Psychiatric and psychosocial disorders in patients with systemic lupus erythematosus: a longitudinal study of active and inactive stages of the disease.

The objective was to analyze psychiatric disorders and psychosocial dysfunction in patients with systemic lupus erythematosus (SLE), studied longitudinally during active and subsequent inactive stage of their disease. During a 6 month period of study, we selected 20 consecutive patients with SLE who presented with a SLE flare. All patients fulfilled the 1982 revised criteria of the American College of Rheumatology for the classification of SLE. When patients entered the study, we performed psychiatric (CIS, RDC, STAI, HD, BDI, GHQ and MMS) psychosocial (GAS and VAS-P) scores assessment. One year later, we repeated the psychiatric and psychosocial assessment when patients showed inactive disease. The 20 patients evaluated were women, with a mean age of 34 y (SE 14.4, range 20-57). According to CIS evaluation, we diagnosed 8 (40%) psychiatric cases in the acute episode of SLE. The RDC diagnosis showed generalized anxiety in 5 patients, panic disorders in 2 patients and generalized anxiety plus depressive symptoms in one patient. One year later, when patients did not show disease activity, we diagnosed 2 (10%) psychiatric cases (P<0.05). When SLE patients were clinically inactive, they showed lower levels of psychological distress (GHQ scale, 1.8 vs 5.6, P<0.001), with a lower grade of anxiety measured by both HA (3.2 vs 8.2, P<0.01) and STAI-S (7.95 vs 20.90, P<0.001) scales. We also found a lower score in pain perception (VAS-P) (2.80 vs 4.25, P<0. 01) and higher occupational activity (VAS-P) (83.9 vs 66.2, P<0.01) and general functioning (GAS) (93.75 vs 83.50, P<0.05) during the inactive stage. No significant differences were found when we compared cognitive impairment, grade of depression and physical disability between inactive and active stages. We conclude that in SLE patients, psychiatric and psychosocial disorders during acute episodes are usually mild and seem to be related to the psychological impact of disease activity on patients. This type of psychiatric pathology is similar to that which would be expected in other groups coping with a stressful event, indicating that our patients did not react in a way specifically determined by their systemic disease.

The efficacy and tolerability of venlafaxine and paroxetine in outpatients with depressive disorder or dysthymia.

A 24-week, double-blind, randomized trial was performed to compare the efficacy and tolerability of venlafaxine and paroxetine in patients with major depression or dysthymia. Outpatients aged 18-70 years with a baseline score of 17 on the 21-item Hamilton Depression Rating Scale (HAM-D) were eligible. Patients were randomly assigned to venlafaxine, 37.5 mg, in the morning and evening or paroxetine, 20 mg, in the morning and placebo in the evening, which could be increased to venlafaxine, 75 mg twice daily, or paroxetine, 20 mg twice daily, after 4 weeks. Efficacy was assessed with the 21-item HAM-D, the Montgomery-Asberg Rating Scale, the Hamilton Anxiety Rating Scale, and the Clinical Global Impressions Scale. Forty-one patients were randomized to venlafaxine and 43 to paroxetine. At week 6, a response was observed in 55% of patients on venlafaxine and 29% on paroxetine (P = 0.03). At week 12, significantly (P = 0.011) more patients in the venlafaxine group had a HAM-D remission score of 8 or less (59% versus 31%). Discontinuation for any reason occurred in 16 (39%) patients on venlafaxine and 11 (26%) on paroxetine. The most common adverse events were nausea (28%), headache (18%) and dry mouth (15%) with venlafaxine and headache (40%) and constipation (16%) with paroxetine. Venlafaxine was effective and well tolerated for the treatment of patients with mild to moderate depression or dysthymia. A consistently higher proportion of patients had a response or remission on venlafaxine than on paroxetine.

Psychological factors and vulnerability to psychiatric morbidity after myocardial infarction.

A sample of 97 males suffering from myocardial infarction was studied in order to determine the influence of psychological variables and emotional states on psychopathology displayed by patients in the course of their cardiological recovery. Discriminant analysis revealed that depression in the coronary unit and nonuse of problem-solving strategies were the most sensitive variables to correctly classify psychiatric and nonpsychiatric cases (76.6% of the total sample). Multiple regression analysis of the psychological variables and emotional states showed that severity of psychopathology was directly related to early depressive reaction and use of avoidant strategies. The prevalence of psychiatric disorders was 55.5%, with depression (RDC) being the most frequent diagnosis (59.4%), followed by 'irritable dysphoria' (27%) and anxiety disorders (RDC; 21.6%).

Denial mechanisms in myocardial infarction: their relations with psychological variables and short-term outcome.

