Behaviour: Psychology

The effect of acute psychologic stress on systemic and rectal mucosal measures of inflammation in ulcerative colitis.
Mawdsley JE, Macey MG, Feakins RM, Langmead L, Rampton DS
Gastroenterology. 2006 Aug;131(2):410-9.

BACKGROUND & AIMS: Recent studies suggest that life events and chronic stress increase the risk of relapse in inflammatory bowel disease. Our aim was to study the effects of acute psychologic stress on systemic and rectal mucosal inflammatory responses in patients with inactive ulcerative colitis (UC). METHODS: Twenty-five patients with inactive UC and 11 healthy volunteers (HV) underwent an experimental stress test. Ten patients with UC and 11 HV underwent a control procedure. Before and after each procedure, systemic inflammatory response was assessed by serum interleukin (IL)-6 and IL-13 concentrations, tumor necrosis factor (TNF)-alpha and IL-6 production by lipopolysaccharide (LPS)-stimulated whole blood, leukocyte count, natural killer (NK) cell numbers, platelet activation, and platelet-leukocyte aggregate (PLA) formation. In patients with UC, rectal mucosal inflammation was assessed by TNF-alpha, IL-13, histamine and substance P release, reactive oxygen metabolite (ROM) production, mucosal blood flow (RMBF) and histology. RESULTS: Stress increased pulse (P < .0001) and systolic BP (P < .0001). In UC, stress increased LPS-stimulated TNF-alpha and IL-6 production by 54% (P = .004) and 11% (P = .04), respectively, leukocyte count by 16% (P = .01), NK cell count by 18% (P = .0008), platelet activation by 65% (P < .0001), PLA formation by 25% (P = .004), mucosal TNF-alpha release by 102% (P = .03), and ROM production by 475% (P = .001) and reduced rectal mucosal blood flow by 22% (P = .05). The control protocol did not change any of the variables measured. There were no differences between the responses of the patients with UC and HV. CONCLUSIONS: Acute psychologic stress induces systemic and mucosal proinflammatory responses, which could contribute to exacerbations of UC in ordinary life.

Somatization an independent psychosocial risk factor for irritable bowel syndrome but not dyspepsia: a population-based study.
Koloski NA, Boyce PM, Talley NJ
Eur J Gastroenterol Hepatol. 2006 Oct;18(10):1101-1109.

BACKGROUND: A psychosocial conceptualization for irritable bowel syndrome and unexplained dyspepsia has been proposed, but remains untested. We conducted a comprehensive population-based study to determine what psychiatric and psychosocial factors, if any, are important in irritable bowel syndrome and dyspepsia. METHODS: Two hundred and seven participants identified from two previous Australian population surveys who also met Rome I criteria for irritable bowel syndrome (n=156) or unexplained dyspepsia (n=51) were included in the study. Consulters (n=103) were those who had had visited their general practitioner for gastrointestinal symptoms at least once in the prior 12 months. Nonconsulters had not sought medical care for gastrointestinal symptoms in the past year. Controls (n=100) did not report having any abdominal pain in a previous population survey. Psychosocial variables were assessed using structured interviews and validated self-report measures. RESULTS: Psychiatric diagnoses, neuroticism, more highly threatening life event stress, an external locus of control and ineffectual coping styles were significantly associated with having a diagnosis of irritable bowel syndrome and/or dyspepsia. Only somatization (odds ratio=5.28, 95% confidence interval 1.57-17.68), however, was independently associated with irritable bowel syndrome. Psychosocial factors did not discriminate between consulters and nonconsulters. CONCLUSIONS: Somatization is likely play a key role in explaining irritable bowel syndrome but not dyspepsia.

Physical and sexual abuse in patients with overactive bladder: is there an association?
Jundt K, Scheer I, Schiessl B, Pohl K, Haertl K, Peschers UM
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 18;.

The known sequelae of sexual abuse include acute and chronic injury. The purpose of this study was to evaluate the association of overactive bladder symptoms (OABs) with a history of physical or sexual abuse. Two hundred and forty-three women who attended the gynaecological out-patient clinic or the urogynaecological clinic were recruited for our study. Based on their clinical examination, they were assigned to three groups of patients with either OAB or with stress urinary incontinence (SUI) without concomitant urgency symptoms (SUI), or without history of incontinence (control group). Afterwards, they completed an anonymous questionnaire about bladder function and physical/sexual violence. Significantly more women (30.6%, 26/85) with OAB had previously been physically or sexually abused than women with SUI (17.8%, 18/101) and of the control group (17.5%, 10/57). Our study showed that significantly more women with OAB report physical and sexual abuse than subjects with stress incontinence or no urinary complaints. Women with stress incontinence had the same rate of self-reported physical/sexual abuse as continent controls.

Where does hypnotherapy stand in the management of irritable bowel syndrome? A systematic review.
Gholamrezaei A, Ardestani SK, Emami MH
J Altern Complement Med. 2006 Jul-Aug;12(6):517-27.

Background: Irritable bowel syndrome (IBS) is a gastrointestinal disorder characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. Despite its prevalence, there remains a significant lack of efficient medical treatment for IBS to date. However, according to some previous research studies, hypnosis has been shown to be effective in the treatment of IBS. Aim: To determine the definite efficacy of hypnosis in the treatment of irritable bowel syndrome. Methods: A systematic review of the literature on hypnosis in the treatment of IBS from 1970 to 2005 was performed using MEDLINE((R)). Full studies published in English were identified and selected for inclusion. We excluded case studies and those studies in which IBS symptoms were not in the list of outcome measures. All studies were reviewed on the basis of the Rome Working Team recommendations for design of IBS trials. Results: From a total of 22 studies, seven were excluded. The results of the reviewed studies showed improved status of all major symptoms of IBS, extracolonic symptoms, quality of life, anxiety, and depression. Furthermore these improvements lasted 2-5 years. Conclusions: Although there are some methodologic inadequacies, all studies show that hypnotherapy is highly effective for patients with refractory IBS, but definite efficacy of hypnosis in the treatment of IBS remains unclear due to lack of controlled trials supporting this finding.

