An innovative approach to the assessment of mood disturbances in patients with acute coronary syndrome.

BACKGROUND: The clinical value of the identification of mood disorders in patients with acute coronary syndrome (ACS) is well established. However, assessment based on DSM criteria presents some limitations. This study aimed to provide an innovative strategy for evaluating the spectrum of mood disturbances in ACS. METHODS: A total of 288 patients with a first episode of ACS underwent interviews based on DSM-IV-TR criteria (major depressive disorder, minor depression, and dysthymia), Diagnostic Criteria for Psychosomatic Research-DCPR (demoralization and type A behavior), and the Clinical Interview for Depression-CID. Additional self-report inventories (psychological well-being and distress) were administered. A total of 100 consecutive patients who satisfied criteria for DSM-IV-TR depression or DCPR demoralization were enrolled in a randomized controlled trial on a sequential combination of cognitive-behavioral and well-being therapy (CBT/WBT) vs clinical management (CM) and reassessed up to 30-month post-intervention. RESULTS: A total of 29.9% of patients showed a DSM-IV-TR depressive syndrome. Inclusion of demoralization and type A identified psychological distress in 58% of the sample. According to CID, reactivity to social environment, fatigue, depressed mood, and somatic anxiety were the most common symptoms. Somatic symptoms were significantly associated with DSM-IV-TR depression (fatigue and changes of appetite), whereas environmental reactivity with demoralization. Both depression and demoralization were associated with higher distress and lower well-being. Unlike CM, CBT/WBT was significantly associated with decrease of guilt, pessimism, fatigue, and early insomnia (CID). CONCLUSIONS: The findings indicate that standard psychiatric approach identifies only a narrow part of mood disturbances affecting ACS patients. A more articulated assessment unravels specific clinical configurations that may entail prognostic and therapeutic implications.

Sequential Combination of Cognitive-Behavioral Treatment and Well-Being Therapy in Depressed Patients with Acute Coronary Syndromes: A Randomized Controlled Trial (TREATED-ACS Study).

INTRODUCTION: Randomized controlled trials (RCT) of psychotherapeutic interventions have addressed depression and demoralization associated with acute coronary syndromes (ACS). The present trial introduces psychological well-being, an increasingly recognized factor in cardiovascular health, as a therapeutic target. OBJECTIVE: This study was designed to determine whether the sequential combination of cognitive-behavioral therapy (CBT) and well-being therapy (WBT) may yield more favorable outcomes than an active control group (clinical management; CM) and to identify subgroups of patients at greater risk for cardiac negative outcomes. METHODS: This multicenter RCT comparedCBT/WBT sequential combination versus CM, with up to 30 months of follow-up. One hundred consecutive depressed and/or demoralized patients (out of 740 initially screened by cardiologists after a first episode of ACS) were randomized to CBT/WBT associated with lifestyle suggestions (n = 50) and CM (n = 50). The main outcome measures included: severity of depressive symptoms according to the Clinical Interview for Depression, changes in subclinical psychological distress, well-being, and biomarkers, and medical complications and events. RESULTS: CBT/WBT sequential combination was associated with a significant improvement in depressive symptoms compared to CM. In both groups, the benefits persisted at follow-up, even though the differences faded. Treatment was also related to a significant amelioration of biomarkers (platelet count, HDL, and D-dimer), whereas the 2 groups showed similar frequencies of adverse cardiac events. CONCLUSIONS: Addressing psychological well-being in the psychotherapeutic approach to ACS patients with depressive symptoms was found to entail important clinical benefits. It is argued that lifestyle changes geared toward cardiovascular health may be facilitated by a personalized approach that targets well-being.

Manifestations of health anxiety in patients with heart transplant.

