Relationship between social support and autonomic function during a stress protocol in ulcerative colitis patients in remission.

BACKGROUND: The relationship of psychological stress to relapse in ulcerative colitis (UC) is inconsistent. This may be due to a failure to identify patient characteristics, such as social support, which moderate the transduction of stress from the central nervous system to the immune system. In this study we tested the hypothesis that social support enhances parasympathetic modulation of heart rate in UC. METHODS: An indirect measure of autonomic function (heart rate variability; HRV) was measured in 108 patients with UC in remission during a standard protocol involving periods of stress, paced breathing, and relaxation. Social support was measured with the Social Support Questionnaire. RESULTS: After controlling for age, which is strongly related to HRV, both satisfaction with social support (F = 5.7, significance = 0.002) and its interaction with age (F = 7.8, significance <0.001) were associated with high-frequency HRV, which measures parasympathetic modulation of heart rate. Social support was associated with higher levels of high-frequency HRV at almost all points in the stress protocol. Neither age nor social support was associated with differences in the LF/HF ratio, which measures sympathetic modulation of heart rate. CONCLUSIONS: Social support is related to parasympathetic activity in UC. Given previous evidence of an antiinflammatory role for the parasympathetic nervous system, this suggests that autonomic function could serve as a mediating link between social support and reduced inflammatory activity.

The impact of ulcerative colitis is greater in unmarried and young patients.

GOALS: To determine whether the perceived impact of ulcerative colitis (UC) on activities of living (illness intrusiveness) is greater for people who are not living in a married or common-law relationship. BACKGROUND: In general, social and occupational achievement is not greatly impaired by UC, yet patients, especially young adults, often have interpersonal concerns. METHODS: One hundred fifty-five outpatients with UC were assessed for disease activity, and completed self-reports of marital status, income, social support and illness intrusiveness. RESULTS: Fifty-one patients (32.9%) were single, separated or divorced, and 104 patients (67.1%) were married or in common-law relationships. Compared with those who were married or in common-law relationships, single or separated patients were younger, had a lower household income, had lived with UC for fewer years and were less satisfied with social support. Among 135 patients in remission, marital status was significantly associated with illness intrusiveness, controlling for age, income and perceived social support (F=5.73; P=0.02). Low social support (F=4.94; P=0.03) and younger age (F=7.24; P=0.008) were independently associated with illness intrusiveness. Single patients in remission reported illness intrusiveness of similar severity to that reported by patients with active disease. CONCLUSIONS: The perceived impact of UC on the lives of patients is greater in those who are not married or living in common-law relationships. Youth, single status and lower social support commonly coexist, and exert additive effects on the functional impact of UC. Resources to improve social support should be directed toward this group of patients.

Insecure attachment in a subgroup with ulcerative colitis defined by ANCA status.

This study is the first test of the novel hypothesis that perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) marks an etiological division between stress-susceptible and stress-neutral ulcerative colitis. Subjects were 47 UC patients with known p-ANCA status (19 p-ANCA-positive, 28 p-ANCA-absent). Controls were 77 university students. Subjects and controls completed the Reciprocal Attachment Questionnaire. Subjects were categorized as avoidant/nonavoidant and anxious/nonanxious based on scores for compulsive self-reliance and compulsive care seeking, respectively. A higher prevalence of avoidant attachment was present in p-ANCA-absent (58.6%) than p-ANCA-positive subjects (22.2%, chi-square = 5.95, P < 0.02). There was no difference in the prevalence of anxious attachment between p-ANCA-absent and p-ANCA-positive subjects. There was no difference in clinical and psychiatric variables between groups. This finding provides support for a psychobiological contribution to UC in a subgroup identified by the absence of p-ANCA.

The perceived family burden scale: measurement and validation.

Findings in family burden research suggest that, in families with a mentally ill relative, patterns of family interaction develop in response to the onset of major mental illness and result from the burden experienced by family members in coping with illness. The present study focused on instrument development and validation of the Perceived Family Burden Scale (PFBS), a measure of those patient behaviors associated with schizophrenia and the impact of these behaviors on relatives. The PFBS was found to be a valid and reliable instrument which demonstrated greater predictive power for early symptomatic relapse in schizophrenia than another measure of family interaction, expressed emotion.

Factors contributing to nurses' difficulty in treating patients in short-stay psychiatric settings.

Difficulties experienced by nurses in treating a total of 249 patients in four short-stay psychiatric units were examined using a rating scale that assessed such factors as overall extent of treatment difficulty, patients' problem behaviors, adequacy of treatment resources, and staff members' affective responses. Data from each site were analyzed separately using stepwise hierarchical regression. The findings indicated that patient problem behaviors and treatment resources were comparable between settings. Except for patient violence, none of the problems were consistently related to overall treatment difficulty across settings. The results suggest that treatment difficulty is related to the unique combination of patient characteristics, resource deficits, and treatment philosophies in particular treatment settings and that efforts to reduce treatment difficulty should address setting-specific issues.