Primary care for lesbians and bisexual women.
Mravcak SA
Am Fam Physician. 2006 Jul 15;74(2):279-86.

For the most part, lesbians and bisexual women face the same health issues as heterosexual women, but they often have difficulty accessing appropriate care. Physicians can improve care for lesbians and bisexual women by acknowledging the potential barriers to care (e.g., hesitancy of physicians to inquire about sexual orientation and of patients to disclose their sexual behavior) and working to create a therapeutic physician-patient relationship. Taking an inclusive and nonjudgmental history and being aware of the range of health-related behaviors and medicolegal issues pertinent to these patients enables physicians to perform relevant screening tests and make appropriate referrals. Some recommendations, such as those for screening for cervical cancer and intimate partner violence, should not be altered for lesbians and bisexual women. Considerations unique to lesbians and bisexual women concern fertility and medico-legal issues to protect familial relationships during life changes and illness. The risks of suicidal ideation, self-harm, and depression may be higher in lesbians and bisexual women, especially those who are not open about their sexual orientation, are not in satisfying relationships, or lack social support. Because of increased rates of nulliparity, the risks of conditions such as breast and ovarian cancers also may be higher. The comparative rates of alcohol and drug use are controversial. Smoking and obesity rates are higher in lesbians and bisexual women, but there is no evidence of an increased risk of cardiovascular disease.

July

A role for genetics in the outcome of antidepressant treatment for major depressive disorder.
Semaka A
Clin Genet. 2006 Aug;70(2):110-1.

The effect of nazism on medical progress in gastroenterology: the inefficiency of evil.
Cappell MS
Dig Dis Sci. 2006 Jun;51(6):1137-58.

While Nazism is almost universally recognized as a great evil, control of science and medicine by the totalitarian Nazi state might be viewed as increasing efficiency. Scientific methods are applied to semiquantitatively analyze the effects of Nazism on medical progress in gastroenterology to document its pernicious effects, and to honor outstanding gastroenterologists persecuted or murdered by the Nazis. This is a retrospective, quasi-case-controlled study. To disprove the null hypothesis that Nazism was efficient, retarded progress in gastroenterology is demonstrated by (1) enumerating the loss to Nazi Germany from 1933 to 1944 due to violent death, incarceration, or forced exile of key researchers in gastroenterology, defined by authorship of at least one book or 10 articles in peer-reviewed journals or other outstanding scholarship; (2) demonstrating a statistically significantly greater loss in Nazi Germany than in non-Nazi (Weimar German Republic from 1921 to 1932) or anti-Nazi (democratic America from 1933 to 1944) control groups; and (3) demonstrating that each loss was directly due to Nazism (murder, incarceration, or exile due to documented threat of violence/death or revocation of medical license). Sources of error in analyzing events from 70 years ago are described. Nazi Germany and Nazi-occupied Europe gained 0 and lost 53 key gastroenterology researchers, including 32 lost due to forced exile, 11 murdered by the Nazis, 5 lost due to suicide under threat of violence, 3 in hiding from the Gestapo, and 2 for other reasons. Fifty-two of the gastroenterologists were persecuted solely because they were Jewish or of Jewish descent and one because he was a Christian anti-Nazi Polish patriot. Particularly severe losses occurred in endoscopy. The loss in Nazi Germany from 1933 to 1944 was significantly greater than that in non-Nazi Germany and Austria from 1921 to 1932 (53 versus 4; odds ratio = 25.27; 95% CI: 9.01-70.48; P < 0.0001) and was significantly greater than that in anti-Nazi America from 1933 to 1944 (53 versus 0; odds ratio > 104.0; 95% CI: 17.62-608.95; P < 0.0001). Lost physicians in Nazi Germany (with reasons for loss) included Ismar Boas, the father of modern gastroenterology (suicide after medical license revoked); Hans Popper, the father of hepatopathology (fled impending arrest); Rudolph Nissen, the father of antireflux surgery (fled after job dismissal); Rudolph Schindler, the father of semiflexible endoscopy (fled after incarceration); Heinrich Lamm, the first to experimentally demonstrate fiberoptic transmission and the first to suggest its applicability for gastroscopy (fled after medical license revoked); Hermann Strauss, a pioneer in rigid sigmoidoscopy (suicide in a concentration camp); A.A.H. van den Bergh, who discovered the van den Bergh reaction to differentiate indirect from direct bilirubin (died in hiding in Nazi-occupied Holland); and Kurt Isselbacher, subsequently the Chief of Gastroenterology at Harvard Medical School (fled in childhood after a grandfather murdered by Nazis). All four refugee physicians who were reexposed to Nazi domination, after a regime change in their country of refuge, fled again or committed suicide. The Nazi damage to German and Austrian gastroenterology was immense, e.g., 13 of 14 major international discoveries in diagnostic gastroscopy were made by Germans or Austrians before the Third Reich, versus only 1 of 8 subsequently (odds ratio = 91; 95%

June

Psychological and behavioral aspects of complex regional pain syndrome management.
Bruehl S, Chung OY
Clin J Pain. 2006 Jun;22(5):430-7.

Psychological and behavioral factors can exacerbate the pain and dysfunction associated with complex regional pain syndrome (CRPS) and could help maintain the condition in some patients. Effective management of CRPS requires that these psychosocial and behavioral aspects be addressed as part of an integrated multidisciplinary treatment approach. Well-controlled studies to guide the development of a psychological approach to CRPS management are not currently available. A sequenced protocol for psychological care in CRPS is therefore proposed based on available data and clinical experience. Regardless of the duration of the condition, all CRPS patients and their families should receive education about the negative effects of disuse, the pathophysiology of the syndrome, and possible interactions with psychological/behavioral factors. Patients with acute CRPS (<6-8 weeks) may not need additional psychological care. All patients with chronic CRPS should receive a thorough psychological evaluation, followed by cognitive-behavioral pain management treatment, including relaxation training with biofeedback. Patients making insufficient overall treatment progress or in whom comorbid psychiatric disorders/major ongoing life stressors are identified should additionally receive general cognitive-behavioral therapy to address these issues. The psychological component of treatment can work synergistically with medical and physical/occupational therapies to improve function and increase patients' ability to manage the condition successfully.

