[Relation between neuroticism and low educational level and the risk of post-traumatic stress disorder in women after miscarriage or stillbirth]. / Verband tussen neuroticisme en laag opleidingsniveau en de kans op posttraumatische stressstoornis bij vrouwen na een miskraam of doodgeboorte.

OBJECTIVE: To determine whether neuroticism and educational level are predictive variables for post-traumatic stress disorder (PTSD) in women following an unsuccessful pregnancy. DESIGN: Prospective. METHOD: In the period June-September 1999, via advertisements in national newspapers, pregnant women with a gestation period shorter than 12 weeks were asked to participate in a study into their perception of the pregnancy. After they had agreed to participate they were given the 'Eysenck personality questionnaire' (EPQ) for neuroticism and other questionnaires, including a scale to determine their highest attained level. Every other month during the pregnancy and one month after the expected date of birth the participants were given brief questionnaires about the pregnancy, in which they were also asked to report miscarriage or stillbirth if such had occurred. Participants in whom the pregnancy had in fact ended unsuccessfully were contacted by telephone and asked to participate in a follow-up study with the 'Post-traumatic symptom scale' (PSS), among others. RESULTS: Of the 1339 women studied, 126 (9%) experienced an unsuccessful pregnancy; 8 of these dropped out of the study (response rate: 94%); one had not indicated her educational level. The remaining 117 women filled out the PSS after about one month. The average age was 31 years (SD: 4). The average duration of gestation at the moment of loss was 12 weeks (SD: 6; range 5-40). The average EPQ-score was 7.3 (SD: 4.6) and the average PSS-score was 18.1 (SD: 9.1). On the basis of the DSM IV, 31 women (26%) fulfilled the criteria for PTSS and 86 women did not. The average PSS-score was 28.2 (SD: 7.0) for the group with PTSS and 14.7 (SD: 6.7) for the group without PTSS. Logistic regression analysis revealed that a later diagnosis of PTSS was significantly associated with a higher score for neuroticism (RR = 4.49; p = 0.004; 95% CI: 1.60-12.60), a lower educational level (RR = 0.65; p = 0.009; 95% CI: 0.48-0.90) and a longer duration of gestation (RR = 2.48; p = 0.001; 95% CI: 1.45-4.25). CONCLUSION: In patients with a high educational level and a low score for neuroticism the risk of developing PTSS was negligible, while with a low educational level and a high score for neuroticism the estimated risk was about 70%. Care and guidance should be concentrated primarily on this group.

Emotion- and intrusion-based reasoning in Vietnam veterans with and without chronic posttraumatic stress disorder.

Patients suffering from anxiety disorders other than posttraumatic stress disorder (PTSD) interpret anxiety responses themselves as evidence that threat is impending: "if anxiety, then threat" (Arntz, Rauner, & van den Hout, 1995, Behaviour Research and Therapy, 33, 917-925). This "emotion-based reasoning" (ER) may render a disorder self-perpetuating. Analogous to ER, danger might also be inferred from the presence of intrusions: "intrusion-based reasoning" (IR). The aims of this study were to test whether ER and IR are involved in chronic PTSD. Vietnam combat veterans with or without PTSD or other anxiety disorders rated perceived danger of brief scenarios in which information about objective danger (danger vs safety) and response (anxiety/intrusions vs non-distressing emotion) was systematically varied. Two series were administered: ER-scenarios were non-specific for PTSD and IR-scenarios were specific for PTSD. Relative to control participants, PTSD patients engaged in both ER and IR: whereas veterans without PTSD inferred the danger of scenarios from objective stimulus information, veterans with PTSD also inferred danger from the presence of anxiety or intrusions. Further analyses showed that these effects were largely mediated by perceived uncontrollability.

Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment.

