[Field of tension between psychomatics and psychiatry]. / Spannungsfeld Psychosomatik und Psychiatrie.

As a medical topic psychosomatic medicine is able to look back on an almost 100-year-old tradition. Nevertheless, questions about its definition, area of application and by whom it should be practiced remains unsolved. This causes considerable tension with the field of psychiatry which has always seen psychosomatic medicine as a subspecialty of its own discipline. In the article, the development and current position of psychosomatic medicine in German speaking countries other than Germany (Austria, Switzerland and South Tyrol) is presented. While psychosomatic care is currently planned and also partially already executed in Austria, psychosomatic medicine in Switzerland is located with general practitioners on the one hand and consultation-liaison psychiatry on the other. After the radical psychiatric reform of the late 1970s in South Tyrol psychosomatic medicine proved to be a means to remove taboos regarding psychiatric institutions and the mentally ill.

[Psychological distress and quality of life in COPD-patients and their spouses]. / Psychische Belastung und Lebensqualität bei COPD-Patienten und bei deren Partnern.

OBJECTIVE: To investigate psychological distress, quality of life, and satisfaction with medical support of patients with COPD and their spouses. METHOD: Questionnaires concerning psychological distress and quality of life were sent by mail to 97 patients and 54 spouses (43 couples). RESULTS: We found increased scores of anxiety and depression. In terms of quality of life the patients reported significantly lower scores than their spouses. Patients as well as their spouses reported a high satisfaction about the given medical support. CONCLUSION: Spouses of COPD patients are at increased risk for psychiatric morbidity und should therefore be included regularly in care programs.

The Pictorial Representation of Illness and Self Measure (PRISM) instrument reveals a high burden of suffering in patients with chronic urticaria.

BACKGROUND: Chronic urticaria severely affects quality of life. To date, no gold standard has been established to measure the burden of suffering, which often correlates poorly with the skin symptoms observed in patients with chronic urticaria. OBJECTIVE: To investigate the effect of psychological factors on the course of urticaria. METHODS: Health-related quality of life was assessed in 95 patients with chronic urticaria using the following instruments: Pictorial Representation of Illness and Self Measure (PRISM), Dermatology Life Quality Index (DLQI), and Skindex-29. Correlations were calculated. Cognitive flexibility and its correlation with the course of urticaria were assessed. Two case reports are presented to further elucidate features of PRISM. RESULTS: PRISM revealed a high burden of suffering that was consistent with considerably impaired quality of life as measured by DLQI and Skindex-29 in the same patients. However, no significant correlation was observed between PRISM and the 2 quality of life questionnaires. From the baseline visit to the follow-up visit, quality of life scores improved significantly (DLQI, P = .001; Skindex-29, P = .001), whereas the PRISM score remained unchanged (P = .085). Disease course was favorable more often in cognitively flexible patients (n=54) (91%) than cognitively inflexible patients (P = .007). CONCLUSIONS: PRISM revealed a high burden of suffering in chronic urticaria and provided helpful additional information for the management of these patients. In our cohort, cognitive flexibility was a positive predictive marker for the course of chronic urticaria.

[Shared decision-making and individualized goal setting - a pilot trial using PRISM (Pictorial Representation of Illness and Self Measure) in psychiatric inpatients]. / «Shared decision making¼ und individualisierte Therapiezielsetzung - eine Pilotuntersuchung mit PRISM (Pictorial Representation of Illness and Self Measure) bei stationären Psychiatriepatienten.

BACKGROUND: Although there is much talk about shared decision making and individualized goal setting, there is a lack of knowledge and knowhow in their realization in daily clinical practice. There is a lack in tools for easy applicable tools to ameliorate person-centred individualized goal setting processes. METHOD: In three selected psychiatric inpatients the semistructured, theory driven use of PRISM (Pictorial Representation of Illness and Self Measure) in patients with complex psychiatric problems is presented and discussed. RESULTS: PRISM sustains a person-centred individualized process of goal setting and treatment and reinforces the active participation of patients. The process of visualisation and synchronous documentation is validated positively by patients and clinicians. The visual goal setting requires 30 to 45 minutes. CONCLUSIONS: In patients with complex psychiatric illness PRISM was used successfully to ameliorate individual goal setting. Specific effects of PRISM-visualisation are actually evaluated in a randomized controlled trial.