BACKGROUND: Health anxiety is an important component of psychological adjustment to chronic medical conditions. However, it has been overlooked after heart transplantation. OBJECTIVES: To examine demographic, clinical, and psychological correlates of health anxiety in heart transplanted patients and to compare health anxiety between patients and a sample of matched controls from the general population. METHODS: The study design was observational. Seventy-three cardiac recipients and 73 controls completed the Illness Attitude Scales and the Symptom Questionnaire. Patients' clinical parameters were collected. RESULTS: Health anxiety was significantly associated with clinical variables suggesting a worse outcome, especially a higher NYHA class and occurrence of cancer. Compared to controls, patients had significantly more "hypochondriacal responses" (32.9% vs. 16.4%), an index of clinically significant health anxiety. CONCLUSIONS: Health anxiety affects a significant subset of heart transplanted patients and deserves a thorough assessment. Cardiologists' and nurses' specific communication skills and psychological treatment strategies may be necessary.

Illness perception in patients with migraine: An exploratory study in a tertiary care headache centre.

BACKGROUND: Illness perception is significantly related to several outcome measures in different medical conditions. However, little is known about headache-related causal attributions and cognitive and emotional representations in patients with migraine. OBJECTIVE: To examine perceived causes of headache and demographic, clinical, and psychological correlates and predictors of illness perception in patients with migraine attending a tertiary care headache centre. METHODS: A sample of 143 patients with migraine (85.3% women, mean age 44.0 ±â€¯12.1 years) completed the Brief Illness Perception Questionnaire (Brief IPQ), the Symptom Questionnaire (SQ), and the Migraine Disability Assessment (MIDAS) Questionnaire. A set of demographic and clinical characteristics was also collected. RESULTS: Stress, heredity, and nervousness were the most frequent perceived causes of headache. Female gender was significantly related to higher Brief IPQ "consequences" and "emotional response" scores. Increased psychological distress and a poorer clinical course were significantly associated with more negative illness representations. In multiple regression analysis, a longer illness duration, increased depressive symptoms, and higher levels of headache-related disability and painfulness of headache attacks independently predicted a worse illness perception. CONCLUSIONS: In patients with migraine, depressive symptoms and a worse disease status, characterized by a longer history of suffering, higher disability and more painful headache attacks, may negatively affect illness perception. It could also be that dysfunctional illness representations lead to depressive symptoms and decrease patients' motivation to adhere to treatments, resulting in a worse outcome. Future studies should examine whether the improvement of illness perception through specific psychological interventions may promote a better adaptation to migraine.

Smoking in Irritable Bowel Syndrome: A Systematic Review.

OBJECTIVE: The aim of this review was to examine (1) the prevalence of smoking in subjects with irritable bowel syndrome (IBS), (2) whether smoking prevalence significantly differs between subjects with and without IBS, and (3) whether smoking significantly predicts the presence or the development of IBS. METHODS: Articles were retrieved by systematically searching the Scopus, Web of Science, and PubMed electronic databases from inception to July 2016, using the keywords "smoking" and "tobacco" combined with "irritable bowel syndrome." Reference lists of included articles were also searched. Articles were included if they (1) reported data on smoking prevalence in subjects with IBS and/or on the association (assessed by means of multivariate analyses) between smoking and IBS, (2) identified IBS according to Manning criteria or Rome I-III criteria, (3) were English-language articles, and (4) involved only adult subjects. RESULTS: The electronic searches yielded a total of 1,637 records, and 42 articles met inclusion criteria. Another 13 articles were retrieved through manual search, leading to a total of 55 included articles. Smoking prevalence in subjects with IBS was assessed by 48 articles and ranged from 0% in university students to 47.1% in patients with microscopic colitis. Thirty-three articles compared smoking prevalence between subjects with and without IBS. In 25 articles no significant difference was found. In seven articles smoking was significantly more frequent in subjects with IBS compared to those without IBS, while one study found a significantly higher smoking prevalence in controls. Eighteen multivariate analyses assessing the association between smoking and IBS were presented in 16 articles. Only one study employed a prospective design. In 11 analyses, smoking was not significantly associated with IBS after adjusting for covariates. In seven studies smoking independently predicted the presence of IBS. CONCLUSIONS: According to the selected articles, a significant association between smoking and IBS cannot be confirmed. However, different shortcomings may hinder generalizability and comparability of many studies. A dimensional assessment of smoking, a prospective design, the differentiation between IBS subgroups, and the recruitment of patients in clinical settings, especially in primary care, are necessary to clarify the role of smoking in IBS.

