Interpersonal functioning and body image dissatisfaction in patients referred for NHS aesthetic surgery: A mediating role between emotion regulation and perfectionism?

BACKGROUND: Few studies have explored psychological factors associated with body image dissatisfaction in individuals seeking aesthetic surgery on the NHS. In NHS Scotland, The Adult Exceptional Aesthetic Referral Protocol (AEARP) states that individuals are only eligible for consideration for surgery where there is significant psychological distress and physical criteria associated with perceived problem of appearance. The AEARP necessitates that individuals seeking aesthetic surgery on the NHS must have a psychological assessment. It is therefore crucial to identify psychological factors associated with body image dissatisfaction that may highlight contraindications for surgery or are amenable to psychological intervention. METHOD: A total of 311 consecutive patients seeking aesthetic surgery who were referred for psychological assessment under the AEARP completed a series of psychometric measures as part of routine clinical practice. Multiple mediation analyses using bootstrapped method was used to explore the relationship between interpersonal functioning, emotion regulation, perfectionism, and body image dissatisfaction. RESULTS: Multiple mediation analysis indicated that emotion regulation partially mediates the relationship between interpersonal functioning and body image dissatisfaction in this clinical population. CONCLUSION: This study indicates that interpersonal functioning and emotion regulation significantly relate to body image dissatisfaction in this patient group. Psychological assessment of patient suitability for aesthetic surgery should include assessment of interpersonal functioning and emotion regulation which may be amenable to psychological intervention and be of significant benefit to patients either pre- or post-operatively or instead of surgery.

Long-term outcome of cognitive behaviour therapy clinical trials in central Scotland.

OBJECTIVES: To establish the long-term outcome of participants in clinical trials of cognitive behaviour therapy (CBT) for anxiety disorders and psychosis, examining the effectiveness and cost-effectiveness associated with receiving CBT in comparison with alternative treatments. DESIGN: An attempt was made to contact and interview all of the participants in eight randomised, controlled, clinical trials of CBT for anxiety disorders and two randomised, controlled, clinical trials of CBT for schizophrenia conducted between 1985 and 2001. Case note reviews of healthcare resources used in the 2 years prior to entering the trials and the 2 years prior to follow-up interview were undertaken. SETTING: Mixed rural and urban settings in five localities in central Scotland. Anxiety disorder trials were conducted mainly in primary care and included three with generalised anxiety disorder, four with panic disorder and one with post-traumatic stress disorder (PTSD). The psychosis studies (one on relapse prevention and one with chronic disorder) were conducted in secondary care. PARTICIPANTS: Of the 1071 entrants to the 10 studies, 489 agreed to participate (46% of original entrants, 52% of those available to contact). INTERVENTIONS: Follow-up interviews took place between 1999 and 2003, 2-14 years after the original treatment. Interviews for Trials 1-8 were conducted by a research psychologist blind to original treatment condition. Interviews for Trials 9 and 10 were conducted by community psychiatric nurses also blind to treatment condition. Case note reviews were completed following the interview. MAIN OUTCOME MEASURES: For Trials 1-8 the main interview-based outcome measures were: Anxiety Disorders Interview Schedule-DSM-IV for diagnosis and co-morbidity, Clinical Global Severity (0-8) and the Hamilton Anxiety Rating Scale. The main patient-rated measures were: Brief Symptom Inventory, SF-36 II, Clinical Global Improvement (1-7), and the Positive and Negative Affect Scale. For Trials 9 and 10 the primary outcome measure was the interview-based Positive and Negative Syndrome Scale (PANSS). RESULTS: For the anxiety disorder studies (Trials 1-8), over half of the participants (52%) had at least one diagnosis at long-term follow-up, with significant levels of co-morbidity and health status scores comparable to the lowest 10% of the general population. Only 36% reported receiving no interim treatment for anxiety over the follow-up period with 19% receiving almost constant treatment. Patients with PTSD did particularly poorly. There was a 40% real increase in healthcare costs over the two time periods, mainly due to an increase in prescribing. A close relationship was found between poor mental and physical health for those with a chronic anxiety disorder. Treatment with CBT was associated with a better long-term outcome than non-CBT in terms of overall symptom severity but not with regard to diagnostic status. The positive effects of CBT found in the original trials were eroded over longer time periods. No evidence was found for an association between more intensive therapy and more enduring effects of CBT. Long-term outcome was found to be most strongly predicted by the complexity and severity of presenting problems at the time of referral, by completion of treatment irrespective of modality and by the amount of interim treatment during the follow-up period. The quality of the therapeutic alliance, measured in two of the studies, was not related to long-term outcome but was related to short-term outcome. The cost-effectiveness analysis showed no advantages of CBT over non-CBT. The cost of providing CBT in the original trials was only a very small proportion (6.4%) of the overall costs of healthcare for this population, which are high for both physical and mental health problems. In the psychosis studies (Trials 9 and 10), outcome was generally poor with only 10% achieving a 25% reduction in total PANSS scores from pretreatment to long-term follow-up, also cost-effectiveness analysis showed no advantages of CBT over non-CBT, although healthcare costs fell over the two time periods mainly owing to a reduction in inpatient costs. CONCLUSIONS: Psychological therapy services need to recognise that anxiety disorders tend to follow a chronic course and that good outcomes with CBT over the short term are no guarantee of good outcomes over the longer term. Clinicians who go beyond standard treatment protocols of about 10 sessions over a 6-month period are unlikely to bring about greater improvement. Poor outcomes over the long term are related to greater complexity and severity of presenting problems at the time of referral, failure to complete treatment irrespective of modality and the amount of interim treatment during the follow-up period. The relative gains of CBT are greater in anxiety disorders than in psychosis. Longitudinal research designs over extended periods of time (2-5 years), with large numbers of participants (500+), are required to investigate the relative importance of patient characteristics, therapeutic alliance and therapist expertise in determining the cost-effectiveness of CBT in the longer term.

