Assessing somatization in urologic chronic pelvic pain syndrome.

BACKGROUND: This study examined the prevalence of somatization disorder in Urological Chronic Pelvic Pain Syndrome (UCPPS) and the utility of two self-report symptom screening tools for assessment of somatization in patients with UCPPS. METHODS: The study sample included 65 patients with UCPPS who enrolled in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Study at Washington University. Patients completed the PolySymptomatic PolySyndromic Questionnaire (PSPS-Q) (n = 64) and the Patient Health Questionnaire-15 Somatic Symptom Severity Scale (PHQ-15) (n = 50). Review of patient medical records found that only 47% (n = 30) contained sufficient documentation to assess Perley-Guze criteria for somatization disorder. RESULTS: Few (only 6.5%) of the UCPPS sample met Perley-Guze criteria for definite somatization disorder. Perley-Guze somatization disorder was predicted by definite PSPS-Q somatization with at least 75% sensitivity and specificity. Perley-Guze somatization disorder was predicted by severe (> 15) PHQ-15 threshold that had > 90% sensitivity and specificity but was met by only 16% of patients. The moderate (> 10) PHQ-15 threshold had higher sensitivity (100%) but lower specificity (52%) and was met by 52% of the sample. CONCLUSIONS: The PHQ-15 is brief, but it measures symptoms constituting only one dimension of somatization. The PSPS-Q uniquely captures two conceptual dimensions inherent in the definition of somatization disorder, both number of symptoms and symptom distribution across multiple organ systems, with relevance for UCPPS as a syndrome that is not just a collection of urological symptoms but a broader syndrome with symptoms extending beyond the urological system.

A naturalistic longitudinal study of the order of service provision with respect to cocaine use and outcomes in an urban homeless sample.

AIMS: Little is known about outcomes of drug abuse related to attainment of stable housing. This study examined outcomes of cocaine use and service provision in an urban homeless sample. METHODS: Two-year longitudinal study of systematically selected homeless individuals (N = 255) in St. Louis, Missouri from 1999 to 2001. The sample was interviewed three times annually using a structured diagnostic interview. Urine drug testing was conducted at every interview, and service utilisation data were obtained from the structured interviews and the agency-provided service use data. RESULTS: Cocaine use disorder and cocaine use proved to be distinct concepts because they predicted different outcomes across time. Cocaine use predicted subsequent poor housing outcomes, but stable housing had no apparent effect on subsequent use of cocaine. Service use predicted neither subsequent reduced cocaine use nor attainment of stable housing. Services used were appropriate to type of mental health need, but cocaine use may have reduced successful utilisation of appropriate psychiatric services. CONCLUSION: These findings reinforce the concept that homelessness represents a complex phenomenon and consequently, service systems need to address multiple problems. Service approaches are needed that simultaneously address the complex needs of homeless individuals.

Knowledge and attitudes about hepatitis C virus (HCV) infection and its treatment in HCV mono-infected and HCV/HIV co-infected adults.

Hepatitis C virus (HCV) treatment is rapidly changing but little is known about patients' attitudes and knowledge about HCV. This study used a cross-sectional survey to examine the relationship between HCV knowledge and attitudes towards HCV in patients with HCV mono-infection and HIV/HCV co-infection. Subsequently, an education intervention was developed with an abridged version of the cross-sectional survey administered before and after the education session to assess changes in knowledge and attitudes. 292 people participated in the cross-sectional survey, and 87 people participated in the education intervention. In the cross-sectional survey, the mean knowledge score regarding HCV was low (<50% of the total possible score). Mono-infected and co-infected individuals shared similar knowledge deficits and attitudes towards HCV despite having distinct demographic differences. Attitudes endorsed by patients included the following: 57% feared the consequences of HCV on their life, 37% felt HCV was not fatal, 27% did not believe they needed HCV medication, 21% felt ashamed of having HCV and 16% felt HCV treatment was not important. Attitudes that reflected indifference and shame towards HCV were associated with lower knowledge scores (HCV knowledge score of 15.1 vs. 17.5, P < 0.01 for indifference and 15.3 vs. 17.2 for shame, P = 0.02). The education intervention improved knowledge scores but did not modify the assessed attitudes. Intervention studies are needed to effectively change attitudes towards HCV infection and treatment.

