Clinical Interviewing: An Essential but Neglected Method of Medicine.

Clinical interviewing is the basic method to understand how a person feels and what are the presenting complaints, obtain medical history, evaluate personal attitudes and behavior related to health and disease, give the patient information about diagnosis, prognosis, and treatment, and establish a bond between patient and physician that is crucial for shared decision making and self-management. However, the value of this basic skill is threatened by time pressures and emphasis on technology. Current health care trends privilege expensive tests and procedures and tag the time devoted to interaction with the patient as lacking cost-effectiveness. Instead, the time spent to inquire about problems and life setting may actually help to avoid further testing, procedures, and referrals. Moreover, the dialogue between patient and physician is an essential instrument to increase patient's motivation to engage in healthy behavior. The aim of this paper was to provide an overview of clinical interviewing and its optimal use in relation to style, flow and hypothesis testing, clinical domains, modifications according to settings and goals, and teaching. This review points to the primacy of interviewing in the clinical process. The quality of interviewing determines the quality of data that are collected and, eventually, of assessment and treatment. Thus, interviewing deserves more attention in educational training and more space in clinical encounters than it is currently receiving.

Clinimetric Criteria for Patient-Reported Outcome Measures.

Patient-reported outcome measures (PROMs) are self-rated scales and indices developed to improve the detection of the patients' subjective experience. Given that a considerable number of PROMs are available, it is important to evaluate their validity and usefulness in a specific research or clinical setting. Published guidelines, based on psychometric criteria, do not fit in with the complexity of clinical challenges, because of their quest for homogeneity of components and inadequate attention to sensitivity. Psychometric theory has stifled the field and led to the routine use of scales widely accepted yet with a history of poor performance. Clinimetrics, the science of clinical measurements, may provide a more suitable conceptual and methodological framework. The aims of this paper are to outline the major limitations of the psychometric model and to provide criteria for clinimetric patient-reported outcome measures (CLIPROMs). The characteristics related to reliability, sensitivity, validity, and clinical utility of instruments are critically reviewed, with particular reference to the differences between clinimetric and psychometric approaches. Of note is the fact that PROMs, rating scales, and indices developed according to psychometric criteria may display relevant clinimetric properties. The present paper underpins the importance of the clini-metric methodology in choosing the appropriate PROMs. CLIPROM criteria may also guide the development of new indices and the validation of existing PROMs to be employed in clinical settings.

Psychosomatic medicine in the 21st century: understanding mechanisms and barriers to utilization.

The psychosomatic approach arose in antiquity as mankind looked for explanations for illness and death. With the rise of modern medicine, the links between emotions and medical conditions, such as cardiac disease and diabetes, were described by astute clinical observers, but the mechanisms for these conditions were based on correlation from observations rather than on experimental design. Psychoanalytic theory was often utilized to explain many common diseases. For example, peptic ulcer disease was blamed upon anger and stress, but scientific methodology discovered Helicobacter pylori to be the significant causal factor of this disease and resulted in the development of more effective treatments. Nevertheless emotional factors are still linked to disease states and morbidity; for example, depression is a risk factor for mortality following myocardial infarction. Advances in neuroscience demonstrate that the reduction of telomere length by anxiety and stress leads to more rapid aging and potential disease vulnerability. Thus, neuroscientific probes may allow for the elucidation of psychosomatic mechanisms. Sadly, clinical barriers, in terms of time pressure upon physicians and the current separation of mental health services from primary care settings, continue the dualistic treatment of many conditions where psychological factors are important. It is not clear whether a mandate for the integration of behavioral health into primary care will remedy this partition and finally maximize a psychosomatic approach to medical care.

Alexithymia and emotional intelligence in patients with panic disorder, generalized anxiety disorder and major depressive disorder.

Emotional Intelligence (EI) is a broad personality construct signifying the ability to perceive and to regulate affects within oneself. Alexithymia is another personality construct denoting difficulty in identifying and expressing emotions, with an externally oriented thinking style. Although previously considered to be independent, some studies have shown that these constructs overlap. The aim of this study was to evaluate and compare the levels of EI and alexithymia in patients with panic disorder, major depressive disorder (MDD), and generalized anxiety disorder (GAD). The subjects included 171 psychiatric patients and 56 non-clinical controls. Psychiatric diagnoses were based on DSM-IV criteria. The Emotional Intelligence Scale-34 (EIS-34) and the Toronto Alexithymia Scale (TAS-20) were used to assess EI and alexithymia. All three patient groups scored statistically significantly higher than the non-clinical controls on TAS-20 total score and the TAS-20 subfactors of difficulty identifying feelings and difficulty describing feelings. EIS-34 scores were lower in patient groups than in the non-clinical controls, but only the EIS-34 intrapersonal subscale was significant difference. Total TAS-20 and EIS-34 scores in the patient cohort were inversely and significantly correlated These results reaffirm an overlap between EI and alexithymia with the intrapersonal factor of EI to be more dependent on the difficulty identifying feelings dimension of alexithymia in subjects with MDD and GAD.