The effects of long-term benzodiazepine treatment and graded withdrawal on psychometric performance.

Twelve patients were assessed prior to and during 4 weeks' graded withdrawal from long-term benzodiazepine treatment. A control group of ten healthy drug-free individuals were assessed over the same period. Psychometric measures included Four Choice Reaction Time--Decision (FCRT-D), Four Choice Reaction Time--Movement (FCRT-M), Sensory Threshold Detection (STD) and Key Tapping Rate (KTR). Patients anxiety level was monitored using the Hamilton Rating Scale (HAM) and a Visual Analogue Self-Report Measure (VASR). There was no evidence of psychometric practice effects and no significant changes in patients anxiety ratings. Prior to withdrawal the patient group showed significantly impaired performance compared to the control group on FCRT-D and STD, tasks primarily involving visual sensory information processing, but there were no differences between the two groups on FCRT-M and KTR, tasks primarily involving motor speed. During withdrawal the patient group showed significant improvements compared to the control group on FCRT-D and STD.

HIV risk behaviour correlates among injecting drug users in Greek prisons.

AIMS: To identify the correlates of injecting drug use within prison. DESIGN: A national cross-sectional study, participation being voluntary and anonymous. SETTING: Ten Greek prisons. PARTICIPANTS: A representative sample of 1000 male inmates; 861 questionnaires were completed and analysed. MEASUREMENT: A self-report questionnaire for demographics, penal history, drug use and sharing injecting equipment. FINDINGS: Two hundred and ninety inmates (33.7%) reported injecting drugs at some time in their lives, of whom 174 (60%) had injected while imprisoned. Among those who had injected while imprisoned, 145 (83%) had shared equipment while incarcerated. Logistic regression analysis suggested that total time in prison, previous drug conviction, being a convict (as opposed to on remand) and having multiple female sexual partners 1 year before incarceration were significant HIV risk behaviour correlates. For every year of imprisonment, the risk of injection in prison increased by about 17% [OR = 1.17 (95% CI: 1.07-1.27)]. Inmates with a previous drug-related conviction were about twice as likely to inject within prison [OR = 1.97 (95% CI: 1.16-3.33)]. Finally, convicted inmates were marginally significantly more prone to inject in prison [OR = 1.58 (95% CI: 0.92-2.74)]. CONCLUSIONS: Variables related to the inmates' prison career influence HIV risk behaviours within prison. There is a need to assist IDUs in reducing the likelihood of high-risk behaviour by considering factors such as frequency of incarceration, length of time incarcerated and availability of detoxification programmes within prison.

Treatment-outcome research in panic disorder: dilemmas in reconciling the demands of pharmacological and psychological methodologies.

Panic disorder with or without agoraphobia has been the subject of sustained treatment-outcome research. Studies have been conducted by both pharmacologically- and psychologically-oriented researchers each employing their own methodologies. Problems arise in attempting to reconcile the demands of these two treatment-outcome methodologies, whilst at the same time ensuring that research designs reflect the reality of wider clinical practice. In the following discussion a series of studies comparing pharmacological and psychological treatments for panic disorder and agoraphobia are reviewed. The review highlights areas where the competing demands of research design and clinical applicability lead to dilemmas for the researcher. Attempts to overcome such dilemmas are described and alternative solutions discussed.