OBJECTIVE: The aim of the current study was to examine the relation between catastrophizing and pain intensity, pain-related disability, and psychological distress in a group of patients with chronic pain, controlling for the level of physical impairment. Furthermore, it was examined whether these relations are the same for three subgroups of chronic pain patients: those with chronic low back pain, those with chronic musculoskeletal pain other than low back pain, and those with miscellaneous chronic pain complaints, low back pain and musculoskeletal pain excluded. DESIGN: Correlational, cross-sectional. PATIENTS AND SETTING: Participants in this study were 211 consecutive referrals presenting to a university hospital pain management and research center, all of whom had a chronic pain problem. RESULTS: Overall, chronic pain patients who catastrophize reported more pain intensity, felt more disabled by their pain problem, and experienced more psychological distress. Regression analyses revealed that catastrophizing was a potent predictor of pain intensity, disability, and psychological distress, even when controlled for physical impairment. No fundamental differences between the three subgroups were found in this respect. Finally, it was demonstrated that there was no relation between physical impairment and catastrophizing. CONCLUSIONS: It was concluded that for different subgroups of chronic pain patients, catastrophizing plays a crucial role in the chronic pain experience, significantly contributing to the variance of pain intensity, pain-related disability, and psychological distress. These relations are not confounded by the level of physical impairment. Some clinical implications of the results are discussed. Finally, the authors concluded that these results support the validity of a cognitive-behavioral conceptualization of chronic pain-related disability.

Posttraumatic stress disorder after pregnancy loss.

This prospective longitudinal study investigated the prevalence of posttraumatic stress disorder (PTSD) in response to pregnancy loss. About 1,370 women were recruited in the early stages of pregnancy and 113 of them had a subsequent pregnancy loss. One and four months after pregnancy loss, they were assessed for PTSD with the Posttraumatic Symptom Scale. Depression was also assessed. The majority had an early loss, i.e., within 20 weeks. At one month, the prevalence of PTSD was 25%, and the symptom-severity was similar to other traumatized populations. Women with PTSD had increased risk of depression: 34% of PTSD cases and 5% of non-cases reported depression. At four months, 7% met the criteria for PTSD, of which half were chronic. In contrast, rates for depression had not declined. The results indicate that pregnancy loss is potentially traumatic, putting women at risk of developing PTSD. In most cases, the disorder is immediate and persists for several months.

A reaction time paradigm to assess (implicit) complaint-specific dysfunctional beliefs.

We investigated whether an implicit association test (IAT) can be used to assess dysfunctional beliefs in the realm of psychopathology. As a first exploration we therefore constructed a IAT that was designed to differentiate between high and low social anxious individuals. Social situation and neutral words were the targets (e.g. date vs hall), and positive and negative outcomes (e.g. compliment vs rejection) the associated attributes. High social anxious women (N=32) showed the predicted deterioration of task performance if the required responses switched from compatible to incompatible with the idea that social situations are related to negative outcomes and vice versa, whereas the opposite was true for low anxious women (N=32). Thus a modified IAT seems a useful and highly flexible tool to implicitly assess complaint-specific dysfunctional associations and may be a valuable addition to the usual (explicit) self-report measures of patients' beliefs.

Does failure hurt? The effects of failure feedback on pain report, pain tolerance and pain avoidance.

In this study an experiment was conducted to examine whether failure experiences have an effect on pain report, pain tolerance and pain avoidance. Furthermore, it was investigated if negative affectivity (NA) affected the impact of failure feedback on pain report, either as a mediator, in the case of negative state affect, or as a moderator when NA as a personality trait was considered. Fifty-four healthy female volunteers were included and randomly assigned to one of three conditions: (1) failure feedback; (2) success feedback; (3) neutral control task. After the manipulation, subjects were given a cold pressor task in order to obtain pain measures. Regarding the effects of failure feedback on pain report, it was found that, in comparison with success feedback, failure feedback led to increased pain report. With regard to pain tolerance, pain was tolerated for longer when preceded by success feedback than when preceded by failure feedback. Differences between failure and control conditions did not reach significance. With regard to pain avoidance, no differences between the conditions were found. The hypothesized mediating role of negative state affect was not found. Though in the hypothesized direction, no significant effect was found for NA-trait moderating the influence of failure on pain. The discussion focuses on a number of research questions that remain to be answered, and the clinical relevance of the effects of failure and success experiences on pain report and pain tolerance.

Counterconditioning in the treatment of spider phobia: effects on disgust, fear and valence.

