Puberty suppression in adolescents with gender dysphoria: an emerging issue with multiple implications.

Controversy exists over puberty suppression (PS) in adolescents with gender dysphoria (GD). PS is preferentially achieved with GnRH analogues. By preventing the development of secondary sex characteristics, PS may improve psychological functioning, well-being, quality of life, emotional and behavioral (especially internalizing) problems and depressive symptoms, thus decreasing suicidality. PS can also extend the diagnostic period and give transgender adolescents time to explore their gender identity. GnRHa may also decrease the need for feminization/masculinization surgery. However, 2-year treatment with GnRHa may result in bone mass accrual retardation (decrease in BMD/BMAD z-scores), growth velocity deceleration (decrease in height SDS), increase in fat mass, temporary pause in oocyte/sperm maturation. The most common side effects of GnRHa are hot flashes, mood fluctuations, fatigue and headache. They are usually mild and rarely lead to GnRHa discontinuation. Based on current scientific evidence, PS could be recommended to adolescents who meet the diagnostic criteria of gender incongruence (by DSM-5 and/or ICD-11) and have long-lasting intense GD, which aggravates with puberty onset. Before initiating PS, possible mental issues should be addressed and informed consent (by the adolescent/caregiver) should be given, after counseling on probable reproductive effects of GnRHa. GnRHa can only be started after the adolescent has entered Tanner stage 2. Nevertheless, published studies are inadequate in number, small in size, uncontrolled and relatively short-term, so that it is difficult to draw safe conclusions on efficacy and safety of GnRHa. Large long-term randomized controlled trials are needed to expand knowledge on this controversial issue and elucidate the benefit and risks of PS.

Efficacy of a dementia intensive support (DIS) service at preventing admissions to medical and psychiatric wards: qualitative and quantitative evaluation.

AIMS AND METHOD: To establish whether a dementia intensive support (DIS) service that is part of a crisis resolution and home treatment team for older people is preventing admissions to acute hospital and psychiatric wards. The number of referrals in 2017 to the DIS service was established and those admitted to hospital ascertained. Senior doctors examined 30 sets of notes in detail and reached a conclusion on whether DIS had contributed to admission prevention. This information was then re-examined in two meetings with at least eight senior psychiatrists present. A consensus opinion was then reached as to whether DIS had contributed to admission prevention in each case. RESULTS: Over 12 months, 30/171 patients (18%) referred were admitted to hospital. For the subset of 30 referrals examined in detail, DIS contributed to admission avoidance in 21 cases (70%). CLINICAL IMPLICATIONS: Our evaluation demonstrates that the DIS service is an effective way of preventing admission.

Sense of Coherence and Defense Style Predict Sleep Difficulties in Early Non-metastatic Colorectal Cancer.

BACKGROUND: Sleep disturbances are common in cancer patients, but little is known about the complex interplay between the background psychological profile, coping with health stressors capacities and psychological distress in the formation of sleep difficulties in colorectal cancer. AIMS: To study the course and to identify psychological predictors of sleep difficulties in early non-metastatic colorectal cancer patients over a one-year period. METHODS: In this 1-year prospective study, we assessed in 84 early non-metastatic colorectal cancer patients the association of psychological distress (SCL-90-R), sense of coherence (SOC-29), and defense styles (Defense Style Questionnaire) with sleep difficulties (SCL-90-R) in multiple regression models. Eighty-two patients with breast cancer and 50 patients with cancer of unknown primary site served as disease controls, and 84 matched for age and sex alleged healthy individuals served as healthy controls. RESULTS: Colorectal cancer patients presented more sleep difficulties compared to healthy participants but fewer than patients with breast cancer and cancer of unknown primary site. Colorectal cancer patients' trouble falling asleep (p = 0.033) and wakening up early in the morning (p < 0.001) deteriorated over time. Sleep that was restless or disturbed was independently associated with low SOC (p = 0.046) and maladaptive defenses (p = 0.008). Anxiety symptoms (p < 0.001) predicted deterioration in trouble falling asleep, while depressive symptoms (p = 0.022) and self-sacrificing defense style (p = 0.049) predicted deterioration in wakening up early in the morning. CONCLUSIONS: Psychological parameters and coping with health stressors capacities are independently associated with sleep difficulties in colorectal cancer patients, indicating the need for psychological interventions aiming at improving adjustment to the disease.