A prospective study of coping after exposure to a mass murder episode.

In a study of 136 survivors of a mass murder spree, multidimensional scaling identified clusters of responses mapping from 75 coping behaviors described by victims. This powerful method identified three coping dimensions: (a) Active Outreach versus Passive Isolation, (b) Informed Pragmatism versus Abandonment of Control, and (c) Reconciliation/Acceptance versus Evading the Status Quo. These coping dimensions were used to predict change in psychiatric status prospectively assessed with structured diagnostic interviews at index 3-4 months after the event and follow-up assessments 1 and 3 years later. Statistically significant changes in the positive direction on each of the three dimensions in this study were associated with reductions of 47-79% of the odds for acute postdisaster major depression, posttraumatic stress disorder (PTSD), and any non-PTSD disorder. These findings suggest mechanisms for development of therapeutic techniques capitalizing on encouraging active outreach, informed focus and pragmatism, and reconciliation and acceptance, and reduction of passive and isolative behaviors, resignation of control, and avoidance of realities of the postdisaster situation.

Laboratory screening prior to ECT.

INTRODUCTION: Screening for occult disease using laboratory testing prior to electroconvulsive therapy (ECT) is a common practice with little empirical support. METHOD: In a pre-ECT and post-ECT sample of 73 and 562 (respectively) patients evaluated for ECT, the utility of the electrocardiogram, serum sodium, serum potassium, serum creatinine, chest radiograph, hemoglobin level, and white blood cell count was examined. RESULTS AND DISCUSSION: Reviewing the electrocardiogram and measuring sodium and potassium levels prior to the administration of ECT appear to be useful screening tests because they detect correctable unexpected conditions that are relevant to the risk of the procedure. Hemoglobin and white blood cell count abnormalities did not influence the administration of ECT or predict ECT complications. An abnormal creatinine level or abnormal chest radiograph prior to the administration of ECT predicted a poor medical prognosis that appeared largely unrelated to the administration of ECT.

The impact of psychiatric diagnosis and family system relationship on problems identified by families coping with a mentally ill member.

The purpose of this study was to explore how psychiatric diagnosis and family relationships relate to problems identified by participants in three one-day public family psychoeducation workshops for families with a member with a serious mental illness. Workshop participants generated lists of problems they had faced, which were coded into eleven categories. Logistic regression models predicting listing of categories were developed based on ill member (diagnosis, sex, treatment compliance) and family member (sex, age, relationship to the ill member) characteristics. For models predicting content category from ill member characteristics, only denial/noncompliance and interpersonal/social categories were significantly predictive as dependent variables. For models predicting content categories from family member characteristics, only the resources/benefits model was predictive. The significant findings, in conjunction with the important negative results, suggest implications for further development of family intervention models. Building on previous research, groups composed of families coping with more than a single diagnosis and including a variety of family member relationships have the potential to reach consensus on curriculum topics.

The association of irritable bowel syndrome and somatization disorder.

BACKGROUND AND OBJECTIVE: Irritable bowel syndrome (IBS) and somatization disorder (SD) are defined by nonobjective symptoms that overlap considerably. Psychiatric symptoms associated with IBS may originate from SD in IBS patients. Previous studies of IBS have not considered SD separately from IBS. METHODS: This study explored psychiatric symptoms and illness behavior in IBS in relation to SD. A total of 50 outpatients with IBS or ulcerative colitis (UC) were evaluated with the Diagnostic Interview Schedule and Illness Behavior Questionnaire. RESULTS: Definite or probable SD was diagnosed in no UC patients and in 42% of IBS patients (confirmed in 25% and lacking one symptom in another 17%). IBS patients with probable or definite SD, but not those without SD, reported more psychiatric symptoms and abnormal illness behaviors than did UC patients. SD accounted for the association of psychiatric symptoms with IBS. CONCLUSIONS: In this university-based office setting, the association of psychiatric features with IBS appears heterogeneous predicated on whether SD is present. Future studies of functional bowel diseases should distinguish between patients with and without SD to clarify its relationship to these disorders. Clinicians should consider whether patients with functional disorders have SD, a diagnosis that indicates specific clinical management strategies.

