Cyclical mastalgia: prevalence and associated health and behavioral factors.

Perimenstrual breast pain (cyclical mastalgia) is a common problem that can be sufficiently severe to interfere with usual activities, and has been associated with elevated mammography usage in young women. This study was undertaken to replicate clinic-based research on cyclical mastalgia, and to examine the association between this disorder and health-related behaviors and perceived stress. Using random digit dialing throughout Virginia, 874 women aged 18-44 were interviewed. Sixty-eight per cent of women experienced cyclical breast symptoms; 22% experienced moderate to extreme discomfort (classified as cyclical mastalgia). Hormonal contraceptive usage was associated with significantly less mastalgia and premenstrual syndrome (PMS). Smoking, caffeine consumption and perceived stress were associated with mastalgia (odds ratios = 1.52, 1.53 and 1.7, respectively). Young women (under 35 years) with mastalgia were more likely to have had a mammogram (20.2%) than those without mastalgia (9.9%). Most women with this disorder (77.5%) did not have PMS. The prevalence of cyclical mastalgia and its association with mammography replicate clinic-based findings. Associations with smoking and stress had not previously been reported. Prospective research is needed to determine the biopsychosocial factors contributing to this disorder.

Assessment and treatment of depression in coronary artery disease patients.

Depressive symptoms occur frequently among patients with coronary artery disease (CAD), with prevalence estimates ranging from 15 to 30%. Risk ratios for first and recurrent cardiac events related to depression are comparable to well-established CAD risk factors and range from 2 to 7. The commonly atypical nature of depression in individuals with CAD plays an important role in the under diagnosis of depression in these patients. This review indicates that presence of atypical and subclinical depression, as well as of clinical major depressive disorders, significantly increase the risk of cardiac events. Pathophysiological mechanisms include altered autonomic nervous system activity, increased tendency toward blood coagulation, and elevated low-grade inflammation. Evidence suggests that depression in CAD patients does not reflect anatomical CAD severity or use of anti-ischemic medications. In addition to these pathophysiological pathways, depression affects CAD progression via adverse health behaviors such as smoking, poor compliance, and reduced exercise levels. Initial screening for depressive disorders can be accomplished using questionnaires, but structured clinical interview are preferred for definite diagnosis of depression. Optimal treatment of depression in CAD generally involves both psychological and pharmacological interventions that affect both depression and its biological correlates relevant to CAD progression.

Cyclical mastalgia: premenstrual syndrome or recurrent pain disorder?

Approximately 8-10% of premenopausal women experience moderate to severe perimenstrual breast pain or cyclical mastalgia, monthly. This mastalgia can occur regularly for years until menopause, can interfere with usual activities, and is associated with elevated utilization of mammography among young women. Although mastalgia is a well documented symptom in premenstrual syndrome (PMS), it is unknown whether PMS is necessarily present in women with cyclical mastalgia. The present study prospectively examined mastalgia and its relationship to PMS. Thirty-two premenopausal women reporting recent mastalgia completed breast pain and menstrual symptom scales daily for 3-6 months. Eleven women (34.4%) met criteria for clinically significant cyclical mastalgia, reporting an average of 10.2 days of moderate-severe mastalgia monthly. Five women (15.6%) met criteria for PMS. Mastalgia was not significantly associated with PMS: 82% of women with clinical cyclical mastalgia did not have PMS. Cyclical mastalgia, although by definition associated with the menstrual cycle, is not simply premenstrual syndrome, and merits further investigation as a recurrent pain disorder whose presentation, etiology, and effective treatment are likely to differ from those of PMS.

Dual agency, dual relationships, boundary crossings, and associated boundary violations: a survey of military and civilian psychiatrists.

We hypothesized that psychiatrists with high dual-agency potential (military and health maintenance organization [HMO] psychiatrists) were more likely than non-HMO civilian psychiatrists to engage in dual relationships, report pressures to do so, participate in other general boundary-crossing activities, and report associated counter-therapeutic outcomes (boundary violations). Ninety military and 191 demographically matched civilian psychiatrists reported the number of boundary-crossing activities (including dual relationships) and associated counter-therapeutic outcomes in the preceding year with adult patients. Military and HMO psychiatrists reported greater external pressures than non-HMO civilian psychiatrists to engage in dual relationships; however, all three groups were similar in their reported numbers of dual relationships. The reported boundary-crossing activities and dual relationships studied here are not necessarily associated with reported boundary violations. The relative risk of a particular boundary crossing associating with harm to a patient likely depends on the therapeutic context and should be determined on a case-by-case basis.

Clinical evaluation of mastalgia.

