Traumatic stress, mental health, and quality of life in adolescents with esophageal atresia

INTRODUCTION

We aimed to investigate QoL in EA patients in relation to comparison groups and to clinical factors including experienced traumatic stress.

MATERIAL AND METHODS

Adolescents with EA in Norway born between 1996 and 2002 were included. Clinical assessment and patient's characteristics were collected. Quality of life (PedsQL), traumatic stress (IES-13) and mental health (SDQ-20) were compared to groups of healthy controls, children with acute lymphoblastic leukemia (ALL) and kidney transplanted children (TX).

RESULTS

68 EA adolescents participated. Total scores for PedsQL were not different from the healthy group and ALL patients, but significantly better than the TX patients. The subscale for physical performance was significantly lower than in healthy adolescents, and nine (17%) patients had scores ≤70 indicating reduced health status. Five EA adolescents (12%) had mental health scores suggesting a psychiatric disorder, and six (9%) reported high traumatic stress scores with a significant correlation to days on ventilator in the neonatal period. The strongest predictors for quality of life among EA adolescents were self-reported mental health, posttraumatic stress and GERD symptoms.

CONCLUSION

Scores for Quality of life in the EA group are good except for subscale for physical performance. Symptoms of posttraumatic stress, mental strain and gastroesophageal reflux are predictors of reduced QoL.

Psychologic Distress and Anxiety in Mothers of Children With Gastroesophageal Reflux Undergoing Antireflux Surgery

OBJECTIVES

Parents of children with a chronic illness are at risk for impaired psychosocial functioning. Gastroesophageal reflux disease (GERD) is such a disease, and no studies have investigated effects of antireflux surgery on parental psychological distress. The aims of this study were to assess psychological distress and state and trait anxiety in mothers of children with GERD, and to explore possible changes after antireflux surgery.

METHODS

Mothers of children referred for antireflux surgery were included in this prospective study. Standardized questionnaires were used to evaluate psychological distress and state and trait anxiety before and 12 months after antireflux surgery.

RESULTS

Of 87 eligible mothers of children with GERD, 62 (71%) agreed to participate. All children had objectively verified GERD by 24-hour pH-monitoring and/or upper gastrointestinal contrast study and unsatisfactory symptom relief of pharmacological treatment. Thirty-one (50%) mothers returned questionnaires postoperatively. Preoperatively, mothers of children undergoing antireflux surgery reported high levels of psychological distress and state anxiety, and 54% had scores indicating clinically significant psychological distress. None of the preoperative child characteristics were found to significantly influence maternal psychological distress or state anxiety. Twelve months postoperatively, both psychological distress and state anxiety were reduced.

CONCLUSIONS

Mothers of children undergoing antireflux surgery reported reduced levels of psychological distress and state anxiety 12 months after the operation.

Core Outcome Domains for Clinical Trials on Somatic Symptom Disorder, Bodily Distress Disorder, and Functional Somatic Syndromes: European Network on Somatic Symptom Disorders Recommendations

OBJECTIVE

The harmonization of core outcome domains in clinical trials facilitates comparison and pooling of data, and simplifies the preparation and review of research projects and comparison of risks and benefits of treatments. Therefore, we provide recommendations for the core outcome domains that should be considered in clinical trials on the efficacy and effectiveness of interventions for somatic symptom disorder, bodily distress disorder, and functional somatic syndromes.

METHODS

The European Network on Somatic Symptom Disorders group of more than 20 experts in the field met twice in Hamburg to discuss issues of assessment and intervention research in somatic symptom disorder, bodily distress disorder, and functional somatic syndromes. The consensus meetings identified core outcome domains that should be considered in clinical trials evaluating treatments for somatic symptom disorder and associated functional somatic syndromes.