Elderly people's views of an annual screening assessment.

A survey was carried out in order to identify elderly patients' perceptions of their health status, their health worries and their opinions regarding health screening before and after the introduction of an annual screening programme. Pre- and post-assessment self report, structured questionnaires and standardized, objectively scored, functional and medical assessments were used. The cohort was an age and sex stratified, 20% sample of those aged 75 years and over (133 patients). Results showed that 96% of patients before the assessment and 98% of patients afterwards, considered the annual assessment useful. The domiciliary visit by the health visitors resulted in one third of those patients who perceived themselves to be in good health and three quarters of those who perceived themselves to be in poor health becoming less worried about their health. Only two patients became more worried. Half of those objectively assessed as being in the medium health risk group and 68% of those in the high health risk group became less worried about their health after screening. Despite the majority of patients having welcomed the assessment their visit resulted in false, and potentially harmful, reassurance for a considerable number of individuals objectively assessed as being at medium and high health risk. An adverse consequence of health screening in elderly people may be inappropriate reassurance for those objectively assessed to be at risk. However, screening procedures are a means to an end, not an end in themselves. The identification of those at high risk should see subsequent implementation of services, investigations and increased support to relieve suffering, so it may have been that patients felt less anxious because they were anticipating relief of their problems.

Reducing therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care: global measures of outcome in a randomised controlled trial.

BACKGROUND: Panic disorder, with and without agoraphobia, is a prevalent condition presenting in general practice. Psychological treatments are effective but are limited by restricted availability. Interest has grown in methods by which the efficiency and thus availability of psychological treatments can be improved, with particular emphasis on reduced therapist contact formats. AIM: To evaluate the relative efficacy in a primary care setting of a cognitive behaviour therapy (CBT) delivered at three levels of therapist contact: standard contact, minimum contact, and bibliotherapy. METHOD: A total of 104 patients were randomly allocated to receive standard therapist contact, minimum therapist contact or bibliotherapy, with 91 patients completing treatment. All patients received an identical treatment manual and were seen by the same psychologist therapist. Outcome was reported in terms of brief global ratings of severity of illness, change in symptoms, and levels of social disruption. These brief measures were chosen to be suitable for use in general practice and were used at treatment entry and endpoint. RESULTS: The standard therapist contact group had the strongest and most comprehensive treatment response, showing significant differences from the bibliotherapy group on all, and the minimum therapist contact group on some, endpoint measures. Some reduction in efficacy was therefore found for the reduced therapist contact groups. CONCLUSION: The standard therapist contact group showed the greatest treatment efficacy in the present study. As it was of notably shorter duration than many other current formulations of CBT, it represents a useful and efficient treatment for panic disorder and agoraphobia in primary care.

Controlled comparison of the characteristics of patients with panic disorder.

BACKGROUND: Increased general practice attendance rates have been associated with the diagnosis of mental illness but panic disorder has not been specifically investigated in this respect. In addition, studies have failed adequately to assess type and frequency of secondary care referral and patterns of psychotropic prescription in patients with panic disorder in relation to matched controls. AIM: This study set out to compare subjects with panic disorder with age and sex matched controls on measures of general practice consultation rate; psychotropic and non-psychotropic drug use; referral to secondary care, laboratory and radiological tests and hospital admissions; history of illness and complaints; and psychiatric comorbidity. METHOD: The study was carried out in nine practices in the Forth Valley area. One hundred patients with panic disorder, previously diagnosed using DSM III-R criteria, were identified and matched by age and sex with controls. Data were collected by review of general practice case notes. RESULTS: Subjects with panic disorder had significantly higher rates of general practice consultation over the 10 year period prior to DSM III-R diagnosis of panic disorder than controls. Subjects with panic disorder had also been prescribed a significantly greater number of psychotropic and non-psychotropic medications over this period, had had more secondary care investigations and had higher rates of mainly minor illness and related complaints than controls. High comorbidity of panic disorder with depression which had been diagnosed over the 10 year period prior to DSM III-R diagnosis of panic disorder was found. CONCLUSION: The results of this study describe a population of subjects with panic disorder who are long-term heavy users of primary care services. The results also suggest an association between panic disorder and both minor illness and psychiatric comorbidity over the 10 year period prior to DSM III-R diagnosis of panic disorder.

Travellers' diarrhoea and the effect of pre-travel health advice in general practice.

