Signalising psychosocial problems in cancer care :the structural use of a short psychosocial checklist during medical or nursing visits

OBJECTIVE

In this summary of literature, we evaluated 16 studies with respect to recognition and screening for psychosocial problems of cancer patients during nursing or medical visits, and with respect to the effects of providing quality of life information during these visits.

METHODS

A review of the literature was conducted. To obtain the relevant literature, a search was made of two databases: Medline and Nursing and Allied Health Literature. The literature from the last 12 years - from 1993 till 2004 - was selected.

RESULTS

The results show that in a number of studies a gap is demonstrated between the presence of cancer patients' psychosocial problems and health care providers' ability to signalise these problems adequately. The outcomes of these studies further show that the use of a psychosocial checklist is helpful in screening and communicating psychosocial problems, and that supplying information about quality of life facilitates provider-patient communication about these issues.

CONCLUSION

None of the studies, however, provides extensive insight into the feasibility of a psychosocial checklist in daily oncology practice. Implementation projects have to be conducted focussing on conditions that block or facilitate the use of a psychosocial checklist in daily practice.

PRACTICE IMPLICATIONS

By monitoring blocking and facilitating conditions strictly and, if necessary, by adjusting them, we can create guidelines to make the use of a psychosocial checklist feasible.

Psychosocial factors and the course of cervical intra-epithelial neoplasia: a prospective study

OBJECTIVE

To investigate the influence of psychosocial factors on the course of cervical intra-epithelial neoplasia (CIN).

METHODS

A group of 93 patients with CIN 1 or 2 was followed for 2.25 years by half-yearly colposcopy and cytology. Negatively-rated life events, social support, and coping style were studied in relation to distress during follow-up and in relation to time till progression and regression of CIN. Human papillomavirus (HPV) infection was controlled for as well as sick role bias caused by suspicion of having cervical cancer and distress due to the abnormal cervical smear.

RESULTS

During follow-up, progression was found in 20 patients (22%), stable disease in 22 patients (24%), and regression in 51 patients (55%). Negatively-rated life events and lack of social support predicted distress longitudinally. No association was found between progression or regression of CIN and negatively-rated life events, lack of social support, coping style, and distress.

CONCLUSION

We found no evidence that psychosocial factors influence the course of CIN.

[Dutch Institute for Healthcare Improvement guideline, "Treatment of breast cancer"]

The first Dutch evidence-based guideline for the treatment of breast cancer has been developed to realise the optimal care of breast cancer patients in the Netherlands. This was possible due to the close cooperation of the Dutch Institute for Healthcare Improvement [Dutch acronym: CBO] and the Dutch Consultative Committee on Breast Cancer [Dutch acronym: NABON]. A broad, multidisciplinary working group was appointed to develop the guideline. This group consisted of surgeons, radiotherapists, internists, pathologists, a radiologist, a nuclear medicine specialist, a plastic surgeon and a clinical geneticist, all of whom had been given a mandate to represent their respective professional societies. In addition to these medical specialists, there were physiotherapists, oncology nurses, psychologists, staff from comprehensive cancer centres and the Dutch Institute for Healthcare Improvement and representatives from the Dutch Breast Cancer Association. This CBO guideline is divided into seven chapters: local treatment of operable breast cancer, systemic adjuvant treatment, locoregionally advanced disease, follow-up, locoregional recurrence, metastasised disease, and the psychosocial aspects of breast cancer. Although the guideline is not intended as a set of instructions that must be rigidly adhered to, deviations from the guideline must be motivated, principally on the basis of published scientific information. To obtain insight into the actual use of the guidelines 'Screening and diagnostics' and 'Treatment of breast cancer' the work group advocates a nationwide prospective registration of all breast cancer patients, including follow-up. Steps to this end have been undertaken. In this way, the CBO guideline will contribute to a further optimisation of breast cancer care in the Netherlands.