The emotional impact of injury following an international terrorist incident.

BACKGROUND: Terrorism represents a major public health threat throughout the world. Bombings of the United States Embassies in East Africa in 1998 resulted in extensive physical and emotional casualties. METHODS: This study examined posttraumatic stress reactions, worry, and feelings of safety in the workplace in the context of injury in a convenience sample of 21 individuals directly exposed to the bombing in Dar es Salaam, Tanzania. Eight months postbombing, participants completed a self-report instrument examining demographics, exposure, injury, initial reaction, posttraumatic stress, worry, and feelings of safety in the workplace. Descriptive statistics and multiple regression were used to analyze the data. The "Impact of Event Scale-Revised" measured current posttraumatic stress. RESULTS: Report of injury predicted posttraumatic stress, intrusion, and arousal but not avoidance/numbing. Injury and intrusion were significant predictors of ongoing worry. CONCLUSIONS: Even relatively minor injury may be associated with ongoing posttraumatic stress and worry. The participants in the sample were all highly exposed which, along with the small sample size, may have limited the ability to establish other expected relationships.

The course of post-traumatic stress disorder after the Oklahoma City bombing.

Oklahoma City bombing survivors (N = 182) were studied 6 months post-bombing and reassessed approximately 1 year later (N = 141) to determine the longitudinal course of post-traumatic stress disorder (PTSD) and other psychiatric disorders. The Diagnostic Interview Schedule assessed lifetime, current, predisaster, and post-bombing psychiatric diagnoses at both assessment points. One-third of the Oklahoma City bombing survivors had PTSD at index, and similar rates were diagnosed at follow-up. More recovery from depression was apparent than from PTSD. No delayed onset PTSD was observed, and all PTSD was chronic. Avoidance and numbing symptoms were dominant in defining the development of PTSD. Early onset and chronicity of PTSD indicate need for prompt and long-term intervention after disasters. Focus on avoidance and numbing symptoms may aid in identification of individuals needing intervention and monitoring the course of PTSD.

Service use over time and achievement of stable housing in a mentally ill homeless population.

OBJECTIVE: Service use among clients of a multiservice agency serving homeless persons with severe mental illness was examined to determine whether patterns of service use reflected two stages in an adaptation of the transtheoretical model of change. In the adapted model, change occurs in five stages-pre-engagement, contemplation, engagement, the strategic moment, and consolidation. It was hypothesized that rates of service use would be highest immediately after clients obtained housing (the strategic moment) and would decrease in the months afterward (consolidation stage), with the greatest decreases occurring immediately after housing was obtained. METHODS: Service use data were collected for two groups: a housed group of 58 clients who had obtained and sustained stable housing for at least 24 consecutive months at the time of sampling and an unhoused group of 55 clients who were matched with the housed clients on month of service entry. Total service use and use of three service types-a drop-in center, counseling, and health services-were examined to test the hypotheses. It was hypothesized that use of services by the unhoused group would show a consistent linear decline rather than a two-stage decline. Linear spline regression using bootstrap sampling methods was used to fit service use data for both groups. RESULTS: The two-stage solution significantly modeled the patterns of service use by the housed but not the unhoused clients, supporting the hypotheses. For the housed group, use of the drop-in center and counseling fit the model, and use of health services did not. CONCLUSIONS: The results provide limited support for the hypothesized five-stage model for achieving change.

Agency-based tracking of difficult-to-follow populations: runaway and homeless youth programs in St. Louis, Missouri.