Mind over matter: psychological factors and the menstrual cycle.
Edozien LC
Curr Opin Obstet Gynecol. 2006 Aug;18(4):452-456.

PURPOSE OF REVIEW: Increasingly, gynaecologists are becoming aware of the impact of psychosocial factors on women's health generally, and on the menstrual cycle in particular. This review highlights developments in this field in the last triennium. RECENT FINDINGS: Stress impairs the ovarian cycle through activation of the hypothalamus pituitary adrenal axis. The effect of psychological stress on the menstrual cycle is mediated by metabolic factors. Stress-induced impairment of ovarian function may not necessarily manifest as menstrual irregularity, and the effects of stress may persist beyond the cycle in which the stress episode occurred. Response to stress may be determined not so much by the nature of the stress as by the intrinsic neuronal attributes of the individual. SUMMARY: Interventions to address underlying stress should be part of the management regime for women with menstrual cycle abnormalities.

Psychological and social interventions in the menopause.
Towey M, Bundy C, Cordingley L
Curr Opin Obstet Gynecol. 2006 Aug;18(4):413-7.

PURPOSE OF REVIEW: Increasingly, menopause research is using knowledge of psychological and social functioning to understand women's experiences of menopause and develop interventions to treat symptoms or reduce risk factors. Clinicians are more aware of the need to take account of psychological processes when discussing treatment choices, risks and quality of life. Here, we review the most recent developments in this area. RECENT FINDINGS: Group interventions based on a cognitive-behaviour therapy approach that address beliefs about symptoms and teach specific techniques (paced respiration) can reduce the frequency of hot flushes. Studies using a health education framework indicate that information is more salient for women when there are given feedback on their own higher osteoporosis risk status. Finally, there are promising signs that interventions to reduce risk factors can lead to sustained lifestyle change. SUMMARY: The increasing interest in psychological and social interventions is reflected in the number of new publications, but there are still too few large-scale well controlled studies. Earlier work on treatment decision making, and the factors predicting treatment choices has not been followed by larger studies. Reported research emphasizes the need for clinicians to assess women's beliefs about menopausal symptoms and use this knowledge to develop shared treatment plans.

Female patients report on health care staff's disobedience of ethical principles.
Swahnberg K, Wijma B, Liss PE
Acta Obstet Gynecol Scand. 2006;85(7):830-6.

Background. Earlier studies have shown a high prevalence of abuse in health care (AHC). We hypothesized that patients might easily feel abused when staff do not follow prevailing ethical principles. Therefore we developed the Violations of Ethical Principles Questionnaire (ViolEP), with 30 examples of situations in health care where four ethical principles are disobeyed (autonomy, nonmaleficence, justice, and integrity). Respondents reported whether or not they had ever experienced each of the situations, and whether or not they had perceived that event as a violation. Research questions: 1. What proportion of female patients have ever experienced staff disobeying ethical principles in health care? 2. To what extent are such events perceived as violations? and 3. How well do perceived violations of ethical principles correspond to experiences of AHC? Method. Our sample was 661 consecutive female patients at the Department of Obstetrics and Gynecology in Linkoping, Sweden. They completed ViolEP and NorVold Abuse Questionnaire (NorAQ) at home and returned them by post. Results. 20/661 (64%) women answered the ViolEP and 426/661 (64%) returned the NorAQ. The majority (73%) (306/420) had experienced staff disobeying ethical principles. More than every second woman had perceived those events as violations (68%) (209/306). The prevalence of AHC was 23%. ViolEP had good sensitivity but low specificity when we used AHC according to NorAQ as the "gold standard". Conclusion. The majority of the patients had experienced health care staff disobeying prevailing ethical principles. These events were not always perceived as violations. The reason for this discrepancy needs to be explored.

May

The prevalence of emotional abuse in gynaecology patients and its association with gynaecological symptoms.
Johnson JK, John R, Humera A, Kukreja S, Found M, Lindow SW
Eur J Obstet Gynecol Reprod Biol. 2006 Jun 3;.

AIM: To determine the lifetime prevalence of emotional abuse in a population of women attending a gynaecology outpatient clinic and also to investigate whether women who reported emotional abuse were more likely to complain of certain gynaecological symptoms. SETTING: A gynaecology outpatient clinic in a North of England Hospital. METHODS: Anonymous confidential questionnaire given to women. RESULTS: Nine hundred and twenty consecutive women were included, 825 questionnaires were returned (90% response rate). The prevalence of emotional abuse was 24% (198/825). Emotional abuse is four times less common in women over 50 years old. Of the fifteen presenting symptoms reported by the women, referral for termination of pregnancy, cervical smear abnormality, worry about cancer and urinary incontinence were significantly more common in the group who reported emotional abuse. The women with emotional abuse also had significantly more consultations; however, the duration of their symptoms was not significantly different. CONCLUSION: The prevalence of emotional abuse in a group of women attending the gynaecology outpatient clinic in a North of England Hospital was 24%. Women who are subjected to emotional abuse tend to have more consultations and are more likely to complain of certain symptoms.

Emotional stress reactivity in irritable bowel syndrome.
Bach DR, Erdmann G, Schmidtmann M, Monnikes H
Eur J Gastroenterol Hepatol. 2006 Jun;18(6):629-636.

OBJECTIVES: Irritable bowel syndrome (IBS) has been proposed to be a stress-related disorder. Research on stress reactivity in IBS has yielded ambiguous results, regarding responses to physical and mental stress. This study aimed to investigate the responses to emotional stress in IBS patients. METHODS: Twelve IBS patients and 12 healthy individuals underwent public speaking anticipation as an emotional stressor and a control situation. Stress reactivity was quantified by subjective and psychophysiological measures. RESULTS: Stress responses were elicited in healthy controls and IBS patients. Differential stress responses were observed in measurements of heart rate. There was no change in rectal sensitivity under stress, whereas patients exhibited lower discomfort thresholds than healthy controls in all conditions. CONCLUSION: This study measured reactivity to an emotional stressor in IBS. It provides evidence that there is a specific alteration of stress responses in IBS patients, but no overall exaggerated stress response. IBS patients showed a broader and less specific response to emotional stress than healthy controls. Rectal sensitivity was unchanged under emotional stress both in IBS patients and healthy controls.