From the perspective that disgust is a core feature of spider phobia, we investigated whether the treatment efficacy could be improved by adding a counterconditioning procedure. Women with a clinically diagnosed spider phobia (N = 34) were randomly assigned to the regular one-session exposure condition (EXP) or to the exposure with counterconditioning condition (CC). In the CC-condition tasty food-items were used during the regular exposure exercises and the participants' favourite music was played. Both treatment conditions appeared very effective in reducing avoidance behaviour and self-reported fear of spiders, strongly attenuated the disgusting properties of spiders and altered the affective evaluations in a positive direction. CC was not more effective in altering the affective valence of spiders than EXP and was not superior with respect to the long term treatment efficacy at 1 year follow up. Apparently, regular exposure treatment is already quite effective in altering the affective-evaluative component of spider phobia and it remains to be seen whether it is possible to further improve treatment outcome by means of procedures which are specifically designed to reduce the spiders' negative affective valence.

Masked fear words produce increased SCRs: an anomaly for Ohman's theory of pre-attentive processing in anxiety.

A. Ohman and J.J.F. Soares (1994) demonstrated that masked presentation of phobic pictures produces increased skin conductance responses (SCRs) in phobic subjects. A. Ohman (1993) explained this phenomenon in terms of a hypothetical "feature detector" that identifies physical characteristics of stimuli and activates the arousal system without involving significance evaluation or consciousness. By exposing spider phobics to spider words, general threat words, and neutral words instead of pictures, this explanation was tested. Words were presented both masked and unmasked while electrodermal activity was measured. Under unmasked conditions, SCRs were largest for spider words followed by general threat words, then neutral words. When masked, the difference between spider words and general threat words disappeared but SCRs remained significantly smaller for neutral words. It is concluded that activation of the arousal system by masked threat cues does not necessarily depend on their perceptual characteristics.

Selective attention for cardiac information in panic patients.

With various reaction time paradigms, panic patients have been shown to have selective attention for threatening sensations. However, almost all of these paradigms use words describing sensations and not the threatening sensations themselves. To increase the ecological validity, in the current study selective attention for heartbeat information was measured with a paradigm derived from the dot probe detection task but using 'real' heartbeat information instead of words. The results indeed showed selective attention for ECG information in panic patients. However, an accelerated ECG did not attract the attention of panic patients more than a slower ECG. Against expectation, both panic patients and normal controls shifted their attention away from an accelerated ECG. Possible explanations are explored.

Selective attention for hyperventilatory sensations in panic disorder.

According to cognitive theories, panic patients are assumed to display selective attention for feared bodily sensations. To date there has only been indirect evidence for this based on performance on reaction time tasks such as the modified Stroop task and the dot probe detection task. In the present study a more direct attempt was made to investigate whether panic patients show selective attention for feared sensations, in particular hyperventilatory sensations. A group of patients with panic disorder and a group of normal controls were compared on their performance on a reaction time task in which tones of different length had to be discriminated. During the task subjects were asked either to hyperventilate, to overbreathe under isocapnic conditions, or to make a neutral movement. No evidence for selective attention for hyperventilatory sensations was found. The article also discusses whether lack of finding interference during hyperventilation might be due to methodological issues.

Assessment of obsessive-compulsive disorder.

Self-report assessment devices of obsessive-compulsive symptoms are widely used by behavior therapists. In the present investigation, psychometric characteristics and concurrent, discriminant, and factorial validity of the Maudsley Obsessional Compulsive Inventory (MOCI) were studied in clinical samples. Test-retest reliability was high. The internal consistency was high for the total score and moderate for the subscales, checking and cleaning. The slowness and doubting subscales appeared to be less useful. The MOCI was found to reliably discriminate between obsessional patients on one hand and normals, patients with anorexia nervosa and anxiety disorders, on the other, but failed to discriminate obsessionals from depressives. Concurrent validity and factorial validity were satisfactory. The MOCI may be used to evaluate effects of treatment, but it is less sensitive than target ratings of obsessional problems.

The effect of paracetamol, fentanyl, and systematic assessments on children's pain after tonsillectomy and adenoidectomy.