The relationship between nurses' limit-setting styles and anger in psychiatric inpatients.

OBJECTIVE: Violence by patients in psychiatric settings is frequently associated with the quality of staff-patient interactions. Impulsivity has been identified as a high risk factor for anger and aggression. This study was designed to test the influence of nurses' limit-setting styles on anger among psychiatric inpatients grouped by high or low levels of impulsivity. METHODS: Ninety-seven patients with various diagnoses and either high or low levels of impulsivity participated in role-play scenarios in which nurse actors played out six limit-setting styles, ranging from belittlement to explanations of rules to empathy linked with a presentation of an alternative course of action. Patients' level of anger in response to the acted scenario was assessed using the Spielberger State-Trait Anger Scale. RESULTS: Patients' level of anger was highest in response to unempathic limit-setting styles, moderate for explanations, and lowest for empathic styles. Impulsive subjects were more likely to respond with anger than nonimpulsive patients, regardless of the limit-setting style. CONCLUSIONS: Although many current intervention programs focus on reducing patients' anger after it occurs, the study results suggest that it may be possible to prevent some of patients' anger by improving nurses' limit-setting styles.

The impact of pain and impaired role performance on distress in persons with cancer.

The observed upward trend in the incidence of many cancers is expected to continue for the next 20 years despite monumental basic research efforts. There are interpersonal and intrapsychic complications associated with cancer and its treatment leading to considerable distress which, in extreme cases, becomes clinical depression and anxiety. Pain and impaired role performance have been cited as being important sources of distress in people with cancer. This paper presents data from a community sample of 1,309 people living with cancer in Prince Edward Island, Manitoba and Quebec and examines risk factors for cancer-related distress. In the model tested in this paper, pain and other symptoms and treatment side-effects as well as cancer-related fears were seen to have direct and indirect effects on psychological symptoms of distress. Impaired role performance was a central mediator for the indirect effects. The model explained 34% of the variance in distress scores (General Health Questionnaire) and was equally applicable to all three study sites, both male and female subjects, rural and urban settings, and to all stages of illness. Pain was the single most important explanatory variable. Impaired role performance had a negative effect on distress over and above the effect of pain. The results suggest that interventions directed at reducing distress in cancer should also address interpersonal issues such as the impact of the illness on family, social network a work.

Recurrent themes of concern in groups for health care professionals.

This paper reports of recurrent themes of concern about AIDS expressed by health care professionals participating in small group sessions. Three dominant themes emerged: fear of contagion, homophobia, and attachment and loss. For each of these themes the possible meanings are explored. Fear of contagion was the dominant theme and is discussed as both a possible expression of displaced homophobia and a 'catastrophic' risk factor (extreme negative consequence). The need of health care professionals to see themselves as 'different' from the person with AIDS is also discussed. Professionals also discussed the emotional burden of caring for young patients often similar in age to themselves. It is suggested that hospital policy makers need to accept the reality of staff concerns and provide adequate forums for expression of concerns since without an opportunity for thoughtful discussion, health care professionals may espouse the 'correct' position and attitude, but believe and practise something else.

Fear of contagion and AIDS: nurses' perception of risk.

Nurses' fear of contagion when caring for persons with AIDS remains high despite increased levels of knowledge. This paper examines the multiple factors that contribute to nurses' perception of risk within the workplace. The authors suggests that constructs from theories such as decision making, psychoanalysis and cognitive psychology can provide insight into the assessment of risk. Findings from a recent survey of nurses are used to illustrate the complex nature of fear of contagion. Understanding this complexity may be an essential first step in order to provide opportunities for resolution of fears and modification of behaviors.

A randomized trial of group interventions for hospital staff caring for persons with AIDS.

The purpose of this study was to develop an educational package for health care providers. Findings from a survey conducted by investigators were used to direct intervention content. All subjects received a 1 hour educational package. Since this type of intervention was not expected to be sufficient to modify attitudes and concerns, 75% of the subjects received an additional 1 hour group discussion intervention (n = 118). In a subgroup of those receiving group interventions, the discussion was preceded by the presence of a person with AIDS (PWA) (in person or on video) discussing his personal experience with the illness and health care workers. It was demonstrated that in order to modify change attitudes, concerns, and affective response, groups were necessary. Furthermore, fear of risk of contagion and homophobia required the presence of a PWA (in person or on video) in order for change to occur.

Marital support and recovery from depression.

A prospective study of 47 married women who met RDC for major depressive disorder investigated the relationship between the social support provided by the husbands and the post-hospital symptom course of the women. Separate taped semistructured interviews were held with the patient and husband at the time of admission. Six months later, symptom course was rated using the LIFE psychiatric status schedule. Only 51% of the sample recovered in the six months. Few demographic or clinical factors were related to symptom course. Recovery was predicted by the depressed woman's ratings of the current marital relationship and by the husband's rating of the pre-morbid relationship but not by the husband's level of expressed criticism or his ratings of the current relationship.