Features associated with laxative abuse in individuals with eating disorders.
Tozzi F, Thornton LM, Mitchell J, Fichter MM, Klump KL, Lilenfeld LR, Reba L, Strober M, Kaye WH, Bulik CM
Psychosom Med. 2006 May-Jun;68(3):470-7.

OBJECTIVE: Laxative abuse is common in patients with anorexia and bulimia nervosa and has been associated with longer duration of illness, suicide attempts, impulsivity, and greater eating and general psychopathology. We explored the extent to which laxative abuse was associated with specific psychopathological features across eating disorder subtypes. METHODS: Participants were 1021 individuals from the multisite, International Price Foundation Genetic Studies. Axis I disorders, personality disorders and traits, and obsessive compulsive features were assessed. RESULTS: Laxative abuse was associated with worse eating disorder and general psychopathology and higher prevalence of borderline personality disorder (BPD). Symptom level analyses revealed that specific features of BPD, including suicidality and self-harm, feelings of emptiness, and anger, were most strongly associated with laxative abuse. CONCLUSIONS: The function of laxative abuse may differ across individuals with eating disorders, alternatively serving as a method of purging and a form of self-harm.

To "lump" or to "split" the functional somatic syndromes: can infectious and emotional risk factors differentiate between the onset of chronic fatigue syndrome and irritable bowel syndrome?
Moss-Morris R, Spence M
Psychosom Med. 2006 May-Jun;68(3):463-9.

OBJECTIVES: Recent academic debate has centered on whether functional somatic syndromes should be defined as separate entities or as one syndrome. The aim of this study was to investigate whether there may be significant differences in the etiology or precipitating factors associated with two common functional syndromes, irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS). METHODS: We prospectively studied 592 patients with an acute episode of Campylobacter gastroenteritis and 243 with an acute episode of infectious mononucleosis who had no previous history of CFS or IBS. At the time of infection, patients completed a baseline questionnaire that measured their levels of distress using the Hospital Anxiety and Depression scale. At 3- and 6-month follow-up, they completed questionnaires to determine whether they met published diagnostic criteria for chronic fatigue (CF), CFS, and/or IBS. RESULTS: The odds of developing IBS were significantly greater post-Campylobacter than post-infectious mononucleosis at both 3- (odds ratio, 3.45 [95% confidence interval (CI), 1.75-6.67]) and 6- (2.22 [95% CI, 1.11-6.67]) month follow-up. In contrast, the odds for developing CF/CFS were significantly greater after infectious mononucleosis than after Campylobacter at 3 (2.77 [95% CI, 1.08-7.11]) but not 6 (1.48 [95% CI, 0.62-3.55]) months postinfection. Anxiety and depression were the strongest predictors of CF/CFS, whereas the nature of the infection was the strongest predictor of IBS. CONCLUSIONS: These results support the argument to distinguish between postinfectious IBS and CFS. The nature of the precipitating infection appears to be important, and premorbid levels of distress appear to be more strongly associated with CFS than IBS, particularly levels of depression.

Psychiatric comorbidities of female inpatients with eating disorders.
Blinder BJ, Cumella EJ, Sanathara VA
Psychosom Med. 2006 May-Jun;68(3):454-62.

OBJECTIVE: We analyze 27 point-prevalent DSM-IV Axis I comorbidities for eating disorder inpatients. METHODS: The sample included 2436 female inpatients treated between January 1, 1995, and December 31, 2000, for primary DSM-IV diagnoses of anorexia, bulimia, and eating disorder not otherwise specified. Analyses were multivariate analysis of variance and multinomial logistic regression; sociodemographics and severity-of-illness measures were controlled. RESULTS: Ninety-seven percent of patients evidenced > or = 1 comorbid diagnoses; 94% evidenced comorbid mood disorders, largely unipolar depression, with no differences across eating disorders; 56% evidenced anxiety disorders, with no differences across eating disorders; and 22% evidenced substance use disorders, with significant differences across eating disorders (p < .0001). Five specific diagnoses differed across eating disorders. Alcohol abuse/dependence was twice as likely with bulimia (p < .0001); polysubstance abuse/dependence three times as likely with bulimia (p < .0001); obsessive-compulsive disorder twice as likely with restricting and binge/purge anorexia (p < .01); posttraumatic stress disorder twice as likely with binge-purge anorexia (p < .05); schizophrenia/other psychoses three times more likely with restricting anorexia (p < .05) and two times with binge-purge anorexia (p < .05). CONCLUSIONS: New findings emerged: extremely high comorbidity regardless of eating disorder, ubiquitous depression across all eating disorders, no difference in overall rate of anxiety disorders across eating disorders, greater posttraumatic stress disorder in binge-purge anorexia, more psychotic diagnoses in anorexia. Certain previous findings were confirmed: more obsessive-compulsive disorder in anorexia; more substance use in bulimia; and a replicated comorbidity rank-ordering for eating disorder patients: mood, anxiety, and substance use disorders, respectively.

Body dissatisfaction in women with eating disorders: relationship to early separation anxiety and insecure attachment.
Troisi A, Di Lorenzo G, Alcini S, Nanni RC, Di Pasquale C, Siracusano A
Psychosom M ed. 2006 May-Jun;68(3):449-53.