Various clinical protocols are used to manage early postoperative tonsillectomy and/or adenoidectomy (T&A) pain in children. Although believed to be effective, these protocols are not evidenced-based. Therefore, a double-blind, randomized, placebo controlled (2 x 2) factorial design was used (1) to evaluate the effectiveness of 2 pain protocols used interchangeably to manage early postoperative T&A pain and (2) to investigate whether nurses' systematic pain assessments improve pain management. In the first protocol children receive a loading dose (30 to 50 mg/kg) of paracetamol (acetaminophen) Formularium der Nederlandse Apothekers (Formulary of the Dutch Royal Society for the Advancement of Pharmacy) intraoperatively, followed by regular doses (70 to 100 mg/kg/24 hours) of paracetamol. In the second protocol children receive the first protocol, plus intramuscular fentanyl citrate (1 microgram/kg) intraoperatively. Subjects were 83 healthy children between the ages of 3 and 12 years, admitted for T&A as an outpatient procedure. The child's pain was measured using observation scales (Children's Hospital of Eastern Ontario Pain Scale and Face Legs Activity Cry Consolability Scale), a visual analogue scale, and self-report measures (Faces Pain Scale and Oucher). Neither pain protocol sufficiently relieved early postoperative T&A pain, and systemic pain assessments did not improve the effectiveness of analgesics. Further research evaluating the effectiveness of pain management protocols is needed.

No superior perception of hyperventilatory sensations in panic disorder.

It has been argued that panic disorder patients may be more skilled at detecting changes in actual physiology than others. The present study investigated if panic patients are better than controls in perceiving sensations produced by light hyperventilation. Twelve panic patients and 28 control subjects underwent a procedure in which they were exposed 12 times to 1 min of light hyperventilation or 1 min of 'placebo' hyperventilation (isocapnia). Differences in sensations reported during real hyperventilation were compared to sensations reported during 'placebo' hyperventilation. Results demonstrated an absence of superior perception of hyperventilatory sensations in panic patients.

Are children given insufficient pain-relieving medication postoperatively?

The literature often suggests and assumes that children are under-medicated postoperatively. A review of the literature leads to the conclusion that only a few studies answer the question of whether children's pain is relieved insufficiently. The lack of consensus on expected pain intensity after surgery and caution about prescribing analgesics could explain why analgesics are often prescribed on a pro re nata (prn) basis. Prescription on a prn basis, in fact, means that the nurse makes the decision whether or not an analgesic should be administered. Some studies suggest, however, that nurses under-medicate children and that postoperative pain is relieved insufficiently. In some situations, nurses under-estimate the child's pain, while in others, nurses' attitudes, beliefs and knowledge regarding pain relief strategies play an important role. On the basis of this review of the literature standard prescription of pain medication instead of prn is recommended. Furthermore, research on the incidence and prevalence of pain in children and on the effectiveness of analgesic administration postoperatively is warranted.

Tactual sensitivity in hypochondriasis.

BACKGROUND: In his article on amplification, somatization and somatoform disorders Barsky [Psychosomatics 1992; 33:28-34] pointed out the importance of studying the perception and processing of somatic and visceral symptoms. Subsequently, it was demonstrated that hypochondriacal patients are not more accurately aware of cardiac activity than a group of non-hypochondriacal patients. Authors concluded that hypochondriacal somatic complaints do not result from an unusually fine discriminative ability to detect normal physiological sensations that non-hypochondriacal patients are unable to perceive. The aim of the present study was to investigate tactual sensitivity to non-painful stimuli in hypochondriacal patients and healthy subjects. METHODS: Twenty-seven outpatients with DSM-III-R hypochondriasis and 27 healthy control subjects were compared. In all subjects the two-point discrimination threshold was measured, as well as subjective sensitivity to harmless bodily sensations as measured by the Somatosensory Amplification Scale. RESULTS: It was found that hypochondriacal patients reported more distress and discomfort with benign bodily sensations. The two-point discrimination threshold of hypochondriacal patients was not significantly lower in patients as compared to controls. CONCLUSIONS: Hypochondriacal subjects considered themselves more sensitive to benign bodily sensations without being better able to discriminate between two tactual bodily signals. These findings of the present study correspond quite closely to those reported earlier.

Suggestibility in hypochondriacal patients and healthy control subjects. An experimental case-control study.

This study examined suggestibility to bodily sensations in hypochondriacal patients and healthy subjects. Both groups participated in an experiment in which electrical current was announced but not delivered. Suggestibility was measured by the number of responses and by response latencies. The authors hypothesized that the hypochondriacal patients would be more easily influenced by the expectation of a forthcoming stimulus, leading to higher and quicker "stimulus detection" rates than those experienced by the healthy subjects. In contrast to these expectations, the healthy subjects showed higher response frequencies and lower response latencies. Thus, the hypochondriacal patients appeared to be less influenced by the expectation that was raised. The theoretical and clinical implications of the results are discussed.