Neonatal procedural pain exposure and pain management in ventilated preterm infants during the first 14 days of life.

OBJECTIVES: Ventilated preterm infants are at high risk for procedural pain exposure. In Switzerland there is a lack of knowledge about the pain management in this highly vulnerable patient population. The aims of this study were to describe the type and frequency of procedures and to determine the amount of analgesia given to this patient group in two Swiss neonatal intensive care units. METHOD: A retrospective cohort study was performed examining procedural exposure and pain management of a convenience sample of 120 ventilated preterm infants (mean age = 29.7 weeks of gestation) during the first 14 days of life after delivery and born between May 1st 2004 and March 31st 2006. RESULTS: The total number of procedures all the infants underwent was 38,626 indicating a mean of 22.9 general procedures performed per child and day. Overall, 75.6% of these procedures are considered to be painful. The most frequently performed procedure is manipulation on the CPAP prongs. Pain measurements were performed four to seven times per day. In all, 99.2% of the infants received either non-pharmacological and/or pharmacological agents and 70.8% received orally administered glucose as pre-emptive analgesia. Morphine was the most commonly used pharmacological agent. DISCUSSION: The number of procedures ventilated preterm infants are exposed to is disconcerting. Iatrogenic pain is a serious problem, particularly in preterm infants of low gestational age. The fact that nurses assessed pain on average four to seven times daily per infant indicates a commitment to exploring a painful state in a highly vulnerable patient population. In general, pharmacological pain management and the administration of oral glucose as a non-pharmacological pain relieving intervention appear to be adequate, but there may be deficiencies, particularly for extremely low birth weight infants born <28 weeks of gestation.

Parents' mental health after the birth of an extremely preterm child: a comparison between bereaved and non-bereaved parents.

OBJECTIVE: To assess the impact of extremely preterm birth (24-26 weeks of gestation) on the mental health of parents two to six years after delivery, and to examine potential differences in post-traumatic growth between parents whose newborn infant died and those whose child survived. METHOD: A total of 54 parents who had lost their newborn and 38 parents whose preterm child survived were assessed by questionnaires with regard to depression and anxiety (HADS) and post-traumatic growth (PTGI). RESULTS: Neither group of parents had clinically relevant levels of depression and anxiety. Mothers showed higher levels of anxiety than fathers. Bereaved parents with no other, living child reported higher levels of depression than bereaved parents with one or more children. Mothers reported higher post-traumatic growth compared to fathers. In particular, bereaved mothers experienced the value and quality of their close social relationships more positively compared to the non-bereaved parents. CONCLUSION: In the long term, bereaved and non-bereaved parents cope reasonably well with an extremely preterm birth of a child. Post-traumatic growth appears to be positively related to bereavement, particularly in mothers.

Quality of life and dyadic adjustment in oral cancer patients and their female partners.

The diagnosis of cancer affects not only the lives of patients, but also the lives of their family members. The purpose of this study was to examine the impact of oral cancer on quality of life (QoL), psychological distress and marital satisfaction in a sample of patients and their wives. Thirty-one men treated for oral cancer (mean time since diagnosis 3.7 years) and their female partners (n = 31) were assessed by questionnaires with regard to QoL (WHOQOL-BREF), anxiety and depression (Hospital Anxiety and Depression Scale, HADS), quality of relationship (Dyadic Adjustment Scale, DAS) and physical complaints (EORTC QOL-H&N35). Quality of life was remarkably high in patients and their partners. In patients, lower QoL was associated with more physical complaints and higher levels of psychological distress (HADS), whereas in wives, QoL was found to be related to marital quality (DAS) and levels of distress. In couples with highly discrepant ratings of marital satisfaction, wives reported more psychological distress. The findings indicate that overall QoL is considerably high in patients treated for oral cancer and their partners living in stable relationships. Quality of life correlates stronger with the quality of relationship in spouses than in patients. Generally, marital satisfaction appears to be an important moderating factor regarding QoL and psychological distress.