OBJECTIVE: It has been suggested that an insecure style of attachment may be one of the factors implicated in the etiology of body dissatisfaction, which, in turn, is a risk factor for eating disorders. The present study analyzed the association among early separation anxiety, insecure attachment, and body dissatisfaction in a clinical sample of 96 women with anorexia nervosa (n = 31) or bulimia nervosa (n = 65). METHODS: Body dissatisfaction was measured using the Body Shape Questionnaire (BSQ), early separation anxiety was measured using the Separation Anxiety Symptom Inventory (SASI), and adult attachment style was measured using the Attachment Style Questionnaire (ASQ). RESULTS: In both anorectic and bulimic women, BSQ scores were strongly correlated with SASI and ASQ scores. In a hierarchical regression model controlling for the confounding effects of body mass index and depressive symptoms, early separation anxiety and preoccupied attachment emerged as significant predictors of high levels of body dissatisfaction. CONCLUSIONS: Based on the cross-sectional findings of this study, insecure attachment appears to be a consistent correlate of negative body image evaluations in women with either anorexia nervosa or bulimia nervosa. If future prospective studies will confirm that an insecure style of attachment plays a role in promoting the development of body dissatisfaction, prevention and treatment of disordered eating pathology might be enhanced by focusing greater attention on attachment relationships.

A brief measure for assessing generalized anxiety disorder: the GAD-7.
Spitzer RL, Kroenke K, Williams JB, Lowe B
Arch Intern Med. 2006 May 22;166(10):1092-7.

BACKGROUND: Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity. METHODS: A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use. RESULTS: A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale. CONCLUSION: The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.

April

Regional variations in health care intensity and physician perceptions of quality of care.
Sirovich BE, Gottlieb DJ, Welch HG, Fisher ES
Ann Intern Med. 2006 May 2;144(9):641-9.

BACKGROUND: Research has documented dramatic differences in health care utilization and spending across U.S. regions with similar levels of patient illness. Although patient outcomes and quality of care have been found to be no better in regions of high health care intensity, it is unknown whether physicians in these regions feel more capable of providing good patient care than those in low-intensity regions. OBJECTIVE: To determine whether physicians in high-intensity regions feel better able to care for patients than physicians in low-intensity regions. DESIGN: Physician telephone survey. SETTING: 51 metropolitan and 9 nonmetropolitan areas of the United States and a supplemental national sample. PARTICIPANTS: 10,577 physicians who provided care to adults in 1998 or 1999 were surveyed for the Community Tracking Study (response rate, 61%). MEASUREMENTS: The End-of-Life Expenditure Index, a measure of spending that reflects differences in the overall quantity of medical services provided rather than differences in illness or price, was used to determine health care intensity in the physicians' community. Outcomes included physicians' perceived availability of clinical services, ability to provide high-quality care to patients, and career satisfaction. RESULTS: Although the highest-intensity regions have substantially more hospital beds and specialists per capita, physicians in these regions reported more difficulty obtaining needed services for their patients. The proportion of physicians who felt able to obtain elective hospital admissions ranged from 50% in high-intensity regions to 64% in the lowest-intensity region (P < 0.001 for the relationship between intensity and perceived ability to obtain hospital admissions); the proportion of physicians who felt able to obtain high-quality specialist referrals ranged from 64% in high-intensity regions to 79% in low-intensity regions (P < 0.001). Compared with low-intensity regions, fewer physicians in high-intensity regions felt able to maintain good ongoing patient relationships (range, 62% to 70%; P < 0.001) or able to provide high-quality care (range, 72% to 77%; P = 0.009). In most cases, differences persisted but were attenuated in magnitude after adjustment for physician attributes, practice characteristics, and local market factors (for example, managed care penetration); the difference in perceived ability to provide high-quality care was no longer statistically significant (P = 0.099). LIMITATIONS: The cross-sectional design prevented demonstration of a causal relationship between intensity and physician perceptions of quality. CONCLUSION: Despite more resources, physicians in regions of high health care intensity did not report greater ease in obtaining needed services or greater ability to provide high-quality care.

Psychosocial aspects of the functional gastrointestinal disorders.
Levy RL, Olden KW, Naliboff BD, Bradley LA, Francisconi C, Drossman DA, Creed F
Gastroenterology. 2006 May;130(5):1447-58.

This report reviews recent research on the psychosocial aspects of the functional gastrointestinal disorders (FGIDs). A review and evaluation of existing literature was conducted by a multidisciplinary committee of experts in this field. This report is a synopsis of a chapter published in the Rome III book. The committee reached consensus in finding considerable evidence supporting the association between psychological distress, childhood trauma and recent environmental stress, and several of the FGIDs but noted that this association is not specific to FGIDs. There is also considerable evidence that psychosocial variables are important determinants of the outcomes of global well-being, health-related quality of life, and health care seeking. In line with these descriptive findings, there is now increasing evidence that a number of psychological treatments and antidepressants are helpful in reducing symptoms and other consequences of the FGIDs in children and adults. The FGIDs are a result of complex interactions between biological, psychological, and social factors, and they can only be treated satisfactorily when all these factors are considered and addressed. Therefore, knowledge about the psychosocial aspects of FGIDs is fundamental and critical to the understanding, assessment, and treatment of these disorders. More extensive physician training is needed if these aspects of treatment are to be used effectively and widely in clinical practice.

Fear of childbirth and history of abuse: implications for pregnancy and delivery.
Heimstad R, Dahloe R, Laache I, Skogvoll E, Schei B
Acta Obstet Gynecol Scand. 2006;85(4):435-40.

BACKGROUND: The aim of this study was to assess the prevalence of fear of childbirth, and to find possible associations to selected sociodemographic factors and important life events. A secondary aim was to explore the relationship between these factors and pregnancy outcome. METHODS: Questionnaire booklets were sent to 2680 women at 18 weeks of gestation, of whom 1452 women (54%) responded. The questionnaire included background factors (marital status, education, history of abuse, current pregnancy), W-DEQ (measurement of fear of childbirth), and STAI (measurement of subjective anxiety). Pregnancy outcome information was recorded. RESULTS: The prevalence of serious fear of childbirth (W-DEQ > 100) was 5.5%. The W-DEQ and STAI scores were positively correlated (r = 0.44, p < 0.001). Among the anxious women, a trend towards more frequent operative vaginal delivery (12.1% versus 6.9%, p = 0.07) was noted, but not for emergency cesarean section (10.6% versus 7.6%, p = 0.34). Women who reported being exposed to physical or sexual abuse in childhood had a higher W-DEQ score (71, SD 31 and 69, SD 27) than did the non-abused (61, SD 23, p < 0.01). Only half of women sexually or physically abused in childhood (54% and 57% respectively) had uncomplicated vaginal delivery at term versus 75% among non-abused (p < 0.001). CONCLUSION: The prevalence of serious fear of childbirth was 5.5%. Fear of childbirth was not associated with mode of delivery, whereas sexual or physical abuse in childhood influenced negatively mode of delivery.