Medically unexplained symptoms and general practitioners: a comprehensive survey about their attitudes, experiences and management strategies.

Background: Medically unexplained symptoms (MUS) are common in primary care and are one of the most challenging clinical encounters for general practitioners (GPs). Objective: To assess GPs' clinical experience with MUS and its relationship with their gender, age and length of practice. Methods: Four hundred and thirty-three Italian GPs were invited to complete a questionnaire encompassing the following MUS-related features: workload, cognitive and emotional responses, management strategies, attitudes towards psychological interventions, sources of education and educational needs. Results: A total of 347 GPs (80.1%) participated in the study. About seven out of ten physicians spent 'much' or 'very much' time and energy for MUS during their daily practice. Fear of neglecting a medical disease was the most frequent (59.1%) response to MUS. Providing reassurance and support (73.8%) and listening to the patient (69.2%) were the most frequent management strategies. More than half of GPs rated psychological interventions as 'much' or 'very much' useful for MUS. However, only a third of GPs were well informed about the role of psychologists in MUS management. The main sources of education about MUS were scientific papers and continuing medical education courses. Most of GPs (77.5%) needed further education about MUS. GPs' younger age and lower length of practice were significantly associated with negative emotional responses to MUS. Conclusion: The introduction of guidelines for MUS in Italian primary care settings would promote a collaborative clinical approach to MUS and more formal training on this topic.

Adolescents' hypochondriacal fears and beliefs: Relationship with demographic features, psychological distress, well-being and health-related behaviors.

OBJECTIVE: There is little previous literature on hypochondriacal attitudes in teens. We examined the relationship between adolescents' hypochondriacal fears and beliefs, demographic features, psychological distress and well-being, and health-related behaviors. METHODS: Nine hundred and forty-eight students (53.4% males), aged 14-19years (mean 15.8±1.3years), completed the Illness Attitude Scales, the Symptom Questionnaire, and the Psychological Well-Being scales. Demographic features and health-related behaviors (smoking, alcohol consumption, illicit substance use, and sedentary, eating and sleep habits) were also collected. RESULTS: Hypochondriacal concerns were significantly higher among females and correlated with increased psychological distress and reduced well-being. One hundred and forty-nine participants (15.7% of the sample) reached the threshold of the "hypochondriacal responses", identified by Kellner as a screening method for clinically significant hypochondriacal symptoms. The "hypochondriacal responses" were significantly associated with higher levels of psychological distress, decreased well-being, and some unhealthy behaviors: smoking, use of illicit substances, physical inactivity, and short sleep. Female gender, physical inactivity, and higher levels of hostility independently predicted the "hypochondriacal responses" pattern. CONCLUSIONS: A substantial percentage of adolescents experience significant concerns about health. Excessive illness fears are associated with less healthy behaviors. A thorough assessment of illness-related concerns may be crucial for the prevention of both the development of more structured forms of abnormal illness behavior (e.g., severe health anxiety) and the engagement in some unhealthy lifestyles in adolescents. However, it may also be that unhealthy behaviors lead to increased preoccupation with one's own health through adolescents' implicit knowledge about possible consequences of such behaviors.

Alexithymia in the medically ill. Analysis of 1190 patients in gastroenterology, cardiology, oncology and dermatology.

OBJECTIVE: To use the Diagnostic Criteria for Psychosomatic Research (DCPR) for characterizing alexithymia in a large and heterogeneous medical population, in conjunction with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and other DCPR criteria. METHOD: Of 1305 patients recruited from 4 medical centers in the Italian Health System, 1190 agreed to participate. They all underwent an assessment with DSM-IV and DCPR structured interviews. A total of 188 patients (15.8%) were defined as alexithymic by using the DCPR criteria. Data were submitted to cluster analysis. RESULTS: Five clusters of patients with alexithymia were identified: (1) alexithymia with no psychiatric comorbidity (29.3% of cases); (2) depressed somatization with alexithymic features (23.4%); (3) alexithymic illness behavior (17.6%); (4) alexithymic somatization (17%) and (5) alexithymic anxiety (12.8%). CONCLUSIONS: The results indicate that DCPR alexithymia is associated with a comorbid mood or anxiety disorder in about one third of cases; it is related to various forms of somatization and abnormal illness behavior in another third and may occur without psychiatric comorbidity in another subgroup. Identification of alexithymic features may entail major prognostic and therapeutic differences among medical patients who otherwise seem to be deceptively similar since they share the same psychiatric and/or medical diagnosis.

