[The unbroken power of psychiatry as seen through the eyes of Michel Foucault]. / De ongebroken macht van de psychiatrie door de ogen van Michel Foucault.

Is the psychiatrist still a powerfulforce in society? Foucault, a 'historical philosopher' concerned with power relations, would have answered this question in the affirmative. Possibly, however, the psychiatrist's sovereign power is weaker than it was a century ago because some of the psychiatrist's tasks have been re-allocated. Some have been assigned to the growing number of specialist groups in the mental health service, others have been put in the hands of 'health managers' who form part of our country's growing bureaucracy and put a financial and economic burden on our health service. Nevertheless, the procedural power of psychiatrist has not been weakened; psychiatrists are able to deprive patients of their freedom, pronounce them unfit for work and reduce punishments and sentences for serious crime on the grounds of diminished responsibility. This procedural power is accentuated by the increasing influence of psychology in society. The power of psychiatric knowledge has shifted from an archaic to a demonstrative discourse about truth which is rooted in evidence-based medicine and which enhances the power of psychiatrists still further. This may also mean that the 19th century concept of hysteria is perpetuated in psychiatric practice in all kinds of modern clinical forms.

[Physician-assisted suicide of a patient suffering from a psycho-organic disorder]. / Hulp bij zelfdoding bij een patiënt met een organisch-psychiatrische stoornis.

A 71-year-old man suffering from vascular dementia since four years asked for physician-assisted suicide. In the Netherlands physician-assisted suicide, which is forbidden by law, remains an intricate dilemma in medical practice. As far as it concerns untreatable terminal patients who decide to put an end to their lives in agreement with and assisted by their physician, procedures are well defined. The present case may be used as an example in the development of a protocol for physician-assisted suicide in patients who are not terminal in the short term, but who suffer unbearably with no prospect of remission. After the protocol securing various formal and medical consequences was run through, the patient was assisted by handling him a high-dose solution of a barbiturate which he drank himself. The procedure incorporates several second and third opinions. First, the chief psychiatrist of the psychiatric hospital assesses the request. Second, a committee consisting of a number of independent professionals form a second opinion. They have no direct responsibility in the treatment of the patient. The patient also may consult an independent consultant psychiatrist with specific knowledge in the domain of his disorder for a third opinion. This procedure was found legally as well as medically sound, and was approved by the public prosecutor after consultation with the Dutch forum of Procurators-General.

Agoraphobic behavior in daily life: effects of social roles and demographic characteristics.

Agoraphobia is related to demographic characteristics and social roles. To unravel behavioral aspects from demographic characteristics, daily life situations were registered with the Experience Sampling Method for 65 panic patients with and without agoraphobia. Surprisingly, panic patients with and without agoraphobia did not differ as hypothesized in reported frequencies of visits to public places. Panic subjects with agoraphobia did, however, spend significantly more time at home and with their families than did panic patients without agoraphobia and normal controls. When adjusted for demographic variables such as sex, marital status, family life, and employment, no significant differences between panic patients with and without agoraphobia emerged on the avoidance variables of remaining at home or being with a family member. The lack of discrimination of the diagnosis on these crucial behavioral variables highlights the influence of demographic characteristics and social roles on agoraphobia in daily life. Such findings challenge current diagnostic conceptualizations that rely on retrospective reports by patients of the avoidance of public places. Moreover, reliance on retrospective reports obscured the important role of significant others for understanding etiology and course.

Reliability and feasibility of measuring medical interviewing skills: the revised Maastricht History-Taking and Advice Checklist.

Medical interviewing skills are integral to good medical care. In order to measure these skills an instrument has been developed, called the Maastricht History-Taking and Advice Checklist (MAAS). It has been studied with regard to interrater reliability and validity. In this study a revised version of the MAAS (MAAS-R), a check-list of concrete interview behaviour, has been investigated concerning feasibility and reliability for examination purposes. Audio-recordings were obtained of 24 doctors, each interviewing eight different standardized patients. The recordings were independently scored by three general practitioners trained in using the MAAS-R. The results of generalizability analysis, considering the influences of doctors, cases and raters, are encouraging. In order to overcome case-specificity feasible and reliable measurement can be accomplished with 8-10 cases in 2-21/2 hours of testing time, each case being scored by a different rater. Reliability improves considerably if assessment is restricted to basic interviewing skills.