[Prevalence of anxiety and depression in cancer outpatients and their spouses]. / Prävalenz von Angst und Depression bei ambulanten Krebspatienten und deren Angehörigen.

OBJECTIVE: To assess prevalence rates of anxiety disorder and depression in patients and their spouses treated in a cancer outpatient clinic of a university hospital. Also the distress-thermometer (DT) was tested as a screening instrument for anxiety disorders and depression. METHOD: 109 patients with different cancer types of different stages as well as their 109 spouses were assessed by questionnaires. RESULTS: In the patient sample anxiety levels were increased in 24.7% and in 20.2% for depression. In spouses anxiety levels were increased in 41.0% and in 21.6% for depression. Female spouses had higher anxiety levels than male spouses (p < 0.01); increased anxiety levels were found in 48% of the female spouses. In the patients sample the distress-thermometer has good values for sensitivity [0.93 (anxiety); 0.82 (depression)] and satisfying measures of specifity [0.68 (anxiety); 0.62 (depression)]. CONCLUSION: Female spouses of cancer patients are at increased risk for psychiatric morbidity, a fact that should be considered in future oncological care. The distress-thermometer is a simple, time saving and sensitive screening instrument to assess psychiatric morbidity in cancer patients, which can be recommended for clinical use.

[Are there associations of health status, disease activity and damage in SLE patients?---Results of a study of a cohort of a Swiss specialized outpatient clinic]. / Gibt es Zusammenhänge von Lebensqualität/Gesundheitszustand und Krankheitsaktivität resp. Krankheitsschädigung bei SLE-Patienten? Resultate einer Kohortenstudie eines Schweizer Rheumatologen.

AIM: To study the relationship between self assessed health status of patients with Systemic Lupus Erythematosus (SLE), lupus activity, damage, patients' age and disease duration in a cohort of a Swiss specialized outpatient clinic. PATIENTS AND METHODS: A cross sectional study of 38 patients fulfilling the classification criteria for SLE. The patients visited a rheumatology outpatient clinic in Switzerland between January 2002 and December 2004. The last assessment during this period was used for the study. The assessment included, besides demographic data, the measurement of disease activity using the BILAG index, the measurement of disease damage using the SLICC/ACR damage index (SDI), as well as the patient's self assessed health status using the patient's questionnaire Medical Outcome Survey Short Form 36 (SF-36). RESULTS: A total of 36 women and 2 men were included in the study (median age: 43 yrs, median disease duration: 11 yrs). Increased disease activity (total BILAG) was shown to be significantly correlated with reduced physical function. A greater damage (total SDI) correlated significantly with reduced role function due to emotional limitations. Neither age nor disease duration showed any significant correlation with health status in this study. CONCLUSION: The present study, which is based on internationally accepted assessment tools for SLE patients, shows a significant relationship between increased disease activity and reduced physical function. This result emphasizes the importance of optimizing treatment aiming at reducing disease activity.

Patient well-being after general anaesthesia: a prospective, randomized, controlled multi-centre trial comparing intravenous and inhalation anaesthesia.

BACKGROUND: The aim of this study was to assess postoperative patient well-being after total i.v. anaesthesia compared with inhalation anaesthesia by means of validated psychometric tests. METHODS: With ethics committee approval, 305 patients undergoing minor elective gynaecologic or orthopaedic interventions were assigned randomly to total i.v. anaesthesia using propofol or inhalation anaesthesia using sevoflurane. The primary outcome measurement was the actual mental state 90 min and 24 h after anaesthesia assessed by a blinded observer using the Adjective Mood Scale (AMS) and the State-Trait-Anxiety Inventory (STAI). Incidence of postoperative nausea and vomiting (PONV) and postoperative pain level were determined by Visual Analogue Scale (VAS) 90 min and 24 h after anaesthesia (secondary outcome measurements). Patient satisfaction was evaluated using a VAS 24 h after anaesthesia. RESULTS: The AMS and STAI scores were significantly better 90 min after total i.v. anaesthesia compared with inhalation anaesthesia (P=0.02, P=0.05, respectively), but equal 24 h after both anaesthetic techniques (P=0.90, P=0.78, respectively); patient satisfaction was comparable (P=0.26). Postoperative pain was comparable in both groups 90 min and 24 h after anaesthesia (P=0.11, P=0.12, respectively). The incidence of postoperative nausea was reduced after total i.v. compared with inhalation anaesthesia at 90 min (7 vs 35%, P<0.001), and 24 h (33 vs 52%, P=0.001). CONCLUSION: Total i.v. anaesthesia improves early postoperative patient well-being and reduces the incidence of PONV.