OBJECTIVE: To describe an accurate and reproducible method to quantify a patient's subjective experience of breast pain. DESIGN: Prospective diary study. SETTING: Military tertiary care hospital. PATIENTS: Thirty female military health care beneficiaries from the Walter Reed Army Medical Center, Washington, DC, gynecology and general surgery clinics. MAIN OUTCOME MEASURES: Daily mastalgia was recorded using a visual analog scale and menstrual symptoms were measured using a daily questionnaire. These measures were correlated with results of a screening questionnaire completed prior to study entry. RESULTS: Patients identified as having cyclical mastalgia based on the screening questionnaire (n= 15) were found to have higher peak perimenstrual mastalgia according to their daily diaries than patients who did not meet diagnostic criteria (n=15) (5.3+/-0.7 vs 3.5+/-0.5, P<.001). Applying the same criteria used in the screening questionnaire to the diary data, 17 of 30 patients met diagnostic criteria for cyclical mastalgia. The ability of the screening questionnaire to predict the results of the prospective diary data was calculated, and positive and negative predictive values were 73% and 60%, respectively. Most patients with cyclical mastalgia also have other perimenstrual psychological and somatic complaints, although a subset of patients has high levels of mastalgia with minimal associated symptoms. CONCLUSIONS: Accurate assessment of mastalgia cannot be done with a retrospective questionnaire and requires prospective diary evaluation, owing to the variable and subjective nature of symptoms and recall bias. A daily visual analog scale provides reproducible results and is easy for patients to use.

Cyclical mastalgia: prevalence and impact in an outpatient breast clinic sample.

BACKGROUND: A descriptive study was conducted to examine prevalence of premenstrual breast symptoms, impact of cyclical mastalgia on various activities, and associated patterns of health care utilization among breast clinic outpatients. STUDY DESIGN: Patients (n = 231, age < 55 years) completed a questionnaire about lifetime and current premenstrual breast discomfort (cyclical mastalgia). RESULTS: Seventy-nine percent reported having regularly experienced cyclical breast symptoms; 48% have asked a health care provider about their mastalgia. Young women (< or = 35 years) were more than three times as likely to have had a mammogram (75%) if they regularly experienced cyclical mastalgia than if they did not (24%; p < 0.05). Current moderate to severe mastalgia lasting 5 days or more monthly was reported by 30% of women. This "clinical" level of mastalgia interferes with usual sexual activity for 33%, with physical activity for 29%, with social activity for 15%, and with work for 15% of these women. CONCLUSIONS: Reported prevalences of mastalgia obtained in this sample are higher than those reported in British studies; possible reasons for these differences are discussed. Cyclical mastalgia is a common problem sometimes severe enough to interfere with normal activity levels, and it is related to excessive use of mammography among young women. Although largely ignored both scientifically and clinically in the United States, this condition merits further biopsychosocial investigation.

Support and rewards for scholarly activity in family medicine: a national survey.

BACKGROUND AND OBJECTIVES: This survey examined how time is allotted for family medicine faculty to pursue scholarly activities and how these activities are rewarded. METHODS: A survey was sent to all directors of family practice residency programs (n = 373) and chairs of family medicine departments (n = 112). Four primary questions were asked: 1) How is faculty time allotted for scholarly activities? 2) Does the residency or department use an explicit reward system? 3) What activities are rewarded? and 4) What rewards are used? RESULTS: A total of 363 surveys were returned, for a response rate of 75%. Forty-nine percent of respondents have regular, protected faculty time for scholarly activities. Faculty at university-based residencies and departments were more likely to have protected time (68/93, 73%) than faculty at community-based residencies (93/238, 39%). Thirty-eight percent of respondents have an explicit reward system. Activities rewarded and rewards used are department and program-type specific. CONCLUSIONS: Only 39% of community-based residencies and 73% of university programs allot regular protected time for faculty. The majority of programs and departments do not have an explicit reward system. Further studies are needed to determine if the use of protected time and reward systems enhance scholarly productivity.

Prevalence and impact of cyclic mastalgia in a United States clinic-based sample.

OBJECTIVES: A descriptive study was conducted to examine the prevalence of premenstrual breast symptoms, the impact of cyclic mastalgia on various activities, and associated patterns of health care utilization. STUDY DESIGN: Patients at an obstetrics and gynecology clinic (n = 1171) completed a questionnaire. RESULTS: Sixty-nine percent of women reported regular premenstrual discomfort; 36% had consulted a health care provider about the symptoms. Current moderate-to-severe cyclic mastalgia was found in 11%. Women <36 years old with cyclic mastalgia were 4.7 times as likely as asymptomatic young women to have had a mammogram. Mastalgia interferes with usual sexual activity in 48% of women and with physical (37%), social (12%), and work or school (8%) activity. CONCLUSIONS: Cyclic mastalgia is a common problem, sometimes severe enough to interfere with usual activities, and it is associated with high use of mammography among young women. Largely ignored both scientifically and clinically in the United States, this disorder merits further biopsychosocial investigation.