A troubled youth: relations with somatization, depression and anxiety in adulthood.

BACKGROUND: Childhood experiences profoundly affect later functioning as an adult. Family practitioners are well-placed to discover the links between childhood troubles and later somatization, depression or anxiety. OBJECTIVES: We aimed to study the interrelation of somatization, depressive and anxiety disorders in frequently attending patients in general practice; to investigate whether these problems are related to a childhood history of illness experiences, deprivation, life events and abuse; and to determine the independent contributions of these childhood factors to the prediction of adult somatization, depressive and anxiety disorders. METHODS: One hundred and six adult general practice patients with high consultation frequency were studied. Somatization was operationalized as a more comprehensive version of DSM-III-R somatization disorder (5 complaints; SSI 5/5). For depression (ever depressive and/or dysthymic) and anxiety (panic, phobias and/or generalized anxiety) DSM-III-R criteria were used. Using a structured questionnaire we assessed illness experiences, deprivation of parental care, abuse (sexual/physical) and other life events before age 19. RESULTS: The overlap between somatization, depression and anxiety was largely accounted for by 16 patients with a triple problem: somatization and depression and anxiety. Somatization was specifically related to deprivation, depression to other life events. Abuse (prevalence 16%) independently predicted psychiatric problems in general. Youth experiences before age 12 were most important. CONCLUSIONS: The high prevalence of triple problems suggests a need to reconsider concepts like somatic anxiety and anxious depression. The specificity of the relation between deprivation and somatization and of the relation between other life events and depression indicates that distinct causal mechanisms (in youth) contribute to these problems.

Somatization in frequent attenders of general practice.

The DSM-III-(R) definition of somatization disorder is too restrictive for use in general practice. A more comprehensive definition, the "somatic symptom index" (SSI) has shown good validity in open populations. However, a definition has to differentiate validly within a population of frequent attenders to be a useful diagnostic instrument in general practice. We studied a threshold of five complaints (nearly identical to the SSI) in 80 Dutch general practice patients. Patients were selected on age (20-44 years), history of back, neck or abdominal complaints, and on frequency of consultation- at least 12 consultations in the previous 3 years, corrected for consultations with compelling somatic reason for encounter. Prevalence of somatization in this group was 45%. Women had a 2 times higher risk of somatization. A relation with age was not found. Somatization was related to depressive complaints (relative risk 2.5) and probably also to anxiety. Somatizing patients consulted their general practitioner more often and had more health problems (especially psychic problems) than non-somatizers. These results support the validity of this definition. The distinction between our definition of somatization and somatization defined as a symptom of psychiatric (e.g. depressive or anxiety) disorder is emphasized.

To what extent are medical interviewing skills teachable?

Growth patterns of medical interviewing skills during a 6-year undergraduate curriculum are assessed by studying 563 medical students taken from five year-groups, interviewing simulated patients. In a cross-sectional, quasi-experimental design their skills are rated by means of the Maastricht History-taking and Advice Checklist (MAAS), an observation instrument which measures five categories of interviewing skills pertaining to initial medical consultations. The findings suggest that the skills for 'history-taking', 'presenting solutions' and 'structuring of the interview' are effectively learned. These learning effects result from a continuous small group teaching program with expert and peer review of videotaped encounters with simulated patients. The teaching effects of this program seem less for the skills pertinent to the phase of 'exploring the reasons for encounter' and to the 'basic interviewing skills', because the students' growing medical knowledge and the increasing ability to solve medical problems exert a counteracting influence on the acquisition of these easily deteriorating skills. The results might be helpful to curriculum planners in order to make their programs for medical interviewing skills more effective.