The knowledge, attitudes and concerns of hospital staff about AIDS.

Staff from 3 Toronto hospitals were surveyed for knowledge, attitudes and concerns about AIDS. 70% of the 1,366 respondents had direct clinical experience with persons with AIDS. Data were analyzed according to hospital setting and professional group: physicians, nurses, technologists and supervisory staff. No setting difference was observed and although statistically significant differences (at the .001 level) were observed between professional groups, these differences are small and have little practical importance. In general, subjects answered 68% of the knowledge questions correctly. All attitudes and concerns were inversely associated to knowledge (Pearson r range was -.31 to -.20). Multivariate analysis demonstrated that knowledge and concern about contagion are important mediating variables (multiple r = .40) for other attitudes and concerns.

The empathic process and its mediators. A heuristic model.

Clinical empathy research has been plagued with conceptual and methodological difficulties. This paper describes a model of the empathic process that enables clinicians, teachers, and researchers to examine specific components of the model and to determine the influence of particular mediators on the empathic process. Empathy is conceptualized as a three-phase time-sequenced process rather than as a multidimensional or multicomponent phenomenon. Stripped of detail, the empathic process reveals an inducement phase, a matching phase, and a participatory-helping phase. By examining these phases, it becomes possible to distinguish empathy from closely related concepts such as sympathy. Each of the phases reveals numerous mediating variables that influence the outcome of the phase, i.e., whether the process of empathy continues or an alternate terminal point is reached. Many of these mediators are derived from existing conceptual and empirical work on empathy. Particular attention is paid to situational or contextual mediators of empathy. Contextual mediators have only recently been acknowledged as an important variable in the empathic process. For clinicians, identification of contextual variables that may be responsive to intervention is a critical step in the modification of the clinical environment. We would suggest that clinical empathy research is largely the study of these mediating influences and should be recognized as such.

How nursing staff respond to the label "borderline personality disorder".

The influence of the diagnostic labels "schizophrenia" and "borderline personality disorder" on the expressed empathy of psychiatric nursing staff was assessed by examining nurses' written responses to a series of hypothetical patient statements. Respondents were more likely to demonstrate affective involvement in response to the schizophrenic patients' statements and were more likely to offer belittling or contradicting responses to the statements of patients with borderline personality disorder. The results corroborate increasing concerns that the diagnosis of borderline personality disorder has become a pejorative label for difficult patients and suggest that staff may provide stereotypic responses and less empathic care to borderline patients than to other patients.

What difference does case management make?

The outcomes of 82 patients in a rehabilitation-oriented case management program six months and two years after they were discharged from an inpatient setting to join the program were compared with those of 82 matched control patients who had been discharged from the same inpatient settings before the case management program was established. At the two-year follow-up, the patients in the case management program were significantly more likely than the control patients to have better occupational functioning, to live in a residence requiring more independence than they did at the six-month follow-up, and to be less socially isolated; in contrast, at the six-month follow-up only their occupational functioning was better than the control group's. The two groups did not differ in number of hospitalizations at either follow-up. The authors believe the study supplies much-needed documentation of the effectiveness of rehabilitation-oriented case management.

Loss and depression. A controversial link.

Inconsistent findings in studies of loss and depression arise from methodological differences, lack of common definitions of depression and loss, and the failure to consider the interaction hypothesis: the effect of early loss on depression is partly conditional on the presence of a current loss. Data were collected from 744 university students. Only 15% of subjects without loss vs. 44% with both types of loss had Beck Depression Inventory scores indicative of moderate depression. Analysis of variance confirmed this strong interaction effect. These results provide empirical support for Freud's view that a recent loss can reactivate depressive feelings associated with earlier loss.

Psychosocial factors and depressive symptoms.

The relationship of four psychosocial factors (family history of psychiatric illness, early loss of a nurturing relationship, stressful life events, and low social support) to depressive symptoms was investigated in university students using a cross-sectional design. A depressed group (N = 160), selected from a consecutive sample of students diagnosed depressed and attending a university psychiatric service, was contrasted with a nondepressed group (N = 206) randomly selected from the general university population within three strata (sex, academic level, and month of the year) to match the clinic group. Depression was measured by the Beck Depression Inventory. It was found that family history of psychiatric illness, stressful life events, and lack of a confidant all had a significant, independent direct effect on the occurrence of depressive symptoms, but early loss was not associated. An interaction effect among the psychosocial factors was not demonstrated.

Impact of a case manager program on psychiatric aftercare.

Shifting the locus of aftercare planning from hospital to community can enhance continuity of care. The authors compared chronically mentally ill patients assessed and managed by community-based practitioners trained in psychiatric rehabilitation with patients whose discharge planning was arranged by inpatient staff members. They found significant differences between the two groups in aftercare needs identified, aftercare referrals made, and use of aftercare services. The authors conclude that this approach to psychiatric aftercare is superior to more traditional models if practitioners are carefully trained.