RESULTS

The following core domains should be considered when defining ascertainment methods in clinical trials: a) classification of somatic symptom disorder/bodily distress disorder, associated functional somatic syndromes, and comorbid mental disorders (using structured clinical interviews), duration of symptoms, medical morbidity, and prior treatments; b) location, intensity, and interference of somatic symptoms; c) associated psychobehavioral features and biological markers; d) illness consequences (quality of life, disability, health care utilization, health care costs; e) global improvement and treatment satisfaction; and f) unwanted negative effects.

CONCLUSIONS

The proposed criteria are intended to improve synergies of clinical trials and to facilitate decision making when comparing different treatment approaches. These recommendations should not result in inflexible guidelines, but increase consistency across investigations in this field.

Consultation-Liaison Psychiatry Literature Database (2003 update). Part I: Consultation - Liaison Literature Database: 2003 update and national lists

Every day there are 10,000 scientific articles published. Since the Consultation-Liaison ("C-L") psychiatrist may be asked to consult on a patient with any medical illness, e.g., severe acute respiratory syndrome (SARS), malaria, cancer, stroke, amytrophic, lateral sclerosis, and a patient who may be on any medical drug, methods need to be developed to review the recent literature and have an awareness of key and essential current findings. At the same time, teachers need to develop a current listing of seminal papers for trainees and practitioners of this newest cross-over subspecialty of psychiatry-now called Psychosomatic Medicine. Experts selected because of their writings and acknowledged contributions to a specific clinical area or problem hope examined thousands of citations to choose those articles, chapters, books, or letters that they regard as most important to Psychosomatic Medicine. In addition, psychiatric specialists in six countries have provided their national Psychosomatic Medicine (Consultation-Liaison) lists as examples of what they regard as the most important teaching materials journals: Australia, Brazil, Greece, Mexico, Portugal, and Taiwan. It is our belief that a cogent, international, systematic review will provide the greatest success in creating a "regionally appropriate" teaching and consultation literature database with world-wide applicability. We review our current progress on this literature database and software, the technical system and data organization involved, the approach used to populate the literature system, and ongoing development plans to bring this system to the physician via mobile technologies.

Referral pattern of neurological patients to psychiatric Consultation-Liaison Services in 33 European hospitals

The referral pattern of neurological patients to 33 European psychiatric consultation-liaison (C-L) services in the general hospital was examined. Analyses were conducted on the ECLW CS data set, which consists of 14,717 psychiatric C-L referrals made in 56 European hospitals during 1991. Psychiatric referrals of patients admitted to neurological wards were compared to referrals from other wards. Information was obtained from 33 neurological wards, consisting of 34,506 neurological admissions. Of these admissions, 839 were referred to C-L psychiatry. The median consult rate among the hospitals was 1.8%. Compared to other hospital wards, patients referred from neurology were more frequently diagnosed as suffering from somatoform (P<.01) and dissociative disorders (P<.01), and less from substance abuse (P<.01) and delirium (P<.01). Referral to C-L psychiatry from neurological wards is characterized by an underestimation of psychiatric co-morbidity and a late detection, comparable to other medical specialties. An appeal is made for a standardized referral procedure including admission screening method, detecting patients at risk for nonstandard care during their hospital admission.

[Psychosocial consequences of presymptomatic genetic testing. A retrospective study of testing for Huntington disease]

We studied the psychological impact and psychosocial consequences of direct presymptomatic testing for Huntington's disease in Norway. We interviewed 30 out of a total of 43 persons at risk for Huntington's disease who had been tested one to three years earlier, and had been through the test program, and 19 of their spouses. We also included 16 persons at risk who had decided not to take the test. 22 persons were non-carriers, and seven carriers. One had decided not to know the answer so far. 13 out of 30 answered that the risk of getting Huntington's disease had influenced choices they had made in their lives, but quite a few did not know that they were at risk before they had grown up. Six couples out of 21 had divorced after the test; only three said it happened because of the test result. The main problem for many of the persons who now know they are non-carriers is that siblings already are sick or know they will get the disease. 15 persons (50%) experienced the need for some kind of psychiatric treatment during the pre-test period, during the test procedure, or after the test. Eight persons said they had wanted a closer follow-up after the test; most of them had got a negative answer. In this study most of those at risk had adapted reasonably well to the test results. Only seven persons out of 30 were found to be carriers in our study. We therefore have reason to believe that among the 13 tested persons who declined to be involved in the study, the majority had been identified as carriers. Our findings may lend support to a hypothesis suggesting two kinds of response to being identified as carrier. According to studies of post-traumatic stress disorders, one group adjusts reasonably well. The other group responds by avoiding follow-up contact with professional teams, which suggests more psychosocial pain and distress.