Psychological functioning of recently bereaved, middle-aged women: the first 13 months

This study examined the natural course of psychological functioning in recently bereaved middle-aged women. 69 widows were assessed four times (T1-T4) between the period of 4 to 13 mo. after the loss and were compared to a matched nonwidowed group of 57. Of the SCL-90 feelings of depression, agoraphobic behavior, anxiety, hostility, somatization, feelings of insufficiency, and sleep disorders were heightened at 4 mo. after bereavement compared to the norm group. Significantly higher psychological dysfunctioning was found on all SCL-90 subscales than for non-widows. Over time, a decrease in psychological dysfunction was found for most widows; however, not every widow appeared to recover psychologically, and 17% of the widows showed severe psychological dysfunctioning at 13 mo. postbereavement (T4). With respect to the predictive value of the Total score on the SCL-90, at 13 mo., 27% of these widows had scores indicating severe psychological dysfunctioning; these were comparable to their scores at 4 mo. postbereavement.

On the role of immunological factors as mediators between psychosocial factors and cancer progression

Thirty-eight prospective studies on the role of psychological factors in cancer initiation and progression are reviewed. Despite the availability of many prospective studies, there is no certainty about the role of any specific factor. An important reason might be that the interactions among several psychological factors, and the interactions of psychological and biomedical risk factors, have rarely been studied. Some evidence has been found that a low level of social support, a tendency towards helplessness, and repression of negative emotions are factors that promote cancer progression. The effect of psychological factors has been more convincingly demonstrated with respect to cancer progression than cancer initiation, and more convincingly in intervention than in natural history studies. Possible mechanisms mediating associations between psychological factors and disease outcome are discussed. The role of immunosurveillance seems modest overall, and alternative pathways are suggested.

The immunological and psychological effects of bereavement: does grief counseling really make a difference? A pilot study

This study evaluates psychological and immunological functioning after bereavement and the influence of group counseling. Eighteen widows (bereaved within 3 months of enrolment) and a reference group of 10 married control subjects were asked to fill in self-report scales and to donate a blood sample (T1). After T1, half of the widows (the experimental group) were randomly assigned to grief counseling (13 sessions over 4 months), while the other subjects (the control group) received no treatment. Seven months after bereavement (T2) or, in the case of the experimental group, immediately after the intervention, a follow-up was conducted in the widowed subsample using the same measures. Blood samples were analyzed to determine the total number of white blood cells, number of lymphocyte subsets, natural killer cell activity (NKCA) and lymphocyte proliferative response to phytohemagglutinin (PHA), anti-CD3 and pokeweed mitogen (PWM). At T1, we found significant differences between widows and non-widows regarding both psychological and immunological measures. Widows felt more anxious, depressed, hostile and agoraphobic. At T1, widows had a lower number of the CD19+CD5+ B cell subpopulation. The cell function tests for T and B cells showed higher responses in widows (lymphocyte proliferation response to PHA, anti-CD3 and PWM). No significant difference in NKCA was found between widows and non-widows. At T2, there appeared to be no significant difference between widows and non-widows on the psychological measures. With respect to the immunological measures, widows and non-widows showed no significant differences for the total number of white blood cells, number of lymphocyte subsets and NKCA. Consistent with our findings at T1, the lymphocyte proliferation response to PHA, anti-CD3 and PWM at T2 appeared to be higher in widows than in non-widows. Comparing the experimental group (widows) and the control group (widows) with respect to psychological measures at T1, widows in the experimental group felt more insufficient and had more sleep disturbances. With respect to the immunological measures, no differences were found between those two groups. When the same two groups were again compared at T2, no differences were found in any of the psychological or immunological measures (lymphocyte sub-populations, proliferation tests and the NKCA).

Fatigue and radiotherapy: (A) experience in patients undergoing treatment

Cancer patients undergoing radiotherapy frequently report fatigue. However, knowledge of the importance of fatigue for these patients and of the factors associated with their fatigue is limited. The aim of the current investigation was to gain more insight into fatigue as related to radiotherapy by answering the following questions. First, how is the experience of fatigue best described? Secondly, to what extent is fatigue related to sociodemographic, medical (including treatment), physical and psychological factors? Finally, is it possible to predict which patients will suffer from fatigue after completion of radiotherapy? Patients with different types of cancer receiving radiotherapy with curative intent (n = 250) were interviewed before and within 2 weeks of completion of radiotherapy. During treatment, patients rated their fatigue at 2-weekly intervals. Results indicate a gradual increase in fatigue over the period of radiotherapy and a decrease after completion of treatment. Fatigue scores obtained after radiotherapy were only slightly, although significantly, higher than pretreatment scores. After treatment, 46% of the patients reported fatigue among the three symptoms that caused them most distress. Significant associations were found between post-treatment fatigue and diagnosis, physical distress, functional disability, quality of sleep, psychological distress and depression. No association was found between fatigue and treatment or personality characteristics. Multivariate regression analysis demonstrated that the intensity of pretreatment fatigue was the best predictor of fatigue after treatment. In view of this finding, a regression analysis was performed to gain more insight into the variables predicting pretreatment fatigue. The degree of functional disability and impaired quality of sleep were found to explain 38% of the variance in fatigue before starting radiotherapy. Fatigue in disease-free patients 9 months after treatment is described in paper (B) in this issue.