OBJECTIVES: This study explored agency-based tracking methods for one of the most difficult-to-follow populations: runaway and homeless youth. METHODS: A total of 118 program discharges from three federally funded agencies serving runaway/ homeless youth in St. Louis, Missouri were tracked for a follow-up study of this population. Agency staff attempted to locate and interview program participants three months post-discharge using a protocol that systematically varied times and location of contact attempts. Separate analyses were conducted to compare the group of subjects whose locations were ascertained with those who were not, and who were successfully interviewed with those who were not. Variables related to the tracking protocol and individual descriptive and service use variables were examined in these analyses. RESULTS: Sixty-nine percent of the sample was successfully located and fifty-nine percent interviewed. Significant findings included: fewer contact attempts over fewer days were made for individuals successfully interviewed, individuals tracked through Division of Family Services were less likely to be both located and interviewed, and individuals successfully located were significantly younger. CONCLUSIONS: This report provides encouraging evidence that even relatively unsophisticated protocols for tracking agency clients developed in collaboration with community agencies can--with consistent implementation--yield follow-up samples that are acceptably representative of program participants.

The American Red Cross disaster mental health services: development of a cooperative, single function, multidisciplinary service model.

Not until 1989 did the Red Cross officially recognize a need for a systematic and organized plan for the mental health needs of disaster survivors. Over the next decade, the Red Cross Disaster Mental Health Services program has developed and evolved to assist both disaster victims and the Red Cross workers who serve them to cope with the overwhelming stresses encountered by both groups in the aftermath of disasters. The Red Cross now coordinates a large and diverse group of mental health professionals from fields of psychology, psychiatry, nursing, social work, marriage and family therapy, and counseling who work together cooperatively. Cross-disciplinary conflicts are minimized by the Red Cross' generic approach to the various mental health professional specialties as functionally interchangeable in performing Red Cross duties. This article reviews the development of this process and describes one local Red Cross chapter's early experience as part of this effort.

What parts of PTSD are normal: intrusion, avoidance, or arousal? Data from the Northridge, California, earthquake.

The incidence and comorbidity of posttraumatic stress disorder (PTSD) are addressed in a study of 130 Northridge, California, earthquake survivors interviewed 3 months post-disaster. Only 13% of the sample met full PTSD criteria, but 48% met both the re-experiencing and the arousal symptom criteria, without meeting the avoidance and numbing symptom criterion. Psychiatric comorbidity was associated mostly with avoidance and numbing symptoms. For moderately severe traumatic events, re-experiencing and arousal symptoms may be the most "normal," and survivors with a history of psychiatric problems may be those most likely to develop full PTSD. A system that considers people who meet all three symptom criteria to have a psychiatric disorder yet recognizes the distress of other symptomatic survivors may best serve traumatized populations.

Irritable bowel syndrome in a psychiatric patient population.

The prevalence of irritable bowel syndrome (IBS) in psychiatric practice was studied in 41 consecutive psychiatric outpatients. Different criteria for IBS were applied to the data set to determine the effects on the rates of IBS obtained. Depending on an option in the Rome criteria, IBS rates varied from 13% using the "and" requirement for combining abdominal pain and altered bowel function symptoms, to 41% using the "and/or" option described in the formal definition statement in 1990. The resultant prevalence rates of IBS varied greatly according to which published criteria were applied, with a maximum of 71%. This wide variation in rates depending on the criteria underscores the critical importance of standardizing diagnostic research criteria for IBS. An exemplary model of empirically based validation has been developed for psychiatric disorder criteria which, like IBS, are symptom-based and lack physiological determinants. Validated diagnostic criteria for IBS await similar study.

Psychiatric disorders among survivors of the Oklahoma City bombing.