The ECLW Collaborative study II: patient registration form (PRF) instrument, training and reliability. European Consultation/Liaison Work group

This paper describes the development and testing of the Patient Registration Form (PRF), a standardized instrument for the description of patients seen by consultation-liaison (C-L) psychiatrists and psychosomatists in general hospitals, the referral patterns, the C-L interventions and their outcomes. The PRF study is part of a large multi-centre. European investigation on the effectiveness of mental health service delivery, conducted by the European C-L Workgroup for General Hospital Psychiatry and Psychosomatics (ECLW) and performed in the framework of the of the E.C. 4th Medical and Health Research Program. The final version of the PRF consists of 68 items. It was developed by the Program Management Group (PMG) and National Coordinators (NC) after long preparatory studies to assure both face and content validity and pilot testing. Two hundred and twenty consultants, who required 40 hours of training and came from 14 different European countries and 90 different sites, participated in the final reliability study. The PRF was tested in 13 written case histories. A "gold standard' for the correct answers in each item was decided by "consensus ratings' of the PMG and a subsequent 80% agreement by the NCs. A high standard (average kappa (k) > or = 0.70; at least 2/3 of the PRF items, kappa > or = 0.70) was required for the rater to be considered as "reliable' (RR). The consultants considered the PRF both "feasible' and 93.2% of them fulfilled the RR criteria. The calculated rater-"gold standard' reliability was satisfactory: only four PRF items were identified with low agreement coefficients and no biases were observed cross-nationally in the ratings. Given the implications of misclassification for evaluating C-L effectiveness and services, these results are important and the achievement unprecedented.

[Psychosocial aspects in presymptomatic testing for genetic diseases. Experiences after 2 years of counseling in Huntington disease]

The authors describe their experience from the psychiatric assessment and psychosocial counselling of 28 persons who sought presymptomatic testing for Huntington's chorea. Half of the persons had lived with a disease-affected parent during childhood and early adolescence. Nine of these persons had suffered from a psychiatric disorder at least once. Of the whole sample, 32% had a psychiatric disorder at the time of the assessment. Most persons experienced major emotional distress in relation to the testing but severe psychiatric responses were not observed. Suicidal ideation in relation to the testing was most often reported by persons who had had extremely negative experiences during childhood with their own affected parent. In some persons who were found to be free of risk, the main problem was guilt owing to survival. The psychosocial and psychiatric aspects of the possibilities of gene technology in the future must be addressed more seriously.

Adverse reaction to food: assessment by double-blind placebo-controlled food challenge and clinical, psychosomatic and immunologic analysis

Double-blind placebo-controlled food challenge (DBPCFC) with food items applied in capsules was performed in a prospective study of 17 selected patients and 34 age- and sex-matched healthy controls in the interdisciplinary clinical setting. Protein immunoblotting showed no differences in antigenicity between foods in the capsules and the corresponding fresh foods. All patients reacted to one or more food substances during DBPCFC, with a doubtful reaction to placebo in 2 patients. Agreement between diet history and provocation was seen in 53 of 85 individual food challenges, 36 being positive with both examinations. In 22 (38%) of the 58 positive provocations, the reactions were not expected from the patients' histories. No reaction to food or placebo occurred in the control group. Related to diet history, sensitivity and specificity of provocation were 62 and 63%, respectively, with a positive predictive value of 78%. Allergy, previous gastroenterologic and infectious diseases among first-degree relatives, immunologic abnormalities and elevation of total IgE were significantly more common for the patients than controls. A positive skin prick test correlated well with diet history, but both prick test and food antibodies correlated poorly with DBPCFC. Assessment by the General Health Questionnaire showed a significant difference towards the controls. After 3-4 months of follow-up on an individually based diet, 11 of 15 patients reported general improvement of their condition. DBPCFC may be a valuable diagnostic test in addition to dietary history as a basis for elimination diet on food-intolerant patients. The effect of the elimination diet on the symptoms may also suggest a therapeutic effect or provocation.(ABSTRACT TRUNCATED AT 250 WORDS)