Diagnostic criteria for psychosomatic research and somatic symptom disorders.

The Diagnostic Criteria for Psychosomatic Research (DCPR) were introduced in 1995 by an international group of investigators to expand the traditional domains of the disease model. The DCPR are a set of 12 'psychosomatic syndromes' which provide operational tools for psychosocial variables with prognostic and therapeutic implications in clinical settings. Eight syndromes concern the main manifestations of abnormal illness behaviour: somatization, hypochondriacal fears and beliefs, and illness denial. The other four syndromes (alexithymia, type A behaviour, demoralization and irritable mood) refer to the domain of psychological factors affecting medical conditions. This review describes the conceptual bases of the DCPR and the main findings concerning their application, with particular reference to the incremental information they added to the customary psychiatric classification. The DCPR were also compared with the provisional DSM-5 somatic symptom disorders. The DCPR were found to be more sensitive than DSM-IV in identifying subthreshold psychological distress and characterizing patients' psychological response to medical illness. DSM-5 somatic symptom disorders seem to neglect important clinical phenomena, such as illness denial, resulting in a narrow view of patients' functioning. The additional information provided by the DCPR may enhance the decision-making process.

The unifying concept of illness behavior.

The concept of illness behavior was introduced to indicate the ways in which given symptoms may be perceived, evaluated and acted upon at an individual level. Illness behavior may vary greatly according to illness-related, patient-related and doctor-related variables and their complex interactions. In the past decades, important lines of research have been concerned with illness perception, frequent attendance at medical facilities, health care-seeking behavior, treatment-seeking behavior, delay in seeking treatment, and treatment adherence. They have, however, mostly investigated single aspects separately. In this concise review, we suggest that the concept of illness behavior may provide a unifying framework and useful insights to observations and findings that would otherwise remain scattered and unrelated in the medical literature. The wide range of expressions of illness behavior is likely to affect the presentation of any disease and its identification, course and treatment. Assessing illness behavior and devising appropriate responses by health care providers may contribute to the improvement of final outcomes.

Assessing psychological factors affecting medical conditions: comparison between different proposals.

OBJECTIVE: We compared the provisional Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for Somatic Symptom Disorders (SSD) and an alternative classification based on the Diagnostic Criteria for Psychosomatic Research (DCPR) as to prevalence and associations with dimensional measures of psychological distress and functioning in a population of medical patients. METHOD: Seventy consecutive outpatients with congestive heart failure were administered an ad hoc structured clinical interview for the identification of DSM-5 SSD, the section concerning hypochondriasis of the Structured Clinical Interview for DSM-IV, the Structured Interview for DCPR and Paykel's Clinical Interview for Depression. Subjects also completed the Symptom Questionnaire and the Psychosocial Index. Global assessment of functioning was performed with the DSM-IV Axis V. RESULTS: A diagnosis within DSM-5 SSD was found in 13 patients (18.5%): 61.5% of them were diagnosed with the Psychological Factors Affecting Medical Condition category. Twenty-nine patients (41.4%) were classified according to the DCPR-based proposal: illness denial, demoralization and irritable mood were the most frequent specifiers. The DCPR-based classification showed a greater number of significant associations with dimensional measures of psychological distress, global functioning and stress. CONCLUSION: Compared to DSM-5 SSD, the DCPR-based proposal was more sensitive in detecting psychological factors relevant to illness course and provided a better characterization of such factors. The DCPR-based proposal was also superior in identifying patients with increased psychological distress and poor psychosocial functioning.

Illness behavior.