Sense of coherence and self-sacrificing defense style as predictors of psychological distress and quality of life in rheumatoid arthritis: a 5-year prospective study.

Individual differences in adjustment during a disease's course determine psychological response and outcome. This study aimed to investigate prospectively whether coping with health stressors and self-sacrificing defense style could predict psychological adjustment and health-related quality of life (HRQoL) in patients with rheumatoid arthritis (RA). Seventy-four consecutive RA patients attending a rheumatology clinic were assessed for psychological distress (SCL-90-R), sense of coherence (SOC scale), self-sacrificing defense style (Defense Style Questionnaire-88), disease activity (DAS-28), pain, disability (Health Assessment Questionnaire) and HRQoL (World Health Organization Quality of Life Instrument, Short Form) at baseline and 5 years later. Multiple regression and moderator analyses were carried out. The results showed that disease activity (p < .001), pain (p = .005), psychological distress (p = .031), social relations HRQoL (p = .042) and environment HRQoL (p = .020) significantly improved over time. SOC was found an independent predictor of improvement in psychological distress (p = .003), overall general health (p = .002) and social relations HRQoL (p = .004); self-sacrificing independently predicted environment HRQoL (p = .042). The self-sacrificing defense style moderated the relationships between improvement in pain and improvement in overall general health (p = .024) and between improvement in pain and improvement in social relations HRQoL (p = .006). These findings indicate that, in RA, SOC predicts improvement in psychological distress and HRQoL over time, while a self-sacrificing defense style moderates the relationship of pain with HRQoL in the long term. These variables may partly explain inter-individual differences in adaptation to RA. Therefore, the design of psychotherapeutic trials targeting the patients' defensive profiles and coping with health stressors capacities is an important research perspective.

The association of illness perceptions with depressive symptoms and general psychological distress in parents of an offspring with autism spectrum disorder.

BACKGROUND: Raising a child with an autism spectrum disorder (ASD) is a severe stressor and parents often present high levels of depression. Depression is associated with illness perceptions but this association has not been studied in parents of ASD offspring. OBJECTIVE: We aimed to assess the prevalence of psychological distress symptoms and their associations with illness perceptions in parents with an ASD offspring. METHODS: In 111 parents of ASD offspring we assessed depressive symptoms (PHQ-9), illness perceptions (B-IPQ) and general psychological distress (GHQ-28). Multiple linear and logistic regressions were used to assess their independent associations. RESULTS: The prevalence of parental clinically significant depressive symptoms was 34.2%, while 55% presented clinically significant levels of general psychological distress. Younger parents and those with lower financial resources had greater psychological distress and more severe depressive symptoms. Parents felt that the condition impacted their lives and believed it would be chronic. Their beliefs about the consequences and the chronicity of the disorder were significant independent correlates of their psychological distress and depressive symptoms severity. CONCLUSIONS: These findings indicate that a remarkable proportion of parents with an ASD offspring present clinically significant depressive symptoms, which were associated with illness perceptions relevant to the consequences and the chronicity of the disorder. Our data encourage psychotherapeutic interventions aiming to support parents to deal with the consequences and chronicity of their offspring's disorder, in order to reduce parental psychological distress.

Personality traits, defense mechanisms and hostility features associated with somatic symptom severity in both health and disease.