Fatigue and radiotherapy: (B) experience in patients 9 months following treatment

Little is known regarding the prevalence and course of fatigue in cancer patients after treatment has ended and no recurrence found. The present study examines fatigue in disease-free cancer patients after being treated with radiotherapy (n = 154). The following questions are addressed. First, how do patients describe their fatigue 9 months after radiotherapy and is this different from fatigue in a nonselective sample from the general population (n = 139)? Secondly, to what degree is fatigue in patients associated with sociodemographic, medical, physical and psychological factors? Finally, is it possible to predict which patients will suffer from fatigue 9 months after radiotherapy? Results indicated that fatigue in disease-free cancer patients did not differ significantly from fatigue in the general population. However, for 34% of the patients, fatigue following treatment was worse than anticipated, 39% listed fatigue as one of the three symptoms causing them most distress, 26% of patients worried about their fatigue and patients' overall quality of life was negatively related to fatigue (r = -0.46). Fatigue in disease-free patients was significantly associated with: gender, physical distress, pain rating, sleep quality, functional disability, psychological distress and depression, but not with medical (diagnosis, prognosis, co-morbidity) or treatment-related (target area, total radiation dose, fractionation) variables. The degree of fatigue, functional disability and pain before radiotherapy were the best predictors of fatigue at 9-month follow-up, explaining 30%, 3% and 4% of the variance respectively. These findings are in line with the associations found with fatigue during treatment as reported in the preceding paper in this issue. The significant associations between fatigue and both psychological and physical variables demonstrate the complex aetiology of this symptom in patients and point out the necessity of a multidisciplinary approach for its treatment.

Understanding the level of fatigue in cancer patients undergoing radiotherapy

This study tests the hypothesis that a discrepancy between resources and demands explains most of the variance in fatigue in cancer patients undergoing radiotherapy. Patients (n=250) were interviewed at pretreatment, posttreatment, and at 9-month follow-up. Resources involved physical condition, neuroticism, optimism, social support, gender, age, and level of education. Demands entailed prognosis, radiotherapy dose, the effort associated with actual activity, and the patient's perception of overall burden. Regression analyses were performed, using interaction terms to operationalize the discrepancy between resources and demands. The hypothesis was not supported. At pretreatment, physical condition explained most of the fatigue, whereas, at posttreatment, both the patients' physical condition and perception of burden contributed to fatigue. At follow-up, demands did not add to the variance already explained by resources, and vice versa. Factors that contribute to the patient's physical condition before starting radiotherapy and to his/her perception of burden need to be addressed to further our understanding of their fatigue.

Workshops to support the bereavement process

When a bereaved person is in need of extra support during the bereavement process, at present four types of support can be distinguished: professional individual- and group counseling and non-professional individual- and group counseling. In this article another support facility is proposed: the workshop. It is indicated that the workshop can be considered as a valuable addition to the current counseling alternatives for bereavement and can possibly prevent more serious bereavement problems. After an explanation of bereavement counseling, the set-up of the workshop is described. Special attention is payed to the group dynamic aspects of the workshop.

Effects of a nursing pain programme on patient outcomes

The effectiveness of a continuing pain education program, directed to surgical cancer nurses, was investigated in a pretest posttest controlled intervention study. ANCOVA for repeated measures revealed that the programme resulted in a lower pain intensity of surgical colon and breast cancer patients (p = 0.02). However, no effects were found on pain duration, sleepless hours as a result of pain, state anxiety, mood disturbances, and duration of hospitalization. It is assumed that because the pain CE programme had a moderate impact on pain intensity, this had no consequences for the other outcome variables mentioned.