Viewpoint: teaching respect for patients.
Branch WT Jr
Acad Med. 2006 May;81(5):463-7.

Respect is a core value of medical professionalism. Respect for patients often manifests itself as an attitude, of which the physician is only partially self-aware. To teach respect means bringing it fully into consciousness. Physicians then should strive to make respect an inner quality, beyond being a behavior. The author illustrates the depth of feeling involved in respecting another person by citing passages from Let Us Now Praise Famous Men, James Agee's classic book that describes Depression-era tenant farmers. However, major barriers inhibit teaching of respect in clinical settings. The author proposes that synergies can be achieved that overcome the barriers by combining the effective modeling of respect in bedside teaching with formal teaching exercises involving patients and deep critical reflection using narratives wherein learners describe their experiences in patient care.

Making Fun of Patients: Medical Students' Perceptions and Use of Derogatory and Cynical Humor in Clinical Settings.
Wear D, Aultman JM, Varley JD, Zarconi J
Acad Med. 2006 May;81(5):454-462.

PURPOSE: It has long been known that medical students become more cynical as they move through their training, and at times even exhibit "ethical erosion." This study examines one dimension of this phenomenon: how medical students perceive and use derogatory and cynical humor directed at patients. METHOD: The authors conducted five voluntary focus groups over a three-month period with 58 third- and fourth-year medical students at the Northeastern Ohio Universities College of Medicine in 2005. After transcribing the taped interviews, the authors analyzed the data using qualitative methods and identified themes found across groups. RESULTS: The categories that emerged from the data were (1) categories of patients who are objects of humor, including those deemed "fair game" due to obesity or other conditions perceived as preventable or self-inflicted; (2) locations for humor; (3) the "humor game," including student, resident, and faculty interaction and initiation of humor; (4) not-funny humor; and (5) motives for humor, including coping and stress relief. CONCLUSIONS: The authors offer recommendations for addressing the use of derogatory humor directed at patients that include a more critical, open discussion of these attitudes and behaviors with medical students, residents, and attending physicians, and more vigorous attention to faculty development for residents.

Improving education on doctor-patient relationships and communication: lessons from doctors who become patients.
Klitzman R
Acad Med. 2006 May;81(5):447-53.

PURPOSE: Medical education faces challenges in training empathetic doctors who have good patient communication skills. The author aimed to understand insights that doctors who become patients may gain concerning ways to improve doctor-patient relationships and communication in order to improve medical education. METHOD: From 1999 to 2002, based in New York, the author conducted two in-depth, semistructured, two-hour interviews with each of 50 doctors who had serious illnesses concerning their overlapping experiences of being health care workers and becoming patients. Interviews examined their views about these issues and how their perspectives changed as a result of patienthood. RESULTS: These doctor-patients questioned whether and to what degree empathy could be taught, but nonetheless provided several techniques for improving communication with patients related to process and content of care. Processes included charting at the bedside rather than at the nursing station, acknowledging having kept patients waiting, and increasing awareness of nonverbal aspects of care. Content issues included communicating directly about taboo topics and being more sensitive in discussing "bad news," adherence, and nonmedical concerns. CONCLUSIONS: Doctors reported increased sensitivity to patients' experiences and empathy in doctor-patient communication. These findings can help in teaching doctors to see more clearly that their specific point of view differs from that of patients, and can be limiting. This study also sheds light on the wide separation between intellectual and experiential learning, which needs to be addressed further in medical education and research.

Alexithymia is associated with gastrointestinal symptoms, but does not predict endoscopy outcome in patients with gastrointestinal symptoms.
van Kerkhoven LA, van Rossum LG, van Oijen MG, Tan AC, Witteman EM, Laheij RJ, Jansen JB
J Clin Gastroenterol. 2006 Mar;40(3):195-9.

BACKGROUND: Alexithymia, where a person has difficulty in distinguishing between emotions and bodily sensations, is considered to be a character trait and a vulnerability factor for various psychosomatic disorders. Assessing alexithymia in patients with gastrointestinal (GI) symptoms before endoscopy might therefore be useful in selecting patients who are more prone to functional GI disorders. GOAL: To determine whether alexithymia might be a useful factor in predicting GI endoscopy outcomes. STUDY: Patients referred for endoscopy between February 2002 and February 2004 were enrolled. They were asked to report alexithymia on the Toronto Alexithymia Scale-20 2 weeks before endoscopy. Information about endoscopic diagnoses was obtained from medical files. RESULTS: A total of 1141 subjects was included (49% male), of whom 245 (21%) reported alexithymia. There was no difference in mean+/-SD alexithymia scores between patients with (51+/-12) and without (50+/-12) an endoscopic organic abnormality at GI endoscopy. When divided into subgroups, according to the most prominent finding at either upper or lower GI endoscopy, there was no association with alexithymia. Patients with alexithymia reported a worse sensation of GI symptoms during the last weeks before enrollment in the study (mean+/-SD symptom severity score: 42+/-34 vs. 34+/-30, respectively; P<0.01). CONCLUSIONS: Alexithymia is not associated with endoscopic findings, and has therefore no additive value in predicting endoscopy outcomes. Patients with alexithymia more often present with a higher number and more severe GI symptoms.

On studying the connection between stress and IBD.
Bernstein CN, Walker JR, Graff LA
Am J Gastroenterol. 2006 Apr;101(4):782-5.

A number of investigators over the years have attempted to determine if a relationship exists between flares of inflammatory bowel disease (IBD) and stress. There are many complexities to addressing this issue, including determining the appropriate tools to measure stress, determining the appropriate measures of quantifying a disease flare and also determining the point at which the timing of the stress could be seen to be reasonably related to the onset of the flare. While advances have been made in understanding physiological responses to acute stress, it is unclear whether it is acute, chronic, or recurrent stress that might most impact on a chronic inflammatory disease. In the case of IBD, the disease itself poses a stress to the individual further clouding the issue.

