues or possible risk factors, and to test the usefulness of self-administered questionnaire screening at the allergy clinic. METHODS Six hundred forty-six (646) consecutive patients with rhinoconjunctivitis (59.3%), asthma (26.8%), or "other" allergy (13.9%), aged 16 to 65 years, completed self-administered questionnaires in six outpatient allergy clinics; 60 of the respondents also participated in structured psychiatric interviews. Anxiety was measured with the Spielberger State-Trait Anxiety. RESULTS According to the interviews, STAI-T > 52 predicted with 86% accuracy a current psychiatric diagnosis, without differentiating between anxiety and depression. Using this threshold, the rate of anxiety and/or depressive disorders is estimated as 19% (95% CI: 15.9-22.1) in our unselected allergic outpatient sample; 46% of these patients never received any psychopharmacological treatment, indicating that anxiety related disorders are underdiagnosed and undertreated. Risk indicators were female gender; asthma; perennial symptoms; sleep problems; nonspecific allergy triggers like strong emotions; stressful situations; and considerable limitation in everyday activities attributed to the allergic symptoms. CONCLUSIONS Our findings confirm a high rate of anxiety and/or depressive disorders in patients visiting the allergy clinic. Self-administered questionnaires such as STAI-T provide reliable help for the identification of these frequent psychiatric problems.
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Affiliation(s)
- Adrienne Stauder
- Semmelweis University, Faculty of Medicine, Institute of Behavioural Sciences, Budapest, Hungary.
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Page LA, Wessely S. Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter. J R Soc Med 2003. [PMID: 12724431 PMCID: PMC539474 DOI: 10.1258/jrsm.96.5.223] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- L A Page
- Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK.
| | - S Wessely
- Academic Department of Psychological Medicine, Guy's, King's and St Thomas'
School of Medicine and the Institute of Psychiatry, London, UK
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van der Weijden T, van Velsen M, Dinant GJ, van Hasselt CM, Grol R. Unexplained complaints in general practice: prevalence, patients' expectations, and professionals' test-ordering behavior. Med Decis Making 2003; 23:226-31. [PMID: 12809320 DOI: 10.1177/0272989x03023003004] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To gain insight into general practitioners' (GPs) test-ordering behavior for patients presenting with unexplained complaints. An unexplained complaint's symptoms are not alarming, and there is no plausible medical or psychosocial explanation for it. The Dutch College of General Practitioners (DCGP) recommends a watchful, waiting attitude for test ordering for unexplained complaints. METHODS Observational, cross-sectional study of 567 doctor-patient consultations performed by 21 GPs. RESULTS On average, 13% of consultations involved complaints considered unexplained by GPs. Unexplained complaints were positively related to test ordering (adjusted odds ratio [OR] = 2.4, 95% confidence interval [CI] 1.1-5.3), despite the DCGP's recommendation. Patients' expectations about testing influenced test ordering even more (adjusted OR = 4.1, 95% CI 2.2-7.6). DISCUSSION Unexplained complaints happen daily in general practice. Besides the DCGP's recommendation, factors such as GPs' desire to understand complaints and patients' expectations seem to have impacts. Guideline development and quality improvement projects should respect, next to Bayesian rules, GP- and patient-related determinants of test ordering.
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Affiliation(s)
- Trudy van der Weijden
- Centre of Quality of Care Research, Institute for Extramural and Transmural Research, Department of General Practice, Maastricht University, The Netherlands.
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Gilbody SM, Whitty PM, Grimshaw JM, Thomas RE. Improving the detection and management of depression in primary care. Qual Saf Health Care 2003; 12:149-55. [PMID: 12679514 PMCID: PMC1743696 DOI: 10.1136/qhc.12.2.149] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The effectiveness of screening and organisational strategies to improve the recognition and management of depression in primary care published in a recent issue of Effective Health Care is reviewed.
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McCullagh S, Feinstein A. Outcome after mild traumatic brain injury: an examination of recruitment bias. J Neurol Neurosurg Psychiatry 2003; 74:39-43. [PMID: 12486264 PMCID: PMC1738189 DOI: 10.1136/jnnp.74.1.39] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Research concerning the natural history after mild traumatic brain injury (TBI) faces a number of methodological challenges, including those related to subject recruitment. The aim of this study was to determine whether subjects who agree to participate in longitudinal research differ from those who do not. The presence of identifiable, selective factors operating during recruitment may be an important source of systematic bias. In Canada, given the presence of universal healthcare coverage, this issue can be examined using population based, administrative databases to obtain information about a cohort that was approached for study enrollment, regardless of whether they ultimately agreed to participate. METHODS A sample of 626 consecutive patients with mild TBI was invited to enroll in TBI outcome research. Those who agreed to participate (n=272) were compared with those who refused (n=354) on demographic, past health, and injury related variables. Thereafter, using encrypted health card data, the two groups were contrasted with respect to pre-injury and post-injury healthcare utilisation. RESULTS No premorbid differences between the groups emerged. However, all early indices of TBI severity were significantly worse for the participants group (p<0.001). Consistent with these findings, healthcare utilisation rates were no different before injury, but were significantly increased after injury for the participants (p<0.001), even beyond the period of study enrollment (p<0.001). Differences remained even after controlling for those with significant non-TBI injuries. CONCLUSIONS Premorbid factors did not predict whether patients comply with, or refuse study participation. However, the participants group was biased toward those with more significant injuries, which translated into higher rates of healthcare utilisation after injury. These results strike a cautionary note, given the apparent systematic bias influencing enrollment in longitudinal studies of mild TBI.