The term illness behavior was introduced by Mechanic and Volkart to describe the individuals' different ways to respond to their own health status. Pilowsky's concept of abnormal illness behavior encompasses several clinical conditions characterized by a maladaptive mode of experiencing, perceiving, evaluating and responding to one's own health status. The concept of somatization was criticized because it implies the presence of psychological distress or an underlying psychiatric disturbance when an organic cause for somatic symptoms is not found. Thus, more atheoretical terms , such as functional somatic symptoms and medically unexplained symptoms, were introduced. Both Kellner's Symptom Questionnaire and Derogatis' Symptom Checklist-90 include a scale for somatic symptoms, and other questionnaires were specifically designed to measure their frequency and severity. Kellner's Illness Attitude Scales appear to be the gold standard for the measurement of the hypochondriacal spectrum, which includes several clinical conditions, such as nosophobia, thanatophobia and health anxiety. The assessment of illness denial should consider that a certain degree of denial may sometimes prevent patients from overwhelming psychological distress resulting from life-threatening or stigmatized diseases. Denial may concern both physical and psychiatric symptoms. Specific instruments are available for both types of denial. The cognitive and emotional representations developed by subjects when they have to cope with an illness or a perceived health threat are subsumed under the concept of illness perception and may be assessed by the Brief Illness Perception Questionnaire.

Kellner's emotional inhibition scale: a clinimetric approach to alexithymia research.

BACKGROUND: Emotional inhibition has been an enduring concept in the psychosomatic literature explaining the onset and course of medical disorders. Currently the personality style of alexithymia is a focus of this dimension in psychosomatic theory, while actual conscious emotional inhibition, which may overlap with alexithymia, has received less attention. In the early 80s Robert Kellner developed the Emotional Inhibition Scale (EIS), a self-rating scale for emotional inhibition based on clinimetric principles. In this study we explored whether the EIS differentiated a sample of cardiac recipients from normal controls, as well as the associations between the EIS and 2 measures of alexithymia, i.e. the Toronto Alexithymia Scale-20 (TAS-20) and the Diagnostic Criteria for Psychosomatic Research (DCPR). We also examined whether the EIS and the TAS-20 were differently related to depressive symptoms measured by the Symptom Questionnaire (SQ). METHODS: Ninety-five heart-transplanted patients and a sample of normal controls, matched for sociodemographic variables, were administered the EIS (total score and 4 subscales concerning 'verbal inhibition', 'timidity', 'disguise of feelings', and 'self-control'), the TAS-20, the SQ, and the Structured Interview according to the DCPR for alexithymia. RESULTS: Cardiac recipients did not display significant differences compared to normal controls in observer (DCPR) and self-rated (TAS-20) measures of alexithymia. There were, however, significant differences in EIS with regard to 'disguise of feelings'. In both groups the EIS 'verbal inhibition' and 'timidity' subscales were positively associated with the TAS-20, while the EIS 'disguise of feelings' and 'self-control' subscales were independent of alexithymia. Depressive symptoms were more related to TAS-20 than EIS total scores. CONCLUSIONS: Our results suggest that emotional inhibition and alexithymia are distinct phenomena even though they may share certain features. The EIS appears to be relatively independent of depressed mood and will be useful in assessing the individual's conscious management of affect in future psychosomatic research.

Psychological characterization of demoralization in the setting of heart transplantation.