March

Autonomic response to standardized stress predicts subsequent disease activity in ulcerative colitis.
Maunder RG, Greenberg GR, Nolan RP, Lancee WJ, Steinhart AH, Hunter JJ
Eur J Gastroenterol Hepatol. 2006 Apr;18(4):413-20.

OBJECTIVES: Prospective studies of the role of psychological stress in ulcerative colitis are inconsistent or show a modest relationship. We tested the hypothesis that individual differences in autonomic function are associated with differences in the disease course of ulcerative colitis. METHODS: The spectral power of heart rate variability, an indirect marker of autonomic function, was measured during a standardized stress protocol in 93 ulcerative colitis patients. Patients were categorized as typical or atypical by an increase or decrease, respectively, in the high frequency band of heart rate variability from a period of acute stress to recovery 5 min later. Disease activity was measured at baseline (time 1) and a second time point (time 2) 7-37 months later. RESULTS: An atypical pattern of heart rate variability at time 1, present in 29% of patients, was associated with lower mean disease activity at time 2 (atypical, 0.56+/-0.93; typical, 2.27+/-2.56, P=0.001). The contribution of heart rate variability pattern to explaining time 2 disease activity was independent of the contributions of other factors that differed between groups, including time 1 disease activity and lifetime corticosteroid use. DISCUSSION: An atypical pattern of autonomic reactivity may be a marker of individual differences in stress regulation that has prognostic significance in ulcerative colitis.

February

Women use voice parameters to assess men's characteristics.
Bruckert L, Lienard JS, Lacroix A, Kreutzer M, Leboucher G
Proc Biol Sci. 2006 Jan 7;273(1582):83-9.

The purpose of this study was: (i) to provide additional evidence regarding the existence of human voice parameters, which could be reliable indicators of a speaker's physical characteristics and (ii) to examine the ability of listeners to judge voice pleasantness and a speaker's characteristics from speech samples. We recorded 26 men enunciating five vowels. Voices were played to 102 female judges who were asked to assess vocal attractiveness and speakers' age, height and weight. Statistical analyses were used to determine: (i) which physical component predicted which vocal component and (ii) which vocal component predicted which judgment. We found that men with low-frequency formants and small formant dispersion tended to be older, taller and tended to have a high level of testosterone. Female listeners were consistent in their pleasantness judgment and in their height, weight and age estimates. Pleasantness judgments were based mainly on intonation. Female listeners were able to correctly estimate age by using formant components. They were able to estimate weight but we could not explain which acoustic parameters they used. However, female listeners were not able to estimate height, possibly because they used intonation incorrectly. Our study confirms that in all mammal species examined thus far, including humans, formant components can provide a relatively accurate indication of a vocalizing individual's characteristics. Human listeners have the necessary information at their disposal; however, they do not necessarily use it.

Munchausen's Syndrome With 20-Year Follow-Up.
Fehnel CR, Brewer EJ
Am J Psychiatry. 2006 Mar;163(3):547.

Menopausal Symptoms in Hispanic Women and the Role of Socioeconomic Factors.
Schnatz PF, Serra J, O'sullivan DM, Sorosky JI
Obstet Gynecol Surv. 2006 Mar;61(3):187-193.

The objective of this study was to assess differences in menopausal symptoms between postmenopausal (PM) Hispanic (H) and PM Caucasian (C) women. This was a prospective survey. Data from a convenience sample of 404 PM women (50% H, 50% C) were evaluated. Comparing H with C women, statistically significant differences (P < 0.05) in symptoms were noted with mood changes (76% H, 54% C), a decrease in energy (56% H, 36% C), palpitations (54% H, 26% C), breast tenderness (39% H, 28% C), memory loss (34% H, 22% C), and vaginal dryness (34% H, 44% C). When controlling for education and income, there were differences in mood changes, a decrease in energy and palpitations between the groups. Consistent with previous data, hot flashes (80% H, 75% C) and night sweats (67% H, 64% C) were the most common symptoms in the PM C women, and there were no significant differences compared with PM H women. Symptoms reported by PM C women in this sample are consistent with rates in the literature, but PM H women reported several symptoms at a higher rate. These differences remain when socioeconomic factors are considered, suggesting ethnicity may be an independent variable in menopausal symptomatology. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state that the symptoms of menopause affect all women independently of race/ethnicity, recall that Hispanic and Caucasian women did differ in the frequency of some common symptoms, and explain that when socioeconomic factors were considered the differences remained suggesting that ethnicity may be an independent variable in menopausal symptomatology.

January

Female pelvic floor dysfunction in the Middle East: a tale of three factors-culture, religion and socialization of health role stereotypes.
Rizk DE, El-Safty MM
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan 13;:1-3.

Pain and Aberrant Drug-Related Behaviors in Medically Ill Patients With and Without Histories of Substance Abuse.
Passik SD, Kirsh KL, Donaghy KB, Portenoy RK
Clin J Pain. 2006 Feb;22(2):173-181.

OBJECTIVES: This study evaluated the prevalence and correlates of aberrant drug-taking behaviors in two populations: patients with HIV-related pain and a history of substance abuse (n = 73) and patients with cancer pain and no history of substance abuse (n = 100). METHODS: All patients completed a Drug-Taking Behaviors Interview, the Brief Symptom Inventory (BSI), Brief Pain Inventory (BPI), Memorial Symptom Assessment Scale (MSAS), and the Marlowe Crowne Social Desirability Scale (MCSDS). The Pain Management Index was calculated to assess the adequacy of opioid prescribing. RESULTS: The cancer sample comprised 38 men and 62 women, and the AIDS sample comprised 63 men and 10 women. Patients with AIDS-related pain had higher global distress on the MSAS (F1, 170 = 20.05, P < 0.001), greater pain-related interference in their daily functioning on the BPI (F1, 161 = 22.87, P < 0.001), and a lower percentage of relief from their current medications (F1, 156 = 76.14, P < 0.001). AIDS patients also reported more than twice as many examples of aberrant drug-related behaviors per patient (mean = 6.14, SD = 4.60) as the cancer patients (mean = 1.42, SD = 1.91). CONCLUSION: These data suggest that AIDS patients with histories of substance abuse receiving opioid therapy are more symptomatic, have more distress, experience more interference from residual pain, and engage in more problematic drug-related behaviors than patients with no history of drug abuse receiving opioids for cancer pain. Treatment of substance abusers with pain requires skills that complement best practices in opioid prescribing. Better approaches to the long-term treatment of these populations are needed.