[A new teaching program in behavioral sciences in Oslo]

The Department of Behavioural Sciences in Medicine at the University of Oslo was established in 1977. The teaching programme followed the same main principles until 1992, and took place in the third and fourth terms. Since 1992, however, several changes have taken place. The teaching is now given together with medical history during ten weeks at the end of the preclinical term. Teaching practical skills in doctor-patient communication is introduced in this term, and is continued in the first clinical year. The students work together in plenary seminars on the main topics presented in the lectures. The teaching is still concentrated on four main topics: Psychobiology, medical psychology, medical sociology and the doctor-patient relationship and communication. We conclude that the changes have improved the teaching. Written evaluation by the students strongly supports this conclusion.

Psychological distress in cancer patients with advanced disease

The objective of this study is to explore the nature and extent of the cognitive behavioral response to treatment, and the accompanying anxiety and/or depression in cancer patients with advanced disease. In a multicenter study, 247 patients treated with palliative radiotherapy filled out a questionnaire before start of treatment. The questionnaire consisted of Impact of Event Scale (IES), General Health Questionnaire (GHQ-20), and two questions assessing pain intensity. Seventy percent of the patients reported a high level of psychological distress. The mean score of the patient population on the IES was 14.4 (IES intrusion) and 15.3 (IES avoidance). The mean Likert score on the GHQ-20 was 27.3. Patients with poor performance status and pain were most distressed. In order to improve patients' care and support, cases at risk must be identified. In the present population, psychological distress is related to pain and reduced performance status.

The long-term psychiatric consequences of accidental injury. A longitudinal study of 107 adults

One hundred and seven accidentally injured adults were studied while in hospital and assessed prospectively twice more in a mean period of 28 months. The patients were studied by means of taped clinical interviews, including the Comprehensive Psychopathological Rating Scale (which includes the Montgomery-Asberg Depression Rating Scale), and several self-report measures of distress (Schedule of Recent Life Events, General Health Questionnaire, Impact of Event Scale and State Anxiety Inventory) at the three assessments. The total incidence of psychiatric disorders considered to be caused by the accident during the follow-up period was 22.4%. The incidence of non-organic psychiatric disorders caused by the accident was 16.8% at the first follow-up and 9.3% at the final follow-up. Depressive disorders of different severity were most often seen. Only one patient suffered from a post-traumatic stress disorder during the follow-up, and none at the final follow-up (DSM-III). Organic mental disorders were diagnosed in 9.3% of the patients. In 5.6% of the patients this was the only disorder.

Psychopathology and accidental injuries

One hundred and twelve adults admitted to a surgical ward due to accidental injuries were studied. Thirty-seven percent had a psychiatric disorder on admission (DSM-III axis I) and 21% had a personality disorder (axis 2). Substance abuse and dependence and antisocial personality disorders were most frequent. Eighteen percent were definitely distressed when injured. Persons with a personality disorder were distressed significantly more often and had sustained clinically more severe injuries. No support could be found for a hypothesis of accidental injuries being the result of hidden or unconscious self-destructive tendencies, and only one patient was injured in a suicide attempt. Defense Mechanism Test applied to a subgroup of 20 patients suggested that high perceptual defense may be related to injury occurrence in patients at fault for the accident.