Differences in pain assessment and decisions regarding the administration of analgesics between novices, intermediates and experts in pediatric nursing.

This article describes a study examining the influence of expertise on nurses' pain assessments and decisions regarding pharmacological interventions in children. In an experimental design, novices (n = 271), intermediates (n = 222), and experts (n = 202) in pediatric nursing, various cases were presented. Each case consisted of a combination of a vignette and a video. Subjects were asked (1) to assess the child's pain intensity, (2) to specify their confidence in the assessment, and (3) to state whether or not they would administer a non-narcotic analgesic. The results indicated that expertise did not influence assessments of pain intensity. However, expertise did have a distinct impact on both the subjects' confidence in their decisions, and the decision to administer analgesics. Experienced nurses were most confident and were most inclined to administer analgesics. The findings of this study are placed in the context of a general theory on the development of expertise, which assumes that experts' decision-making is based on cognitive structures that describe features of prototypical or even actual patients, so called "illness scripts". From this theory it can be deduced that mainly practical experience is responsible for the (lack of) differences in decision-making between novices, intermediates and experts.

Hypochondriasis and symptom reporting--the effect of attention versus distraction.

BACKGROUND: This study examined symptom perception in hypochondriacal patients without physical stimulation. METHODS: Seventeen outpatients with DSM-III-R hypochondriasis and 16 healthy control subjects were compared. All subjects were asked to report perceived sensations in three conditions: attention, distraction and control. RESULTS: It was found that hypochondriacal subjects showed remarkably higher levels of symptom reporting than healthy subjects in all three conditions. In spite of excessive attention to bodily sensations in a control condition, attention instructions still added significantly to symptom reporting in hypochondriacal patients. The effect of distraction was not significant in either of the groups. Furthermore, group differences in symptom reporting appeared to be related to preoccupation with bodily symptoms rather than to general anxiety level as measured by the STAI. CONCLUSIONS: Hypochondriacal patients report more bodily sensations than healthy controls when no instructions are given. In addition, focussing on bodily sensations seems to cause a significant overall increase of perceived symptoms in hypochondriacal patients, whereas in healthy subjects there is a trend towards an increase in symptom reporting.

Startle responses of spider phobics to masked stimuli: a pilot study.

The present study tested the hypothesis that briefly flashed and backwardly masked phobic stimuli potentiate startle reflexes in phobic subjects. Spider phobic (n = 17) and normal control (n = 12) subjects were exposed to short (30 ms) and backwardly masked presentations of phobic slides (i.e., spiders) and neutral slides (i.e., flowers, mushrooms, snakes). On half the trials, eyeblink startle reflexes were elicited with auditory probes following presentation of the slides. In spite of the degraded stimulus conditions, there were some indications that phobics exhibited a startle pattern different from control subjects. More specifically, phobic subjects tended to react with larger startles during the second block of spider trials than control subjects. No such group differences were found for the neutral trials. As the eyeblink startle reflex is closely linked to the thalamo-amygdala pathway, the present findings provide some preliminary support for the idea that the preattentive processing of phobic cues is located at the subcortical level.

Covariation bias and the return of fear.

Several studies have indicated that phobic fear is accompanied by a covariation bias, i.e. that phobic Ss tend to overassociate fear relevant stimuli and aversive outcomes. Such a covariation bias seems to be a fairly direct and powerful way to confirm danger expectations and enhance fear. Therefore, it has been suggested that covariation bias is an important factor in the maintenance of phobic fear. However, thus far there are no empirical data available to exclude the alternative possibility that covariation bias is a mere epiphenomenon of fear. To explore the "causal" status of covariation bias, successfully treated spider phobics who participated in an earlier study on covariation bias were asked to complete a Spider Phobia Questionnaire at 2 yr follow up. Results indicate that Ss who displayed a covariation bias immediately after treatment are more vulnerable to relapse than Ss who did not show such a bias. This finding strengthens the idea that covariation bias may enhance fear, thereby contradicting the suggestion that covariation bias is a mere epiphenomenon of phobic fear.