['Abbreviated fatigue questionnaire': a practical tool in the classification of fatigue]

The 'Shortened fatigue questionnaire' (SFQ) is a short, reliable and easily used instrument to determine the intensity of the patient's bodily fatigue. It consists of four questions which the patient answers by checking an item at a 7-point scale ('I feel tired', 'I tire easily', 'I feel fit' and 'I feel physically exhausted'). The physician can then calculate a total score and compare it with the score in standard groups (standardized by load-bearing). The questionnaire can be completed simply and quickly. It constitutes a valuable addition in daily medical practice and in clinical scientific studies for the assessment of fatigue complaints.

Phase II study of psychotherapeutic intervention in advanced cancer

The effect of psychosocial counseling on tumor progression was studied in 96 cancer patients, who were no longer amenable to regular medical treatment. Patients were offered 12 session of individual experiential-existential counseling, each sessions lasting 1.5 to 2 hours. In addition patients participated fortnightly in group counseling meetings. In five out of 35 evaluable patients, tumor growth became stationary during or immediately following therapy. In four patients this stationary period last 3-9 months, and in one patient 2 years. Natural Killer cell activity, self-reported loneliness, depression, purpose in life and locus of control showed no change from pre- to post intervention.

Hyperventilation syndrome: an elegant but scientifically untenable concept

The concept of hyperventilation and the principle of a vicious circle provide an elegant explanation for the development of a wide range of somatic and psychological symptoms, the so-called hyperventilation syndrome (HVS). The model has a high degree of credibility and has led to the development of therapeutic interventions that appeared beneficial. However, recent investigations dismiss hyperventilation as an important symptom-producing mechanism. First, the hyperventilation provocation test appears to be invalid as a diagnostic test. Second, studies using ambulant monitoring of pCO2 demonstrate that the vast majority of real-life attacks are not attended by decreases in pCO2. Third, the evaluation of therapy outcome studies indicate that the beneficial effect of breathing retraining is probably not mediated by reducing the tendency to hyperventilate. We conclude that a diagnosis of HVS should be avoided.

The low specificity of the Hyperventilation Provocation Test

The Hyperventilation Provocation Test (HVPT) has become a routine procedure in the diagnosis of hyperventilation syndrome (HVS). During an HVPT the patient voluntarily overbreathes for several minutes to produce hypocapnia. The test is considered positive if the induced symptoms are recognized by the patient as similar to those experienced in daily life. The present study tests the assumption that hypocapnia is the primary trigger for symptoms during an HVPT. In a randomized double-blind crossover design. 115 patients suspected of HVS and 40 healthy controls performed an HVPT and a placebo test (PT, isocapnic overbreathing). The HVPT induced more symptoms than the PT, especially more neuromuscular symptoms, cerebral symptoms, paresthesias, and temperature sensations. However, the absolute difference between the number of symptoms induced by the HVPT and PT was small. In patients, the PT induced 66% of symptoms induced by the HVPT. In the control group this percentage was 60%. The low specificity of the HVPT implies that symptom recognition during the HVPT is invalid as a diagnostic criterion for HVS.

Continuing pain education in nursing: a literature review

Twelve studies on the effects of pain programmes for nurses were reviewed. Most of the programmes focused on aspects of pain, pain medication or pain assessment. Only two programmes (Ferrell et al., 1993, J. Pain Symptom Management, Vol. 8, No. 8, pp. 549-556; Sofaer, 1983, Nurs. Times, Vol. 79, No. 47, pp. 38-42; 1984, Ph.D. Thesis, University of Edinburgh) also paid attention to non-pharmacological nursing interventions. Randomized control groups, established measurement instruments, testing statistics, and long-term follow-up measurements, were not often used in the effect evaluation of the programmes. Effects reported on both nurses and patients were for the most part positive. Given the small number of studies and their methodological limitations, further research into the effectiveness of continuing pain education in nursing is indicated.

Double-blind placebo-controlled study of the hyperventilation provocation test and the validity of the hyperventilation syndrome

BACKGROUND

Hyperventilation syndrome (HVS) describes a set of somatic and psychological symptoms thought to result from episodic or chronic hyperventilation. Recognition of symptoms during the hyperventilation provocation test (HVPT) is the most widely used criterion for diagnosis of HVS. We have investigated the validity of the HVPT and of the concept of HVS.