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Affiliation(s)
- S McCullagh
- Neuropsychiatry Program, Sunnybrook and Women's College Hospital, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5.
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Guthrie E, Jackson J, Shaffer J, Thompson D, Tomenson B, Creed F. Psychological disorder and severity of inflammatory bowel disease predict health-related quality of life in ulcerative colitis and Crohn's disease. Am J Gastroenterol 2002; 97:1994-9. [PMID: 12190166 DOI: 10.1111/j.1572-0241.2002.05842.x] [Citation(s) in RCA: 211] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The determinants of health-related quality of life in inflammatory bowel disease are not completely understood. The present study aimed to assess two factors in patients with inflammatory bowel disease: a) whether health-related quality of life is independently associated with both bowel disease severity and psychological disorder, and b) whether Crohn's disease is associated with more marked psychological disorder than ulcerative colitis. METHODS 116/170 (68%) consecutive patients with inflammatory bowel disease attending a GI clinic (37 patients with ulcerative colitis, 75 patients with Crohn's disease, and four unspecified) completed the following self-report questionnaires: demographic details, a modified disease activity index, a total severity measure, the Hospital Anxiety and Depression Scale, and the Short Form-36. RESULTS Thirty patients (25.9%) scored 11 or more on either the depression or anxiety subscales of the Hospital Anxiety and Depression Scale indicating probable psychological disorder; 55% (47.4%) scored over 8 indicating possible psychological disorder. Stepwise multiple regression analyses showed that both psychological symptoms and disease severity or activity contributed independently to impaired health-related quality of life. After severity of disease was taken into account, there were no significant differences between Crohn's disease and ulcerative colitis in terms of depression scores and health-related quality of life. CONCLUSIONS The presence of psychological disorder in inflammatory bowel disease contributes to poor health-related quality of life, regardless of the severity of the condition. Detection and treatment of psychological disorder in inflammatory bowel disease carries the potential to improve health-related quality of life for these patients.
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Affiliation(s)
- Elspeth Guthrie
- School of Psychiatry and Behavioural Sciences, University of Manchester, United Kingdom
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Van Duyse A, Mariman A, Poppe C, Michielsen W, Rubens R. Chronic fatigue syndrome in the psychiatric practice. Acta Neuropsychiatr 2002; 14:127-33. [PMID: 26984154 DOI: 10.1034/j.1601-5215.2002.140306.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Chronic fatigue syndrome (CFS) is a complex syndrome with a psychiatric comorbidity of 70-80%. A psychiatric interview is necessary in order to exclude psychiatric illness and to identify psychiatric comorbidity. Studies have demonstrated that in general medical practice and in the non-psychiatric specialist practice, physicians tend to underdiagnose psychopathology in patients with CFS. There are many questions unanswered about the treatment of CFS Aim: Typical issues for the psychiatric practice are reviewed: psychiatric comorbidity, dysregulation of the PHA-axis and the treatment of CFS. CONCLUSIONS Depression, somatization, sleeping disorders and anxiety disorders are the most important psychopathological symptoms found in CFS patients. CFS should not be regarded as a masked (somatoform) depression. Although the results from neuroendocrinological studies assessing the hypothalamic-pituitary-adrenal axis (HPA-axis) are inconsistent, they suggest that there is a subgroup of CFS patients suffering from a discrete dysregulation of the HPA-axis resulting in basal hypocortisolaemia. These findings, however, do not reveal a causal relationship. Antidepressants do not seem to have a positive influence on the symptom of fatigue, but appear to be beneficial in alleviating the symptoms of depression and social functioning. Cognitive behaviour therapy and graded exercise show a significant improvement on fatigue and other symptoms and are the only treatments available for CFS patients.
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Affiliation(s)
| | - A Mariman
- 2Department of Psychiatry, University Hospital, Ghent, Belgium
| | - C Poppe
- 1Psychosomatic Centre, Ghent, Belgium
| | - W Michielsen
- 3Internal Medicine University Hospital, Ghent, Belgium
| | - R Rubens
- 4Endocrinology, University Hospital, Ghent, Belgium
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Abstract
Symptom episodes often show a spatio-temporal structure, that is, they occur in a specific context for a certain duration. Repeated experiences may therefore be construed as associative learning trials, in which context elements are turned into predictive cues, triggering anticipatory processes conducive to subjective health complaints. A series of experiments, using inhalations of air enriched with CO2 and external (odors) or internal (mental images) stimuli as cues, is discussed to show that subjective health complaints may occur upon presenting the cue alone. Learned symptoms may be unrelated to bodily responses and easily generalize to new related cues. Better learning occurs to cues with a negative affective valence and in participants scoring high for negative affectivity. Our findings are relevant to the understanding of medically unexplained ("functional") syndromes and the poor relationship between objective and subjective health indicators in general.
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