Five years of experience with the DSM-III system in clinical work and research: some concluding remarks

The reliability of the DSM-III is superior to other classification systems available in psychiatry. However, reliability depends on proper knowledge of the system. Some pitfalls reducing reliability of axis 1 diagnosis which commonly are overlooked are discussed. Secondly, some problems of validity of axis 1 and 2 are considered. This is done by discussing the differential diagnosis of organic mental disorders and other psychiatric disorders with concomittant physical dysfunction, and the diagnoses of post-traumatic stress disorders and adjustment disorders among others. The emphasis on health care seeking behaviour as a diagnostic criteria in the DSM-III system, may cause a social, racial and sexual bias in DSM-III diagnoses. The present discussion of the DSM-III system from a clinical point of view indicates the need for validation studies based on clinical experience with the DSM-III. These studies should include more out-patients and patients with psychopathology who do not seek psychiatric treatment. Such studies must also apply alternative diagnostic standards like the ICD-9 and not only rely on structured psychiatric interviews constructed for DSM-III diagnoses. The discussion of axis 4 points to the problem of wanting to combine reliable rating with clinically meaningful information. It is concluded that the most important issue to be settled regarding axis 4 in the future revisions is the aim of including this axis. The discussion of axis 5 concludes that axis 5 is biased toward poor functioning and thus may be less usefull when applied on patients seen outside hospitals. Despite these problems of the DSM-III, our experiences indicate that the use of the DSM-III is fruitful both for the patient, the clinician and the researcher. Thus, the cost of time and effort needed to learn to use the DSM-III properly are small compared to the benefits achieved by using the system.

A comparison of DSM-III and ICD-8 diagnoses for major affective disorders and the use of biological markers for depression

The aims of the present study were to investigate the value of adding DSM-III diagnosis and Newcastle Scale Rating to the ICD-8 diagnosis currently used and to investigate the association between Dexamethasone Suppression Test (DST) and the Thyrotropine Releasing Hormone- Thyroid Stimulating Hormone (TRH-TSH) test and the three classification systems for depression. Twenty-six depressed in-patients were included, 17 women and 9 men, with a mean age of 51.5 years. Fourteen patients were psychotic depressed. DST and Newcastle Scale Rating were performed on 18 patients and TRH-TSH test was performed on 16 patients. The addition of DSM-III diagnosis on the 4-digit level did not have any value compared to the ICD-8 diagnosis. However, DSM-III diagnosis on the 5-digit level added important clinical information which corresponded better to Newcastle Scale scores and DST and TRH-TSH test results than ICD-8 diagnosis. The main advantage of the DSM-III classification of depression on the 5-digit level compared to ICD-8 concerns depression on the border between psychosis and neurosis. In clinical practice there is a risk of underestimating the severity of a depression if ICD-8/9 is used as the only criterion for severity. This may have tragic consequences for the patient. This study suggests that rating of the depression on the Newcastle Scale or provision of a DSM-III diagnosis on the 5-digit level are valuable assessment procedures of severity.

Classification and diagnosis of depression

There is no general consensus how to classify and diagnose depressive disorders. The main reason is disagreement regarding etiology. This is reflected in the several theoretical models of depression which has been proposed. On the other hand, a reliable way of characterizing groups of patients that can be used by both clinicians and researchers, is necessary both for communication and progress of research. Facing this situation, the inclusion of etiological theories in classification of depression obviously would be an obstacle to the use of such a classification system by clinicians of various theoretical orientation at current. Thus, a classification system which describes the clinical features of the mental disorders comprehensively and at the lowest order of inference necessary to identify the disorder in a reliable way is needed. The third edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-III) represents such a classification system. By providing operational diagnostic criteria for each diagnosis, DSM-III represents a major achievement of classification in clinical psychiatry and research. This paper will present the classification of depression and the problem of differential diagnosis as outlined in DSM-III. Further, the validity of the DSM-III classification of depression will be discussed with reference to some recent research findings on biopsychosocial and treatment aspects of depressive disorders.