METHODS

In a randomised, double-blind, crossover design, the ability of 115 patients with suspected HVS to recognise symptoms during the HVPT was compared with the ability to recognise symptoms during a placebo test (isocapnic overbreathing, with carbon dioxide levels maintained by manual titration). 30 patients who had positive results on the HVPT underwent ambulatory transcutaneous monitoring of pCO2 to ascertain whether they hyperventilated during spontaneous symptom attacks.

FINDINGS

Of the 115 patients who underwent the HVPT and the placebo test, 85 (74%) reported symptom recognition during the HVPT (positive diagnosis HVS). Of that subset, 56 were also positive on the placebo test (false-positive), and 29 were negative on the placebo test (true-positive). False-positive and true-positive patients did not differ in symptom profile or in physiological variables. During ambulatory monitoring (15 true-positive, 15 false-positive) 22 attacks were registered. Transcutaneous end-tidal, pCO2 decreased during only seven. The decreases were slight and apparently followed the onset of the attack, which suggests that hyperventilation is a consequence rather than a cause of the attack. There were no apparent differences between false-positive and true-positive patients.

INTERPRETATION

The HVPT is invalid as a diagnostic test for HVS. Hyperventilation seems a negligible factor in the experience of spontaneous symptoms. The term HVS should be avoided.

Effects of a pain programme on nurses' psychosocial, physical and relaxation interventions

The effectiveness of a continuing education programme on pain assessment and management was investigated in 106 surgical cancer nurses. It was found that the programme led to a more positive attitude towards physical and relaxation interventions (such as the use of relaxation, distraction and massage techniques). In addition, an increase in the duration and quality of psychosocial interventions (provision of information, emotional support, and promotion of autonomy) was established. Furthermore, the programme resulted in an increase in the quality of physical and relaxation interventions. However, the programme did not lead to more positive attitudes towards psychosocial interventions, or to increases in the numbers of psychosocial, physical and relaxation interventions.

Adjustment to breast cancer: the psychobiological effects of psychosocial interventions

This review focuses on the effects of psychosocial interventions on psychological and biological functioning of breast cancer patients. Once in their lifetime, one out of eleven women receive a diagnosis of breast cancer. A diagnosis of breast cancer is a severe stressful life event with profound consequences on all aspects of human life. Whether a woman will regain emotional balance and accept the idea of living with a potentially life threatening disease depends on her psychological resiliency. Provision of psychosocial interventions can improve these women's coping abilities and reduce emotional distress and feelings of isolation, and improve psychosexual functioning. Additionally, there exists some evidence that psychotherapy may prolong survival. Prolongation of survival may be related, in part, to an increase in certain aspects of immune function (e.g., natural killer cell activity). This is plausible because the function of the immune system seems to be related to mammary tumor growth. Therefore, future research should examine the degree to which the effects on mammary tumor growth relate to immune system changes.

Hyperventilation and panic attacks

OBJECTIVE

Hyperventilation has been posed as an important symptom-producing mechanism in panic attacks. Some arguments and experimental findings, such as the possibility of inducing panic symptoms by voluntary hyperventilation in panic disorder patients, seem to favor this suggestion. This study was undertaken to clarify the role of hyperventilation in panic disorder. Long-term ambulatory measurement of transcutaneous arterial CO2 pressure (PCO2) offers an opportunity to test directly the co-occurrence of panic and hyperventilation under natural conditions.

METHOD

Transcutaneous PCO2 was measured during three to four sessions of approximately 7 hours each in 28 panic disorder patients. Patients were instructed to expose themselves to fear-provoking situations and to press a button as soon as they experienced panic. One-half of the patients experienced one or more panic attacks during these sessions.

RESULTS

A decrease in PCO2 was observed during only one of the 24 registered panic attacks that lasted at least 3 minutes. Even during this particular attack, the degree of hyperventilation was not impressive.

CONCLUSIONS

These findings indicate that the hypothesis that hyperventilation is an important symptom-producing mechanism in panic may be dismissed.