Improved quality of life after lung volume reduction surgery.

Lung volume reduction surgery (LVRS) improves dyspnoea, pulmonary function, and physical performance in patients with severe pulmonary emphysema. This study investigated the impact of LVRS on health-related quality of life (HRQL) over a 2-yr period following surgery. Thirty-nine consecutive patients were prospectively assessed before LVRS, and followed over 24 months postoperatively. The assessments included pulmonary function, dyspnoea (Medical Research Council (MRC) dyspnoea score), 6-min walking distance (6MWD) and HRQL using the Short Form 36-item questionnaire (SF-36). Several domains of SF-36 improved considerably over 2 yrs after surgery: Physical Functioning: 39 +/- 4 (mean +/- SEM) versus 16 +/- 2 (p<0.01); Vitality: 51 +/- 3 versus 32 +/- 3 (p<0.01); Social Functioning: 72 +/- 4 versus 51 +/- 5 (p<0.01). Also, improvements in pulmonary function (forced expiratory volume in one second (FEV1): 27 +/- 1% predicted, residual volume (RV)/total lung capacity (TLC): 0.65 +/- 0.01), 6 MWD (274 +/- 16 m) and dyspnoea (MRC: 3.9 +/- 01) were sustained for up to 2 yrs after LVRS (FEV1 36 +/- 2% pred, RV/TLC: 0.58 +/- 0.02; 6 MWD: 342 +/- 19 m; MRC: 2.0 +/- 0.2; p<0.05). In patients with severe emphysema, lung volume reduction surgery had positive effects on health-related quality of life and pulmonary function over 2 yrs.

Prediction of depression in systemic lupus erythematosus patients using SF-36 Mental Health scores.

OBJECTIVE: As depression is common in systemic lupus erythematosus (SLE) patients, we investigated whether and how the Medical Outcome Survey Short Form 36 (SF-36) scores, routinely used in the assessment of SLE patients, would indicate the absence or presence of depression. METHODS: The Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) and the SF-36 were applied in a cross-sectional cohort of 60 SLE patients [mean age 45 (S.D. 15) yr, disease duration 11 (9) yr, 90% female, 100% Caucasians]. The SF-36 domain score with the closest association with HADS-D was used for further analysis. On the basis of HADS-D scores, the patients were split into two groups: one without depression (score<8) and the other with possible depression (score > or =8). RESULTS: The SF-36 Mental Health score was most closely correlated to the depression score (rho=-0.69, P<0.0005). The calculated Mental Health score cut-off value which significantly differentiated possibly depressed from non-depressed SLE patients was 61. Its sensitivity for the detection of possible depression was 89%, its specificity 77% and its negative predictive value 97%. CONCLUSIONS: The present study contributes to knowledge of means of excluding depression and the prevention of underdiagnosis and undertreatment of depression in SLE patients.

How different from pacemaker patients are recipients of implantable cardioverter-defibrillators with respect to psychosocial adaptation, affective disorders, and quality of life?

OBJECTIVE: To assess differences in psychosocial adaptation, quality of life, and incidence of affective disorders between patients with pacemakers and those with implantable cardioverter-defibrillators (ICDs). DESIGN: Patients aged 40-70 years who underwent a first pectoral implantation of a pacemaker or an ICD system were studied. All subjects were asked to complete the hospital anxiety and depression scale (HAD), the short form general health survey (SF-36), and a specially designed device related questionnaire. Data analysis was performed for three patient groups: pacemaker (n = 76), ICD patients who received therapeutic shocks (n = 45), and ICD patients who did not receive shocks (n = 31). RESULTS: There were no differences between the three patient groups in HAD scores or in any of the SF-36 subscales or summary ratings. Probable depressive disorder (depression score > 10) was observed in 5.2%, 6.5%, and 6.6%, and probable anxiety disorder (anxiety score > 10) in 13.1%, 9.7%, 13.3% of the pacemaker, non-shocked ICD, and shocked ICD patients, respectively. There were no sex differences. However, patients in the shocked ICD group were more likely than those in the other groups to report limitations in their leisure activities, to perceive their device as a "life extender," and to admit anxiety about battery depletion and technical problems. Forty per cent of shocked ICD patients would be interested in joining a support group. CONCLUSIONS: Despite having distinctly different medical histories and treatments, patients with pacemakers and ICDs responded similarly to validated tools of health status assessment. ICD patients who had received shocks perceived their device as prolonging their life and had greater anxiety about technical problems. Their endorsement of the potential benefits of a support group warrants further investigation.