BACKGROUND: Rates of travel-related diarrhoea vary from 8% to 50% depending on the country visited. Travellers' diarrhoea has social, health and economic costs. The impact of these may be reduced by relevant pre-travel advice. Little is known of the effect of pre-travel advice on the incidence of diarrhoea among travellers abroad. AIM: To determine the 'true' attack rate of travellers' diarrhoea and to assess the effectiveness of pre-travel health advice in reducing the incidence of diarrhoea and the need for subsequent GP consultation. METHOD: A retrospective study was carried out in a general practice in Stirling, Scotland, using a standardized, structured questionnaire to obtain demographic details and patients' home and foreign health experience in the previous 12 months. The questionnaire was administered to a 20% sample (n = 1771) of practice patients aged 16 years or over, stratified by age and sex. Main outcome measures were reported diarrhoeal illness while abroad, its management and outcome, and a record of diarrhoea in the two weeks prior to responding to the questionnaire. RESULTS: The response rate was 97% (n = 1649). Of those responding, 44% had travelled abroad in the past 12 months; 39% of travellers reported having diarrhoea while abroad, while 6% of the same group reported diarrhoea in the two weeks prior to being questioned; 9.7% of non-travellers reported diarrhoea in the two weeks prior to being questioned. Travellers were 6.5 times more likely to experience diarrhoea while abroad than when spending a comparable 2-week period at home. Travellers who had sought pre-travel advice were more likely to be travelling to a high-risk destination (P < 0.0001) and were more likely to suffer diarrhoea while abroad (P < 0.05); however, they were less likely to need medical help while abroad or on their return (P < 0.0001). The results indicate a markedly higher attack rate of diarrhoea in patients travelling abroad than would be expected if they stayed at home. CONCLUSION: Pre-travel advice does reduce the need for medical assistance while abroad; it also reduces GP work-load in terms of post-travel health consultations with returning travellers.

Controlled comparison of pharmacological and psychological treatment of generalized anxiety disorder in primary care.

A sample of 101 patients with generalized anxiety disorder were randomly allocated to one of five groups--diazepam, placebo, cognitive-behaviour therapy, diazepam plus cognitive-behaviour therapy, or placebo plus cognitive-behaviour therapy--and treated over 10 weeks in a primary care setting. All groups received a similar amount of contact with the psychologist and general practitioner. The greatest improvement in ratings of severity of symptoms and overall change in symptoms occurred with cognitive-behaviour therapy combined with diazepam; cognitive-behaviour therapy alone also performed well and cognitive-behaviour therapy plus placebo performed slightly less well. Diazepam alone showed improvement relative to placebo alone. There was a high level of agreement between ratings by the general practitioners, psychologist, and the patients of the response to treatment. At six months follow-up there was no difference between treatment groups in the proportion of patients receiving psychotropic medication after the end of the study. However, cognitive-behaviour therapy, either alone or in combination with drug or placebo, showed the lowest incidence of referral for psychological or psychiatric treatment at six months follow-up.

Global measures of outcome in a controlled comparison of pharmacological and psychological treatment of panic disorder and agoraphobia in primary care.

BACKGROUND: Panic disorder, with and without agoraphobia, is a prevalent condition which presents primarily in general practice. Previous clinical outcome studies have been conducted mainly in specialist university departments or hospital settings, and have tended to employ complex rating scales that are not well suited for use as outcome measures in primary care. AIM: To evaluate the outcome, in a primary care setting, of fluvoxamine versus cognitive behaviour therapy, each used alone and in combination in a double-blind placebo-controlled framework, balanced for therapist contact. METHOD: A total of 149 patients satisfying DSMIII-R criteria for panic disorder were randomly allocated to receive one of the following: fluvoxamine, placebo, fluvoxamine plus cognitive behaviour therapy, placebo plus cognitive behaviour therapy, and cognitive behaviour therapy alone. These five treatment groups represent the minimum number acceptable for such a comparison to be made. All patients received an identical schedule of contact over 13 weeks. Measures of symptom severity, general health and social disruption were taken at entry point and end point; measures of change in symptoms were taken at end point only. Outcome was reported in terms of brief global ratings of severity of illness and change in symptoms, and of ratings of general health and social disruption that are suitable for use in general practice. RESULTS: All active treatment groups showed statistically significant advantages over placebo over a range of outcome ratings. The groups employing cognitive behaviour therapy showed the most robust and consistent response. CONCLUSION: The brief global measures reported here proved adequate to the task of assessing treatment outcome. Results indicate that treatments including cognitive behaviour therapy can be effective in the treatment of panic disorder and agoraphobia in primary care.