Application of the multidimensional fatigue inventory (MFI-20) in cancer patients receiving radiotherapy

In this paper the psychometric properties of the multidimensional fatigue inventory (MFI-20) are established further in cancer patients. The MFI is a 20-item self-report instrument designed to measure fatigue. It covers the following dimensions: general fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue. The instrument was used in a Dutch and Scottish sample of cancer patients receiving radiotherapy. The dimensional structure was assessed using confirmatory factor analyses (Lisrel's unweighted least-squares method). The hypothesised five-factor model appeared to fit the data in both samples (adjusted goodness of fit; AGFI: 0.97 and 0.98). Internal consistency of the separate scales was good in both the Dutch and Scottish samples with Cronbach's alpha coefficients ranging from 0.79 to 0.93. Construct validity was assessed by correlating the MFI-20 to activities of daily living, anxiety and depression. Significant relations were assumed. Convergent validity was investigated by correlating the MFI scales with a visual analogue scale measuring fatigue and with a fatigue-scale derived from the Rotterdam Symptom Checklist. Results support the validity of the MFI-20. The highly similar results in the Dutch and Scottish sample suggest that the portrayal of fatigue using the MFI-20 is quite robust.

Qualitative Needs Assessment Prior to a Continuing Education Program

The usefulness of qualitative research is illustrated by the presentation of a needs assessment among Dutch surgical cancer nurses and patients. Participant observations and qualitative interviews showed that nurses usually did not assess pain systematically, gave insufficient pain medication, were unaware of the effectiveness of some nonpharmacological techniques, and often felt powerless in giving psychosocial support. Patients appeared inhibited in expressing pain and inhibition was reinforced by ineffective interactions with nurses. using these findings, a continuing education program on pain assessment and management was developed.

Voluntary hyperventilation: the influence of duration and depth on the development of symptoms

Hyperventilation is considered an important factor in the development of somatic symptoms or even panic attacks, though its role has recently been disputed. Arguments are often based on findings from the so-called Hyperventilation Provocation Test (HVPT), which is a procedure consisting of voluntarily overbreathing. The HVPT has been widely used for diagnosing Hyperventilation Syndrome and for experimentally eliciting panic attacks. Almost no attention, however, has been paid to standardizing the test and determining critical values with respect to depth and duration of hyperventilation. In the present study, symptom development was examined in 16 healthy subjects who underwent four HVPTs that differed in depth of hyperventilation (end-tidal PCO2 < 2.4 kPa or < 1.9 kPa), as well as duration of hyperventilation (2 or 5 min). Both depth and duration appeared to have an independent effect on the development of symptoms. In the 5-min condition, symptoms appeared mainly within the first 3 min. To be sure that the HVPT is long enough and deep enough to elicit symptoms in most people, a minimum duration of 3 min is advised, with end-tidal PCO2 decreasing to at least 1.9 kPa or dropping well over 50% of baseline.

Effects of high and low anxiety provoking instructions on the responses to the hyperventilation provocation test

This study examined the effect of high and low anxiety provoking instructions in subjects submitted to a Hyperventilation Provocation Test (HVPT). Subjects were 43 out-patients referred to our clinic for a diagnostic examination of Hyperventilation Syndrome (HVS). Results showed that anxiety levels were affected by the instruction manipulation, but the magnitude of this effect was less than expected and the instruction manipulation had no effect on intensity arid type of reproduced symptoms, nor on symptom recognition. Subjects who met Diagnostic and Statistical manual of Mental Disorders (3rd ed., rev,; American Psychiatric Association, 1987) criteria for Panic Disorder (PD) were not more responsive to the instruction manipulation than non-PD patients. It is argued that the small effect of the manipulation is probably not due to the solidity of the HVPT but to the pervasiveness of pretest cognitions and expectations. In line with this, the report of HVS symptoms appeared highly related to psychological trait measures like anxiety, fear of bodily sensations, and a general tendency to report somatic symptoms.