OBJECTIVE: Somatic symptoms are widespread in clinical practice. The association of somatic symptom severity with impaired health status holds both when symptoms are medically unexplained and when they are medically explained. The role of personality dimensions in the formation of somatic symptoms in patients with established, chronic diseases when compared to healthy participants had not been investigated prior to this study. METHODS: In samples of 411 healthy subjects and 810 participants with any of 9 established, chronic medical conditions, we measured psychological distress (SCL-90-R), personality traits (Zuckerman-Kuhlman Personality Questionnaire), defensive profiles (Defense Style Questionnaire), individual defenses (Life Style Index) and hostility features (Hostility and Direction of Hostility Questionnaire). Hierarchical multivariate models were used to assess the independent associations between personality dimensions and somatic symptom severity in both samples. The SCL-90-R somatization scale served as the outcome variable. RESULTS: In both samples, older age, less education, higher neuroticism, adoption of the displacement defense and depressive symptoms were independently and positively associated with somatic symptom severity. Higher somatic symptom severity was also associated with more "introverted" features (i.e., the self-sacrificing defensive style and self-criticism) among participants with established, chronic medical conditions. CONCLUSIONS: These data suggest that similar personality traits and defense mechanisms are associated with somatic symptom severity in health and disease, indicating that somatic symptoms are not simply consequences of having a medical condition. The specific associations of the self-sacrificing defensive profile and self-criticism with somatic symptom severity in the patient sample may have important clinical implications.

Does psychological distress vary between younger and older adults in health and disease?

OBJECTIVE: The effect of age on psychological distress remains controversial and it is unclear how a chronic medical illness influences this association. We aimed to compare the level of psychological distress between younger and older patients with chronic medical conditions attending hospital specialty clinics and to test whether a different pattern emerges when comparisons with individuals without long-term conditions are made. METHODS: In 519 individuals without chronic medical conditions and 949 patients with established severe chronic medical illnesses, we compared psychological distress (GHQ-28 and SCL-90R) between younger (<65, N=1040) and older (≥65, N=428) participants after controlling for gender, marital status, education and primary diagnosis in multiple logistic regression models. RESULTS: Among the healthy participants, a greater proportion of older individuals presented mild/moderate psychological distress (p=.026), predominantly depressive and somatization symptoms. Among the medical patients, both age groups presented elevated levels of psychological distress, but a greater proportion of younger patients had severe psychological distress (p=.016), predominantly depressive, anxiety and hostility symptoms. Younger patients reported similarly high levels of somatization symptoms compared to older patients. The odds of being assessed with severe psychological distress were significantly greater for younger individuals with physical illnesses, independently of gender, marital status, education and primary diagnosis. CONCLUSIONS: Medical patients from both age groups had significant psychological distress symptoms scores. Younger patients with chronic medical illnesses were more vulnerable to severe psychological distress, including symptoms of anxiety, depression, hostility and somatization. Therefore, clinicians should direct efforts to recognize these symptoms in order to prevent further functional impairment.

Assessing ego defense mechanisms by questionnaire: psychometric properties and psychopathological correlates of the Greek version of the Plutchik's Life Style Index.

The Life Style Index (LSI; Plutchik, Kellerman, & Conte, 1979 ) was designed to assess defense mechanisms, assuming that their use is related to specific affective states and diagnostic concepts. We aimed to assess the psychometric properties of its Greek version and its relation to psychopathological symptoms. The LSI was back-translated into Greek and was administered to 1,261 participants. Six factors were identified, 5 of them largely corresponding to the original version's defenses (compensation, denial, projection, reaction formation, and repression). The sixth factor, named regressive emotionality, included mainly the original scale's regression and displacement factors. Test-retest reliabilities, internal consistencies, and construct validity were quite satisfactory. Most defenses were able to discriminate psychiatric patients from healthy participants and were associated with specific psychopathological symptoms in a theoretically expected mode, further supporting the validity of the Greek version. Our findings suggest that the LSI, based on both psychoevolutionary and psychoanalytic theory, can provide a solid ground for assessing ego defense mechanisms.

General hospital staff worries, perceived sufficiency of information and associated psychological distress during the A/H1N1 influenza pandemic.