CONTEXT: Disasters expose unselected populations to traumatic events and can be used to study the mental health effects. The Oklahoma City, Okla, bombing is particularly significant for the study of mental health sequelae of trauma because its extreme magnitude and scope have been predicted to render profound psychiatric effects on survivors. OBJECTIVE: To measure the psychiatric impact of the bombing of the Alfred P. Murrah Federal Building in Oklahoma City on survivors of the direct blast, specifically examining rates of posttraumatic stress disorder (PTSD), diagnostic comorbidity, functional impairment, and predictors of postdisaster psychopathology. DESIGN, SETTING, AND PARTICIPANTS: Of 255 eligible adult survivors selected from a confidential registry, 182 (71%) were assessed systematically by interviews approximately 6 months after the disaster, between August and December 1995. MAIN OUTCOME MEASURES: Diagnosis of 8 psychiatric disorders, demographic data, level of functioning, treatment, exposure to the event, involvement of family and friends, and physical injuries, as ascertained by the Diagnostic Interview Schedule/Disaster Supplement. RESULTS: Forty-five percent of the subjects had a postdisaster psychiatric disorder and 34.3% had PTSD. Predictors included disaster exposure, female sex (for any postdisaster diagnosis, 55% vs 34% for men; chi2 = 8.27; P=.004), and predisaster psychiatric disorder (for PTSD, 45% vs 26% for those without predisaster disorder; chi2 = 6.86; P=.009). Onset of PTSD was swift, with 76% reporting same-day onset. The relatively uncommon avoidance and numbing symptoms virtually dictated the diagnosis of PTSD (94% meeting avoidance and numbing criteria had full PTSD diagnosis) and were further associated with psychiatric comorbidity, functional impairment, and treatment received. Intrusive reexperience and hyperarousal symptoms were nearly universal, but by themselves were generally unassociated with other psychopathology or impairment in functioning. CONCLUSIONS: Our data suggest that a focus on avoidance and numbing symptoms could have provided an effective screening procedure for PTSD and could have identified most psychiatric cases early in the acute postdisaster period. Psychiatric comorbidity further identified those with functional disability and treatment need. The nearly universal yet distressing intrusive reexperience and hyperarousal symptoms in the majority of nonpsychiatrically ill persons may be addressed by nonmedical interventions of reassurance and support.

Psychiatric symptoms endorsed by somatization disorder patients in a psychiatric clinic.

Patients with somatization disorder (SD) endorse high rates of psychiatric symptoms. However, prior studies have not addressed whether these endorsed symptoms reflect underlying psychiatric illness or whether they represent symptom overendorsement mirroring somatic complaints in patients with SD. Thirty-two female outpatients with SD and 101 with other psychiatric disorders completed a checklist of current and lifetime psychiatric symptoms. These findings were analyzed with respect to the diagnoses given by their treating psychiatrists. Patients with SD displayed significantly more current and lifetime psychiatric symptoms than did patients without either SD or cluster B personality disorder. Patients with SD endorsed a large number of psychotic, manic, depressive, and anxiety symptoms; however, they endorsed few alcohol use disorder symptoms. Psychotic and manic symptoms endorsed by patients with SD did not reflect their clinical diagnoses: only two patients with SD carried an additional clinician diagnosis of either schizophrenia or bipolar disorder, despite high rates of endorsed symptoms by the group. Patients with cluster B personality disorders but without SD showed a symptom profile similar to that of patients with SD. Psychiatric outpatients with SD endorse many more psychiatric symptoms than do other psychiatric patients. Patients with SD in the psychiatric treatment setting may mimic other psychiatric illnesses; therefore, SD should be considered in the differential diagnosis for a wide variety of psychiatric illness, including psychotic and mood disorders.

Correlates of early onset and chronicity of homelessness in a large urban homeless population.

This study examined temporal relationships between relative onsets of mental illness and homelessness in a cross-sectional study of 900 homeless people compared with a matched, never-homeless sample from the Epidemiologic Catchment Area study. All psychiatric disorders preceded homelessness in the majority. Only one disorder, alcohol use disorder (in men only), had significantly earlier onset in homeless subjects. Regarding number of symptoms or earlier age of onset of psychiatric disorders, earlier onset of homelessness was associated with several diagnoses: schizophrenia, major depression, generalized anxiety disorder, alcohol and drug use disorders, and antisocial personality. In multiple regression models, history of dysfunctional family background and maternal psychiatric illness were also associated with earlier onset of homelessness, whereas education was protective. Chronicity of homelessness was associated with number of symptoms of alcohol use disorder and earlier age of onset of drug use disorder, presence and number of symptoms of schizophrenia and antisocial personality, and earlier onset of major depression and conduct disorder. In multiple regression models, more education, but not family background problems, was associated with shorter lifetime duration of homelessness. These findings provide information relevant to the roles of mental illness and personal vulnerability factors in the onset and chronicity of homelessness.