Controlled comparison of the characteristics of long-term benzodiazepine users in general practice.

From three general practices, served by 11 principals, 205 long-term benzodiazepine users were identified and matched for age and sex with controls. Benzodiazepine users had significantly higher rates of previous physical illness, consultation and non-psychotropic drug consumption than controls. The characteristics of those receiving prescriptions for benzodiazepine hypnotics alone, anxiolytics alone and anxiolytics plus hypnotics were also investigated. Significant differences emerged between these three groups. Patients receiving hypnotics only were older, had a history of more physical illness and had received more non-psychotropic medication than patients receiving anxiolytics only. The anxiolytic plus hypnotic group had previously received more hypnotics and were currently receiving more medication than the group receiving anxiolytics alone. The results are discussed in relation to current concerns about benzodiazepine dependence and withdrawal.

Anxiety and health problems related to air travel.

BACKGROUND: A significant proportion of air travelers experience situational anxiety and physical health problems. Take-off and landing are assumed to be stressful, but anxiety related to other aspects of the air travel process, anxiety coping strategies, and in-flight health problems have not previously been investigated. METHODS: We aimed to investigate frequency of perceived anxiety at procedural stages of air travel, individual strategies used to reduce such anxiety, and frequency of health problems on short-haul and long-haul flights. A questionnaire measuring the occurrence and frequency of the above was administered to two samples of intending travelers during a 3 month period to: (a) 138 travel agency clients, and (b) 100 individuals attending a hospital travel clinic. RESULTS: Of the 238 respondents, two thirds were women. Take-off and landing were a perceived source of anxiety for about 40% of respondents, flight delays for over 50%, and customs and baggage reclaim for a third of individuals. Most frequent anxiety-reduction methods included alcohol and cigarette use, and distraction or relaxation techniques. Physical health problems related to air travel were common, and there was a strong relationship between such problems and frequency of anxiety. Travel agency clients reported more anxiety but not more physical health symptoms overall than travel clinic clients. Women reported greater air-travel anxiety, and more somatic symptoms than men. CONCLUSIONS: Significant numbers of air travelers report perceived anxiety related to aspects of travel, and this is associated with health problems during flights. Airlines and travel companies could institute specific measures, including improved information and communication, to reassure clients and thereby diminish anxiety during stages of air-travel. Medical practitioners and travel agencies should also be aware of the potential stresses of air travel and the need for additional information and advice.

The impact of travel acquired illness on the world traveller and family doctor and the need for pre-travel health education.

This retrospective study involved a 20% quota, age and sex stratified sample of people over 16 years of age, presenting to a group medical practice over a period of one year (N = 1568). A standardised, computer-scored, self-report questionnaire was administered. The response rate was 98.3%. 42% of respondents had travelled outwith the UK in the previous year. Of those, 42% had become ill whilst abroad. In 20.5% of cases the illness settled without treatment. However, 26% of the patients required consultation with a doctor whilst abroad and 48.4% of those becoming ill required further attention from the family doctor on return home. 5% of ill travellers were admitted to hospital abroad. 8% of all travellers did not have medical insurance cover. A large and significant population of travellers become ill whilst abroad, and travel-acquired illness has a large impact on general practice, with 1 in 5 travellers seeking GP consultation on return home. Improved practice-generated pre-travel health advice might decrease this burden on primary care.

A comparison of sources of nursing stress and job satisfaction among mental handicap and hospice nursing staff.

This study compares sources of nursing stress and job satisfaction among 181 mental handicap and 24 hospice nurses. It was hypothesized that nursing stress varies as a consequence of nursing specialty. Analysis of variance revealed differing features of nursing stress between the two specialties. Hospice nurses reported stress as primarily associated with death and dying and inadequate preparation to meet the emotional needs of patients and their families, while mental handicap nurses reported stress related to workload, conflict with other nurses and nursing environment. The results suggest that two additional factors that did not differ between specialties require further examination, namely patient behaviour and purposelessness of nursing care. Job satisfaction also differed between specialties with hospice nurses reporting higher satisfaction with supervision, co-workers, and pay, and lower satisfaction with promotion in comparison to mental handicap nurses. Within the mental handicap groups nursing stress correlated with job satisfaction, state-trait anxiety and non-psychotic psychiatric disturbance in predicted directions. Analysis of the above variables with respect to mental handicap nursing grade was also undertaken. Overall results indicate the importance of nursing specialty as a major factor influencing nursing stress.