The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue

The Multidimensional Fatigue Inventory (MFI) is a 20-item self-report instrument designed to measure fatigue. It covers the following dimensions: General Fatigue, Physical Fatigue, Mental Fatigue, Reduced Motivation and Reduced Activity. This new instrument was tested for its psychometric properties in cancer patients receiving radiotherapy, patients with the chronic fatigue syndrome, psychology students, medical students, army recruits and junior physicians. We determined the dimensional structure using confirmatory factor analyses (LISREL's unweighted least squares method). The hypothesized five-factor model appeared to fit the data in all samples tested (AGFIs > 0.93). The instrument was found to have good internal consistency, with an average Cronbach's alpha coefficient of 0.84. Construct validity was established after comparisons between and within groups, assuming differences in fatigue based on differences in circumstances and/or activity level. Convergent validity was investigated by correlating the MFI-scales with a Visual Analogue Scale measuring fatigue (0.22 < r < 0.78). Results, by and large, support the validity of the MFI.

Determinants of changes in nurses' behaviour after continuing education: a literature review

Nursing continuing-education programmes may differ in the extent to which they affect nursing practice. Differences may be explained by characteristics of the participants' background, the programme itself, teacher(s), relationship between participants, relationship between participants and teacher(s), physical environment during the programme, participants' social system, knowledge, skills and attitudes, and intention to change. In this literature review, a model is presented which integrates these variables and which may be used to explain why continuing-education programmes have no, little or considerable effect. On the basis of current scientific knowledge, colleagues' and superiors' support emerges as the most important determinant of behavioural changes in nursing practice.

Continuous monitoring of panic

Data on naturally occurring panic attacks were gathered through continuous self-monitoring for 94 patients suffering from panic disorder with agoraphobia. A total of 1276 panic attacks were collected. In this article various aspects of panic attacks, including severity, duration and time of onset and situations in which panic occurs are addressed. In addition, the symptoms of panic were investigated, examining the (in)variability of attacks within each patient and the patterning of symptoms in the entire group of patients. The most important findings were as follows: attacks occurred predominantly in nonphobic situations; nocturnal panic attacks were generally more severe than attacks during the day; symptom patterns across various attacks, stemming from the same patient, were rather variable; and finally, a substantial number of the attacks (40%) did not meet the DSM-III-R criteria for number of symptoms.

[When is continuing education useful? A literature analysis of determinants for behavioral change in nurses who finished continuing education]

Nursing continuing education programmes may differ in the extent in which they affect nursing practice. Differences may be explained by: background characteristics of the participant; characteristics of the programme itself; characteristics of the teacher(s); characteristics of the relationship between the participant and the teacher(s); characteristics of the relationship between the participant and the other participants; characteristics of the social system; knowledge, skills and attitudes; and intention of the participant to change behavior. In this literature review, a model is presented in which these variables are integrated and which may be used to explain why continuing education programmes have no, little or much effect. On the basis of the present scientific knowledge, support from colleagues, supervisors and administrators (a characteristic of the social environment) emerges as a very important determinant of positive behavior changes in nursing practice.

Fatigue in cancer patients

In this paper an overview is presented on what is currently known of fatigue in cancer. Fatigue is considered to be a multi-dimensional concept, that should be measured as such. However, fatigue has been assessed mostly by single items in general symptom checklists. The few specific instruments that have been used in cancer patient populations are discussed. The majority of cancer patients, about 70%, report feelings of fatigue during radio- or chemotherapy. Follow-up results show that, at least for some diagnoses, patients remain fatigued long after treatment has ended. Somatic and psychological mechanisms that have been proposed to explain fatigue are discussed. It is argued that the significance of the results obtained on fatigue as a symptom in cancer depends on comparison with other patient and non-patient populations. Also the occurrence of a response-shift has to be considered, leading to under reporting of fatigue. Finally, possible interventions to decrease feelings of fatigue are presented.

The role of hyperventilation in panic disorder: a response to Ley (1991)

Ley (Behaviour Research and Therapy, 29, 301-304, 1991) provided a reinterpretation of experimental findings on the efficacy of breathing retraining plus cognitive restructuring in reducing the symptomatology of patients with panic disorder with agoraphobia which were presented in a 1989 article in this journal. On the basis of his reinterpretation, they concluded that our findings supported the central role of hyperventilation in panic attacks. Ley's arguments are discussed and we conclude that his reinterpretation provides new arguments against a hyperventilation theory of panic. Furthermore, recent evidence from empirical studies does not support a central role for hyperventilation in panic attacks.