Principles of psychosomatic assessment.

There is increasing awareness of the limitations of disease as the primary focus of medical care. It is not that certain disorders lack an organic explanation, but that our assessment is inadequate in most clinical encounters. The primary goal of psychosomatic medicine is to correct this inadequacy by incorporation of its operational strategies into clinical practice. At present, the research evidence which has accumulated in psychosomatic medicine offers unprecedented opportunities for the identification and treatment of medical problems. Taking full advantage of clinimetric methods (such as with the use of Emmelkamp's two levels of functional analysis and the Diagnostic Criteria for Psychosomatic Research) may greatly improve the clinical process, including shared-decision making and self-management. Endorsement of the psychosomatic perspective may better clarify the pathophysiological links and mechanisms underlying symptom presentation. Pointing to individually targeted methods may improve final outcomes and quality of life.

The psychosomatic interview.

The psychosomatic interview is a patient-focused dialogue between physician and patient. It differs from the traditional disease-focused encounter in that the psychosomatic approach includes the biological, psychological, and sociocultural domains irrespective of the patients initial complaint, whether somatic or psychological. The process of dyadic interaction and the techniques of open questions are reviewed. Specific issues such as the alexithymic patient and breaking bad news are challenges in such communications. Organizing the data into the perspectives of diseases, dimensions, behaviors, and life stories allows the clinician to best understand their patients within a psychosomatic milieu.

Update on diagnoses of sexual dysfunctions: controversies surrounding the proposed revisions of existing diagnostic entities and proposed new diagnoses.

The diagnosis of sexual dysfunction(s) or disorder(s) is paramount to the development of the field of sexual medicine. Historically, the diagnoses of these disorders have been considered reliable. The validity of diagnoses of sexual disorders (and the rest of our classification systems) has recently been questioned, especially from the point of clinical utility and homogeneity. This review discusses the issues involved in the development of valid and useful diagnoses of sexual disorders, reviews the proposed changes in the upcoming Diagnostic and Statistical Manual of Mental Disorders, 5th edition, as well as the problems inherent in the revision of this (and any) diagnostic system, and suggests some possible remedies to this process.

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.

Cognitive performance enhancement: misuse or self-treatment?

OBJECTIVE: This cross-sectional survey study examines the link between ADHD medication misuse and a positive screen for adult ADHD symptoms. METHOD: Surveys from 184 college student volunteers in Northern Virginia are collected and analyzed. RESULTS: A total of 71% of ADHD stimulant misusers screen positive for ADHD symptoms. Misusers are 7 times more likely to be symptomatic for ADHD than those who do not misuse. Also, 87% of misusers indicate that they do so for academic reasons, and 76% believe that the misuse of the ADHD stimulants improve their grades. CONCLUSION: ADHD stimulant misuse in college students is found to be strongly linked to having symptoms of adult ADHD. The desire for cognitive performance enhancement in college students may be a form of self-treatment for undiagnosed ADHD. College students need more accessibility to medical diagnosis and treatment of adult ADHD to reduce the incidence of misuse in the future.

Physician staffing for the practice of psychosomatic medicine in general hospitals: a pilot study.

BACKGROUND: The treatment of psychiatric illnesses, prevalent in the general hospital, requires broadly trained providers with expertise at the interface of psychiatry and medicine. Since each hospital operates under different economic constraints, it is difficult to establish an appropriate ratio of such providers to patients. OBJECTIVE: The authors sought to determine the current staffing patterns and ratios of Psychosomatic Medicine practitioners in general hospitals, to better align manpower with clinical service and educational requirements on consultation-liaison psychiatry services. METHOD: Program directors of seven academic Psychosomatic Medicine (PM) programs in the Northeast were surveyed to establish current staffing patterns and patient volumes. Survey data were reviewed and analyzed along with data from the literature and The Academy of Psychosomatic Medicine (APM) fellowship directory. RESULTS: Staffing patterns varied widely, both in terms of the number and disciplines of staff providing care for medical and surgical inpatients. The ratio of initial consultations performed per hospital bed varied from 1.6 to 4.6. CONCLUSION: Although staffing patterns vary, below a minimum staffing level, there is likely to be significant human and financial cost. Efficient sizing of a PM staff must be accomplished in the context of a given institution's patient population, the experience of providers, the presence/absence and needs of trainees, and the financial constraints of the department and institution. National survey data are needed to provide benchmarks for both academic and nonacademic PM services.

Teaching psychiatric residents about paraphilic disorders.

OBJECTIVE: The author describes a program for psychiatric residents in evaluating patients with paraphilic disorders. METHODS: The program curriculum offers clinical education in paraphilic disorders and is organized by various perspectives within psychiatry, including the disease model, the life story, the dimensional perspective, and the behavioral perspective. RESULTS: Graduates of this program generally find this clinical and educational rotation very useful in their future work. CONCLUSION: To develop an effective teaching module for paraphilic disorders, programs need an interested and knowledgeable faculty and an adequate clinical experience.