[How do patients assess caring they have experienced from nurses. Patients evaluate caring]. / Wie schätzen Patientinnen und Patienten Caring ein, welches sie von Pflegenden erfahren haben? Patientinnen und Patienten beurteilen Caring.

In this study, former patients who received a questionnaire by mail, were asked to evaluate Caring from their point of view. As a base, the 59-items measuring instrument "Humane Caring Scale HSC" by Töyry et al., which was translated into German by the author of this article and a team of experts, was used to collect data. In general, the patients (n = 178) feel they are respected, secure, treated friendly and with patience, pain is relieved, they can ask questions and receive answers in a language which they understand. On the other hand, patients cannot enough influence the planning of the care, they cannot always confide in the nurses or personnel, they experience the hospital activity as hectic, they feel nursing staff do not have sufficient time and there is not enough personnel. These results clearly show that nursing is not yet patient focused enough and that the patients have little possibility to influence the course of action. Should this situation be improved, a change of attitude is asked of individual members of the nursing staff as well as of the nursing management, but structures would also have to be adapted. The purpose of questioning patients is the development of quality. It is, therefore, important to ask for the significance of the results, and it has to be determined through which appropriate measures the quality of nursing can be improved and further developed. This measuring instrument has proved to be sound. A clear strong/weak profile could be presented. A final judgement of the validity and reliability of the instrument can, however, not be made today and should be subject to further studies.

Antonovsky's sense of coherence: trait or state?

BACKGROUND: The aim of this study was first to analyze the stability of Antonovsky's Sense of Coherence (SOC) as a measure of a person's world view over time; secondly, to investigate its relationship with depression and anxiety. METHODS: Data from two longitudinal studies were used: a study of severely injured accident victims (n = 96), and a study of patients suffering from rheumatoid arthritis (RA, n = 60). The 13 items short version of the SOC scale and measures of depression and anxiety (Symptom Checklist, Hospital Anxiety and Depression Scale) were administered repeatedly over 6-12 months in both studies. RESULTS: In the sample of accident victims, a significant decrease in the SOC mean score was observed during the first half year after the accident. During the same time period, symptoms of anxiety and depression decreased significantly. In the second half year after the accident, SOC as well as measures of psychopathology remained stable. RA patients showed high stability of SOC and measures of anxiety and depression over time. In both samples, between-time correlations of SOC scores were high (r > or = 0. 70, p<0.01), indicating a high test-retest stability of SOC. Furthermore, in both samples, significant negative correlations of a moderate to high degree (r = -0.28 to -0.73, p<0.01) were found between SOC and measures of anxiety and depression. CONCLUSIONS: SOC can be seen as a relatively stable (trait) measure. However, traumatic events such as life-threatening accidents may change a person's world view and thus their SOC, even if psychiatric symptoms abate. This suggests that SOC is not merely a proxy measure of psychopathology, but rather a partially independent, general measure of a person's world view.

PRISM (Pictorial Representation of Illness and Self Measure)- a novel visual method to assess the global burden of illness in patients with systemic lupus erythematosus.