A follow-up study on short-term treatment of agoraphobia

The differential effectiveness of three treatment packages for agoraphobia was tested. Patients received one of three short-term treatments: Breathing Retraining and Cognitive Restructuring, graded Self-Exposure in vivo, or a combination of both. No differential effects were found between the treatment conditions at posttest and at an 18 months follow-up. Improvement at follow-up assessment was associated with whether patients had further treatment during the follow-up period. No relationship was found between further improvement and demographic variables, pre- and posttest scores on psychological questionnaires or the use of medication at follow-up. Implications of these findings are examined.

[Criteria for differential diagnosis in cardial symptoms; left- or right-sided chest pain?]

We studied the localization of pain in the acute phase of myocardial infarction in comparison with localization in non-cardiac chest pain. Myocardial infarction patients could not be differentiated from patients with non-cardiac chest pain in localization of pain on mid-chest, left side of the chest and left arm. However, myocardial infarction patients reported pain on the right side of the chest and in the right arm twice as often as non-cardiac chest pain patients. Results are similar when patients indicated the localization of the pain symptoms on attending the Emergency Coronary Care Unit, or when asked five days later. Pain symptoms on the right side of the chest and the right arm differentiate better between myocardial infarction and non-cardiac chest pain than the 'classical' symptom pattern.

Symptom reporting during voluntary hyperventilation and mental load: implications for diagnosing hyperventilation syndrome

Hyperventilation is considered an important factor in the production of a variety of somatic symptoms. This complex of symptoms is called the Hyperventilation Syndrome (HVS). Recognition of symptoms during the hyperventilation provocation test (HVPT) is a widely used criterion for diagnosing HVS. The validity of this criterion is tested in the present study. Twenty-three patients suspected of HVS performed a HVPT (hyperventilation during 3 min) and a mental load task (Stroop Color Word Test; CWT). It appeared that about the same number of patients (61%) recognized symptoms during the HVPT as during the CWT (52%), despite severe hypocapnia in the first test and normocapnia in the second. Reporting of symptoms was significantly related to psychological state and trait measures (SCL-90 and STAI scores) and unrelated to the degree of hypocapnia. These data have far reaching consequences, as they not only undermine the validity of the HVPT, but also question the tenability of the concept of HVS.

The hyperventilation syndrome in panic disorder, agoraphobia and generalized anxiety disorder

The symptom complex of panic disorder and generalized anxiety disorder suggests an etiological role for hyperventilation. The present study investigates the overlap between DSM-III-R panic disorder, panic disorder with agoraphobia and generalized anxiety disorder with hyperventilation syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS determined by the so-called hyperventilation provocation test (a brief period of voluntary hyperventilation with recognition of symptoms). The overlap rates with HVS were: 48% for panic disorder, 83% for panic disorder with agoraphobia and 82% for generalized anxiety disorder. However, a pilot study on transcutaneous monitoring of carbon dioxide tension leads us to question the validity of the voluntary hyperventilation method that we used to determine HVS-status. It is unclear whether hyperventilation plays an important role in panic and general anxiety, as our overlap findings suggest. For patients who recognize the symptoms induced by voluntary hyperventilation, the hyperventilation provocation procedure provides a therapeutic means of exposure to feared bodily sensations.

Breathing retraining, exposure and a combination of both, in the treatment of panic disorder with agoraphobia

The present study investigates the differential effectiveness of three treatment packages for agoraphobia. Patients suffering from panic disorder with agoraphobia (DSM-III-R) received one of three treatments: Breathing Retraining with Cognitive Restructuring (BRCR), graded self-exposure in vivo (EXP), or a combination of BRCR and EXP. Treatments consisted of 8 sessions. Assessment consisted of self-report measures for panic, phobic anxiety and avoidance, depression, general anxiety, somatic complaints and fear of body sensations, and of two respiratory measures (respiratory rate and alveolar pCO2). The treatments resulted in a reduction in symptomatology on all self-report measures, except panic frequency, and in a decrease in respiratory rate. There was no evidence for a differential efficacy for any of the treatments on any of the variables. Contrary to expectation, and at odds with findings from earlier studies, BRCR had no significant effect on panic frequency. A detailed comparison of sample characteristics of patients in our study and previous studies, did not yield insight into possible causes for the failure to replicate earlier results. The limited effectiveness of breathing retraining in reducing panic, as observed in the present study, leads us to conclude that the role of hyperventilation in panic is less important than previously thought.