OBJECTIVE: The aims of this study were to examine the psychological features of demoralization and its overlap with major depressive disorder in a sample of cardiac transplant recipients, with special reference to psychological well-being, quality of life, and psychological distress. We also tested whether demoralization was significantly associated with demographic characteristics and clinical parameters, including survival status at a 6-year follow-up. METHOD: From May to December 2002, 95 heart transplanted patients were administered the Structured Clinical Interview for DSM-IV and the Diagnostic Criteria for Psychosomatic Research, leading to the identification of major depressive disorder and demoralization, respectively. Patients also completed Ryff's Scales of Psychological Well-Being, Kellner's Symptom Questionnaire, and the World Health Organization Quality of Life-Brief Version scale. RESULTS: Demoralization was related to impairments in physical, psychological, social, and environmental quality of life and in psychological well-being, especially self-acceptance and environmental mastery (all P ≤ .05). It was also associated with higher levels of psychological distress, and it was more frequent in women (P = .027) and in single patients (P = .038). The co-occurrence of a major depressive episode did not alter this pattern of associations. The addition of demoralization to major depressive disorder resulted in decreased Scales of Psychological Well-Being autonomy, positive relations, and self-acceptance (all P ≤ .05). Demoralization and major depressive disorder were identified in 31 (32.6%) and 14 (14.7%) patients, respectively. Among depressed subjects, 5 (35.7%) were not demoralized, and 22 (71%) of those with demoralization did not satisfy the criteria for major depressive disorder. Nine patients were both depressed and demoralized. CONCLUSION: Diagnostic Criteria for Psychosomatic Research-defined demoralization has some distinctive features that confirm previous phenomenological observations.

Predictors of perceived social support in long-term survivors of cardiac transplant: the role of psychological distress, quality of life, demographic characteristics and clinical course.

AIM: To examine associations between perceived social support, quality of life, psychopathological, demographic and clinical variables in long-term heart transplant survivors. METHODS: Sixty six patients transplanted from 10.2 ± 3.3 years completed the Interpersonal Support Evaluation List, Symptom Questionnaire and World Health Organization Quality of Life-BREF. Parameters of post-transplant medical course were retrieved. Spearman rank order correlation, Mann-Whitney U test, Kruskal-Wallis test and multiple regression analyses were performed. RESULTS: At multiple regression analyses SQ depression significantly predicted Interpersonal Support Evaluation List (ISEL) total and appraisal scores (p = 0.005 and p = 0.047), indicating better satisfaction for support in patients with less depressive symptoms. Low levels of depression and being married or living as married were significantly associated with better ISEL belonging (p = 0.03 and p = 0.008) and self-esteem (p < 0.001 and p = 0.038). Skin cancer significantly correlated with better tangible (p = 0.02) and total (p = 0.05) support. Social quality of life was positively associated with ISEL total (p < 0.01), appraisal (p < 0.05), belonging (p < 0.01) and tangible (p < 0.05) scores; yet, it significantly predicted none of the them. CONCLUSIONS: Depressive symptoms may worsen patients' satisfaction for their interpersonal support. Marital status seems to foster sense of belonging and self-esteem. The paucity of significant associations between ISEL and clinical parameters may reflect the caregivers' continuous provision of support regardless of clinical status.

Psychological predictors of mortality in heart transplanted patients: a prospective, 6-year follow-up study.

BACKGROUND: Some reports suggest a link between poor psychological adjustment to heart transplantation and an increased risk of subsequent adverse clinical outcome. Despite its prognostic and therapeutic implications, this issue is still lacking adequate empirical studies. We prospectively tested the predictive value of a complete set of psychiatric and psychological variables, collected with both self-rating and observer-based instruments at midterm after heart transplantation, on the subsequent 6-year survival status. METHODS: Ninety-five heart transplanted patients underwent the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-4th Edition and the structured interview for Diagnostic Criteria for Psychosomatic Research and filled three questionnaires assessing the dimensions of psychological distress, quality of life, and psychological well-being. Demographic characteristics and several clinical parameters were also collected. A 6-year follow-up survival was performed. RESULTS: Analyses of survival showed that hostility, depression, purpose in life, the occurrence of at least one cardiac event, chronic renal insufficiency, diabetes, number of drug prescriptions, a New York Heart Association (NYHA) class more than or equal to II, and ischemic origin of the cardiopathy significantly predicted subsequent survival duration. When multivariate analyses were performed, high levels of hostility and the presence of diabetes resulted the independent predictors of survival status. CONCLUSIONS: These findings point out the predictive role of specific components of psychological adjustment to heart transplantation and pose the basis for the evaluation of whether the provision of pharmacologic and psychotherapeutic interventions, aimed at reducing the empirically identified psychological risk factors, may result in a better long-term outcome.