BACKGROUND: Health care workers (HCWs) presented frequent concerns regarding their health and their families' health and high levels of psychological distress during previous disease outbreaks, such as the SARS outbreak, which was associated with social isolation and intentional absenteeism. We aimed to assess HCWs concerns and anxiety, perceived sufficiency of information, and intended behavior during the recent A/H1N1 influenza pandemic and their associations with psychological distress. METHOD: Between September 1st and 30th, 2009, 469 health-care workers (HCWs) of a tertiary teaching hospital completed a 20-item questionnaire regarding concerns and worries about the new A/H1N1 influenza pandemic, along with Cassileth's Information Styles Questionnaire (part-I) and the GHQ-28. RESULTS: More than half of the present study's HCWs (56.7%) reported they were worried about the A/H1N1 influenza pandemic, their degree of anxiety being moderately high (median 6/9). The most frequent concern was infection of family and friends and the health consequences of the disease (54.9%). The perceived risk of being infected was considered moderately high (median 6/9). Few HCWs (6.6%) had restricted their social contacts and fewer (3.8%) felt isolated by their family members and friends because of their hospital work, while a low percentage (4.3%) indented to take a leave to avoid infection. However, worry and degree of worry were significantly associated with intended absenteeism (p < 0.0005), restriction of social contacts (p < 0.0005), and psychological distress (p = 0.036). Perceived sufficiency of information about several aspects of the A/H1N1 influenza was moderately high, and the overall information about the A/H1N1 influenza was considered clear (median 7.4/9). Also, perceived sufficiency of information for the prognosis of the infection was significantly independently associated with the degree of worry about the pandemic (p = 0.008). CONCLUSIONS: A significant proportion of HCWs experienced moderately high anxiety about the pandemic, and their degree of worry was an independent correlate of psychological distress. Since perceived sufficiency of information about the A/H1N1 influenza prognosis was associated with reduced degree of worry, hospital managers and consultation-liaison psychiatry services should try to provide for HCWs' need for information, in order to offer favourable working conditions in times of extreme distress, such as the current and future pandemics.

Comparison of health-related quality of life and associated psychological factors between younger and older patients with established rheumatic disorders.

OBJECTIVES: To compare health-related quality of life (HRQOL) between younger and older patients with established rheumatic disorders and to assess the relative impact of a number of psychosocial parameters on HRQOL. METHODS: In a cross-sectional study of 320 patients (245 < 65 and 75 > or = 65 years old, response rate: 74.9%) with various rheumatic disorders (rheumatoid arthritis, 168; systemic lupus, 56; scleroderma, 56; and Sjogren's syndrome, 40) attending a follow-up clinic, HRQOL was assessed by the WHOQOL-BREF. Functional limitations (Health Assessment Questionnaire), psychological distress (Symptom Distress Checklist-90-R), defense mechanisms (Defense Style Questionnaire and Life Style Index), sense of coherence, and interpersonal difficulties (Inventory of Interpersonal Problems-40) were also assessed. RESULTS: Older patients presented more impaired physical HRQOL (p = 0.018) and social relationships HRQOL (p = 0.041) independent of disease type, education, and pain. Functional limitations were more prominent in the older group (p = 0.030). Pain, functional limitations, and psychological distress were independently associated with physical HRQOL in both groups. Psychological distress was the only common independent correlate of social relationships HRQOL. Personality factors were significant correlates of physical and social relationships HRQOLs only in the younger group, while the impact of pain in physical HRQOL was greater for younger than older patients, as shown by a moderator analysis. CONCLUSION: Older patients with rheumatic diseases experience more impaired HRQOL than the younger ones, and the management and prevention of functional limitations and psychological distress should be a priority, since they are strongly associated with HRQOL. Pain also warrants attention in all age groups, but especially in younger patients. Personality factors impact on HRQOL in younger patients, and this might be relevant to psychological interventions.

Narcissistic rage: The Achilles' heel of the patient with chronic physical illness.