Information seeking and interactive videodisc preparation for third molar extraction.

Patient response to interactive videodisc preparation for third molar extraction surgery was examined as a function of self-reported information-seeking style. Amount learned was compared among patients informed via an interactive videodisc, noninteractive videotape of the same material, or surgeon only. Anxiety levels and satisfaction with preparation were compared between the videodisc and videotape groups. At consultation, patients (n = 35) were randomly assigned to either the disc- or the tape-viewing group. First, subjects completed a demographic survey, state anxiety scale, quiz on knowledge about third molars and surgery risks and complications, and information-seeking scales. Immediately after viewing the video, subjects completed another anxiety scale and a multiple-choice quiz covering the material presented. Subsequently, another 25 patients undergoing the routine (surgeon-only) consultation procedure were given the same multiple-choice quiz following consultation. Quiz scores differed significantly among the groups; mean percent correct for the tape-viewing subjects was 85; for disc-viewing subjects 72.6; for surgeon-only subjects, 40. Self-rated information seeking was unrelated to amount of video viewed by disc subjects (on average, 64% of the videodisc was viewed), and disc subjects who rated themselves higher in information-seeking achieved the lowest postpreparation quiz scores. Subjects in the disc group were significantly more satisfied with the amount of preparation than the tape group. Although disc group subjects were significantly less knowledgeable following consultation than were tape group subjects, interactive videodisc preparation for third molar extraction appears to have some advantages over more traditional approaches. Further research is needed to determine whether this approach to preparing patients is suitable for widespread clinical use.

Group size, cage shelf level, and emotionality in non-obese diabetic mice: impact on onset and incidence of IDDM.

We hypothesized that differential housing, shown to influence emotionality and health in infectious and neoplastic disease, would influence onset/incidence of diabetes in an autoimmune animal model of insulin-dependent diabetes mellitus (IDDM). Non-obese diabetic mice were assigned to same-sex groups of one, five, or eight animals/cage, counterbalanced across shelf level by sex and group. During weekly urine glucose testing, presence of behaviors indicating emotional arousal was recorded. Sex, group, and shelf level affected emotionality: males, animals housed alone, and those on the top of the rack exhibited higher emotionality. Emotionality and shelf level predicted IDDM in females only. Delayed onset of IDDM was associated with high emotionality and with being housed on the top of the rack. Group size had no significant effect on IDDM. Emotionality may be a mediating factor in animals genetically predisposed to develop IDDM. This variable and cage shelf level should be incorporated into the design of studies in which IDDM is the outcome.

Shock controllability and the nature of stress-induced analgesia.

Three experiments were conducted to examine the impact of the escapability of shock on the nature of the analgesia produced by shock. In Experiment 1, rats were exposed to 0, 20, 40, or 80 escapable or yoked inescapable shocks. Tail-flick testing revealed a "double-peak" pattern in which analgesia was present after 20 and 80 shocks. This was true for both escapable and inescapable shock. Analgesia after 20 escapable or inescapable shocks was insensitive to naltrexone, as was the analgesia after 80 escapable shocks. However, the analgesia after 80 inescapable shocks was completely blocked by naltrexone. Moreover, in Experiment 2 the analgesia following 80 inescapable shocks persisted for at least 2 hr, whereas it dissipated rapidly following 80 escapable shocks. Further, the analgesia produced by escapable shock even dissipated with the continued occurrence of escapable shock. Finally, shock controllability was shown to alter the analgesia produced by subsequent exposure to shock. Prior experience with controllable shock completely blocked the late-appearing naltrexone reversible analgesia; prior experience with uncontrollable shock led it to appear sooner.

Formal thought disorder, the type-token ratio and disturbed voluntary motor movement in schizophrenia.

Little work has been done to determine objective, reliable differences in formal characteristics of the actual utterances of thought-disordered and non-thought-disordered subjects. The type-token ratio (TTR), a quantitative measure of repetition in language, correlated highly with clinical judgments of thought disorder when spoken language was examined, and statistically differentiated thought-disordered from non-thought-disordered schizophrenics and psychiatric and normal controls. Elicited and spontaneous motor abnormalities were associated with reduced TTRs both in schizophrenics and in affective subjects with motor disturbance. The TTR is a reliable, objective indicator of language deviance and thought disorder, and strongly associated with motor disturbances.