JAMA patient page. Depression.
Torpy JM, Burke AE, Glass RM
JAMA. 2006 Jan 18;295(3):348.

Stem cell transplantation: Risk factors for psychiatric morbidity.
Prieto JM, Blanch J, Atala J, Carreras E, Rovira M, Cirera E, Gasto C
Eur J Cancer. 2006 Jan 17;.

The aim of this study was to determine the risk factors for psychiatric disorder in haematological cancer patients during hospitalization for stem cell transplantation. In this 3-year prospective study, 220 patients received stem cell transplantation at a single institution. Structured psychiatric interviews applying standardized diagnostic criteria were performed at hospital admission and weekly during hospitalization until discharge or death, yielding a total of 1062 interviews. Psychiatric disorder (any depressive, anxiety, or adjustment disorder) prevalence at the time of hospital admission was 21% and psychiatric disorder incidence during post-admission follow-up was 22%. After adjusting for multiple confounders in multivariate logistic regression analyses, we found that younger age, women, a past psychiatric history, lower functional status, pain, smoking cessation, and higher regimen-related toxicity were significantly associated with psychiatric disorder risk. Our study findings may help to improve identification of the patients most at risk for psychiatric disturbances during hospitalization for stem cell transplantation.

Commentary: coming to america: the integration of international medical graduates into the american medical culture.
Whelan GP
Acad Med. 2006 Feb;81(2):176-8.

This Commentary is a companion piece to two Research Reports appearing in this issue: "Behavioral Science Education and the International Medical Graduate," by Searight and Gafford, and "International Medical Graduates and the Diagnosis and Treatment of Late-Life Depression," by Kales et al. International medical graduates (IMGs) come to America from diverse cultures around the world to complete their graduate medical education (GME). These residents are and will continue to be a fundamental part of the American health care delivery system. IMGs' acculturation into the norms and standards of medicine as practiced in the U.S. is crucial to their education as well as to quality patient care. The time has come for GME to begin to systematically and effectively address the cultural challenges that IMGs face not only within the context of American medicine and GME, but in the larger context of American culture. Specific programs and strategies need to be developed and put in place early in the GME experience-or even before entry into GME-to assist IMGs in understanding the context for, and issues associated with, providing optimum health care in the United States. The author reflects on the findings of the two Research Reports, and calls for increased attention in the medical education community to acculturating and educating IMGs for optimal patient care.

International medical graduates and the diagnosis and treatment of late-life depression.
Kales HC, Dinardo AR, Blow FC, McCarthy JF, Ignacio RV, Riba MB
Acad Med. 2006 Feb;81(2):171-5.

Purpose International medical graduates (IMGs) constitute a significant number of physicians in the United States. Because of cultural differences in the manifestations and acceptance of mental disorders, depression may be less recognized in countries where IMGs train than in the United States. Differences in medical training may affect IMGs' recognition of depression. The authors hypothesized that the diagnosis and treatment of late-life depression would differ between United States medical graduates (USMGs) and IMGs. Method Physicians, both USMGs and IMGs, at two different professional physician association meetings in 2002 were asked to view a multimedia computer program including a vignette of an elderly patient-actor with late-life depression. They completed a computerized survey, including their diagnosis and recommendations for management. Statistical analyses were performed to compare the two groups for physician characteristics and patient treatment recommendations. Results Study subjects were 178 primary care physicians and 321 psychiatrists. Three hundred fifty-three (71%) respondents were USMGs and 146 (29%) were IMGs. IMGs were significantly less likely than USMGs to make the correct diagnosis of depression (p < .004) or recommend treatment with a first-line antidepressant (p < .001). When specialty, other physician characteristics, and patient race and gender were controlled for, IMGs still differed significantly in their diagnoses (p = .006) and treatment (p = .006) of depression. Conclusion The authors found significant differences between USMGs and IMGs for the diagnosis and treatment of late-life depression. This could be due to IMGs' lesser familiarity with depressive symptoms or different cultural conceptions of depression. These findings may point to the need for additional depression training initiatives for IMGs.

Behavioral science education and the international medical graduate.
Searight HR, Gafford J
Acad Med. 2006 Feb;81(2):164-70.

Purpose International medical graduates (IMGs), many of whom are recent immigrants to the United States, are filling an increasing proportion of U.S. family medicine residency positions. Therefore, assumptions about the training experiences of first-year residents may no longer apply to a large percentage of incoming residents. The authors sought to improve the behavioral science education in their residency program by learning about IMGs' previous training and experience in behavioral science before coming to the United States. Method Ten first-, second-, and third-year family medicine residents, representing medical school training from India, Macedonia, Bosnia-Herzegovina, The Philippines, Egypt, and Iraq, were individually interviewed using an inductive, qualitative approach. Transcripts were reviewed and double coded. Categories and story lines were identified, and member checking was employed. Results Segments were classified into seven categories: residents' behavioral medicine training prior to coming to the United States; reflections on the inclusion of mental health and psychosocial content in clinical family medicine; training in medical interviewing; reflections on the physician-patient relationship; perceptions of U.S. family life; recommendations for improving IMGs' understanding of psychosocial aspects of patient care; and specific challenges residents face as IMGs. Conclusions The narrative data suggested several possible modifications to the family medicine curriculum, including expanding new resident orientation content about U.S. health care, introducing behavioral science content sooner, and having IMGs observe quality physician-patient interactions. Interview data also yielded concrete suggestions for improving residents' psychiatric interview knowledge and skills, such as instruction in specific wording of questions.

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