Based on the psychoanalytic reading of Homer's Iliad whose principal theme is "Achilles' rage" (the semi-mortal hero invulnerable in all of his body except for his heel, hence "Achilles' heel" has come to mean a person's principal weakness), we aimed to assess whether "narcissistic rage" has an impact on several psychosocial variables in patients with severe physical illness across time. In 878 patients with cancer, rheumatological diseases, multiple sclerosis, inflammatory bowel disease, and glaucoma, we assessed psychological distress (SCL-90 and GHQ-28), quality of life (WHOQOL-BREF), interpersonal difficulties (IIP-40), hostility (HDHQ), and defense styles (DSQ). Narcissistic rage comprised DSQ "omnipotence" and HDHQ "extraverted hostility". Hierarchical multiple regressions analyses were performed. We showed that, in patients with disease duration less than one year, narcissistic rage had a minor impact on psychosocial variables studied, indicating that the rage was rather part of a "normal" mourning process. On the contrary, in patients with longer disease duration, increased rates of narcissistic rage had a great impact on all outcome variables, and the opposite was true for patients with low rates of narcissistic rage, indicating that narcissistic rage constitutes actually an "Achilles' Heel" for patients with long-term physical illness. These findings may have important clinical implications.

Delirium, a 'confusing' condition in general hospitals: The experience of a Consultation-Liaison Psychiatry Unit in Greece.

BACKGROUND/AIMS: A plethora of studies showed that delirium is common in hospitalized populations. We aimed to examine the characteristics of delirium patients referred to our Consultation-Liaison Psychiatry Unit (CLPU). METHODS: Our CLPU database was used to obtain data of all referred patients admitted to our hospital and diagnosed with delirium. All referred nondelirious patients served as controls. RESULTS: During one year, 483 patients were referred to the CLPU. Ninety-three (19.3%) were diagnosed with delirium. Delirious patients were older than nondelirious patients (P < 0.001), with 76.3% aged over 70 years. The majority of the referrals came from surgical specialties. Common etiological factors were fluid and electrolyte imbalance (29%), fractures (28%) and infections (24%), but laboratory tests for the investigation of the etiology prior to the consultation had been performed in only 12 patients (12.9%). The syndrome resulted in prolonged hospitalization and greater use of CLPU services. CONCLUSIONS: Referrals for delirium are frequent in CLPUs in Greece. Although delirium is common, it remains a 'confusing' condition for health practitioners. The under-diagnosis of delirium, the prolonged hospitalization and the time that the CLPU dedicated to these patients underlines the role of the CLPU psychiatrists in the management of the syndrome.

Disability status, disease parameters, defense styles, and ego strength associated with psychiatric complications of multiple sclerosis.

OBJECTIVE: The aim of the present study was to identify disease parameters, defensive styles and ego strength measurements associated with various forms of psychiatric complications in patients with multiple sclerosis (MS). METHODS: Seventy-nine patients with MS participated in the study and 158 healthy subjects matched for age and sex served as controls. A wide range of clinical information was collected and the following self-report instruments were used: General Health Questionnaire, Symptom Distress Check List, Defense Style Questionnaire, MMPI Ego Strength Scale and Hostility and Direction of Hostility Questionnaire. RESULTS: The odds of being assessed with a psychiatric diagnosis upon interview were 6.7 times greater among patients compared to controls and 9.3 times greater among patients with recent-onset MS compared to patients with long-term disease. Psychiatric complications of MS were closely associated with age of the disease onset and the degree of disability due to MS. Additionally, higher rates of introverted hostility, adoption of maladaptive ego defenses and weakened ego strength were also closely associated with several forms of psychological distress, especially depressive symptoms. CONCLUSIONS: MS patients experience elevated symptoms of psychological distress, especially depressive symptoms, which are most closely associated with disease parameters. However, the crucial role of various personality traits such as ego defenses and hostility features in the psychiatric symptom formation also appear to contribute to the development of depressive symptoms. Clinicians involved in the clinical management of patients with MS should identify and modify treatment if these specific personality markers that indicate the exhaustion of the patient's resources to cope with the physical and psychological stress of the illness are present.