OBJECTIVE: For patients with chronic illnesses the global burden of illness is a crucial health measure hitherto neglected in research studies and clinical practice. We tested the application and validity of PRISM (Pictorial Representation of Illness and Self-Measure), a novel visual method for assessing the burden of illness, in patients with systemic lupus erythematosus (SLE). METHOD: PRISM was applied in a cross sectional sample of 60 patients with SLE. Correlations were assessed between a quantitative measure derived from PRISM (Self-Illness Separation-SIS) and sociodemographic factors, measures of disease activity, damage, physical and psychological disability variables, as well as coping resources. RESULTS: The PRISM task was understood by all but one patient, and was in every instance completed in less than 3 minutes. SIS correlated with SF-36 physical health, coping resources as assessed by Sense of Coherence (SOC), and age, but not with disease activity or damage. In multiple regression analyses, independent contributions to SIS were observed for SF-36 physical component scale (contributing 12% of the variance). SOC (10%) and age (14%). CONCLUSION: PRISM is a new non-verbal measure to assess burden of illness. As in previous studies, PRISM was well accepted and understood by patients with SLE, quick to complete, and yielded meaningful information consistent with that in earlier research work.

[Inpatient rehabilitation in inpatients with chronic obstructive lung diseases (COPD): effect on physical capacity for work, psychological wellbeing and quality of life]. / Stationäre Rehabilitation bei Patienten mit chronisch obstruktiver Lungenkrankheit (COLK): Effekte auf körperliche Leistungsfähigkeit, psychisches Wohlbefinden und Lebensqualität.

Success of inpatient rehabilitation for patients with chronic obstructive pulmonary disease (COPD) was assessed in a prospective study of 39 patients (mean age = 71 years). Six months after hospital stay (mean duration 22.4 days), physical endurance as assessed by the 6-minute walk distance remained unchanged. Subjective health measures improved (SF36 21 vs 29%; p < 0.05), MRC-dyspnoea was reduced (2.61 vs 2.19; p < 0.05) and measures of global quality of life also improved (56.1 vs 67.5; p < 0.05). Meanwhile, anxiety symptoms were reduced (7.7 vs 6.0; p < 0.05); no changes in depression scores were observed (6.8 vs 6.2; p = 0.271). A novel visual method to assess the burden of suffering, PRISM (Pictorial Representation of Illness and Self Measure), was applied for the first time in COPD patients. PRISM scores improved significantly (6.3 vs 12.2; p < 0.001). In conclusion, inpatient pulmonary rehabilitation improved subjective physical health measures and reduced anxiety levels.

PRISM: Pictorial Representation of Illness and Self Measure. A brief nonverbal measure of illness impact and therapeutic aid in psychosomatic medicine.

The burden of illness is important for patients but complex and difficult to describe, let alone measure. A novel instrument is described that, according to preliminary data, measures what in German is termed Leidensdruck--the perceived burden of suffering due to illness. The measure--Pictorial Representation of Illness and Self Measure (PRISM)--takes less than 5 minutes to complete and is unusual in relying only minimally on language. The PRISM is being developed as a research tool and has been used effectively in routine clinical practice. To illustrate the latter application, three case vignettes are presented, demonstrating how the PRISM can enhance the patient's description and understanding of his/her illness and circumstances, facilitate patient-clinician communication, and help to monitor salient changes with treatment.

Sense of coherence - a mediator between disability and handicap?

BACKGROUND: The aim of this study was first to analyze the associations between disability and handicap and Antonovsky's concept of sense of coherence (SOC); secondly, to find out how the SOC concept could be integrated in the WHO model of impairments, disabilities, and handicaps (ICIDH). METHODS: Data from two studies were used: one on patients with rheumatoid arthritis, one on severely injured accident victims. Objective measures of the illness or the injury were conceptualized as indicator variables for disability, whereas variables related to the patients' subjective judgement were conceptualized as indicator variables for handicap. Correlations were calculated between both sets of variables and the SOC scale total score. RESULTS: SOC showed no significant correlation with 'disability variables' (rheumatoid arthritis: HAQ, SF36 physical functioning; accidental injuries: ISS, GCS). However, significant correlations were found between SOC and all 'handicap variables' (rheumatoid arthritis: HAD, SF36 social functioning; accidental injuries: CAPS-2, IES, SCL-90-R depression subscale). CONCLUSIONS: SOC is related to the psychosocial effects of health problems. It may be understood as a mediator between disability and handicap. Prospective studies are needed to clarify whether the SOC scale can be used as an outcome predictor with regard to psychosocial adaptation, in acute as well as in chronic health problems.