From a selected sample of 97 males suffering from a first myocardial infarction, 67 patients were studied to ascertain the influence of denial mechanisms (DM) on their cardiological and psychological outcome. There were no differences among high deniers and low deniers with respect to the cardiological outcome, but high deniers showed less anxiety and depressive reactions both in the coronary unit and 1 month later, and also presented less psychopathology in general. In the last evaluation, one year after leaving the hospital (N = 52), there was no difference among deniers and non deniers in demand for psychiatric attention.

[Prognostic predictors of left ventricular aneurysm after myocardial infarct]. / Predictores del pronóstico del aneurisma ventricular izquierdo postinfarto de miocardio.

We have prospectively studied the prevalence and natural history of left ventricular aneurysm in a series of 386 consecutive male patients with an acute myocardial infarction. Definition of aneurysm was angiographic and based on a single plane left ventricular angiogram. There were 52 (13.5%) left ventricular aneurysms. Mean follow-up was 57 +/- 29 months (range 40-100). During this interval, 15 of the 52 patients died (29%). Univariate analysis showed that survivors had at admission significantly less prevalence of hypercholesterolemia, previous myocardial infarction and intraventricular conduction disturbances. In addition, their Killip class was better (p less than 0.02) and the left ventricular ejection fraction was higher (p less than 0.002). The survival rates of patients with ventricular aneurysm at 1, 3 and 5 years were 88, 82 and 75%, respectively. Left ventricular end diastolic pressure, number of diseased vessels and the presence of bifascicular block were independent predictors of survival. Stratification of patients according to the risk factors allowed identification of patients with excellent prognosis (those with left ventricular end diastolic pressure less than 20 mmHg, single vessel disease and no conduction disturbances) and others with high risk of death (left ventricular end diastolic pressure greater than or equal to 20 mmHg, three vessel disease and bifascicular block). Survival at 5 years for these two groups were 81% vs 50%, respectively (p less than 0.005).

Examination-associated anxiety in students of medicine.

The authors studied 262 medical students who were in the second year at the University of Barcelona School of Medicine in 1988. The authors measured the students' anxiety as the students were taking each of two examinations on different subjects: one on medical psychology and one on physiology. The State-Trait Anxiety Inventory questionnaire, recently validated in Spanish, was used to measure the students' anxiety associated with the examinations. In addition, analog scales were used to obtain the students' assessment of each examination's difficulty and its importance to them. The findings showed different levels of anxiety in examinations of different subject matters, with a positive correlation between the importance attributed to the examination and the associated anxiety, and a negative correlation between the importance of the examination and the importance attributed to chance in the marking. Implications of these findings and directions for future research are discussed.

Risk stratification and prognosis of patients with recent onset angina.

We prospectively assessed coronary artery disease and natural history in a series of 104 patients (99 males, mean age 52 +/- 8 years) admitted with recent onset angina (defined as a history of angina of less than 1 month duration). Coronary angiography showed one-vessel disease in 31, two-vessel disease in 22 and three-vessel disease in 14; 37 patients had normal coronary arteries. After a mean follow-up of 36 (range 1 to 52) months, one patient died, 13 sustained a myocardial infarction and 21 underwent surgery. The univariate analysis showed four of 12 clinical features derived from clinical history and data from CCU (exertional angina (P less than 0.001), and recurrence of angina (P less than 0.05)) to be associated with the presence of coronary artery disease. These clinical features were termed clinical risk characteristics. Three-year probability of medical events (death or acute myocardial infarction) for patients with 0-1 clinical risk characteristics was 0 and that of combined events (need for revascularization with or without a preceding medical event) 0.11, whereas patients with 2 or more risk characteristics had probabilities of 0.27 and 0.49, respectively. Multivariate analysis identified the number of clinical risk characteristics as the only independent predictor of medical events (P less than 0.002) and a positive thallium stress test (P less than 0.0001), the number of clinical risk characteristics (P less than 0.002) and the number of involved arteries (P less than 0.002), as independent predictors of combined events.(ABSTRACT TRUNCATED AT 250 WORDS)

Does left ventricular aneurysm influence survival after acute myocardial infarction?

To test whether left ventricular aneurysm independently influences survival after acute myocardial infarction, a series of 386 consecutive men aged 60 years or less, were followed up for 57 (40-100) months. Catheterization was performed 1 month following the infarct. Aneurysm, defined as a diastolic outward bulging with akinetic or dyskinetic systolic motion, was diagnosed in 52 patients (13.5%). Mortality was higher (29% vs 14%; P less than 0.02) in patients with left ventricular aneurysm; their probability of survival at 60 months was 75% vs 90% in patients without aneurysm. Cox regression analysis for the whole population identified ejection fraction, bifascicular block, number of diseased vessels and angina after infarction as the only independent predictors of survival; when adjusted for these variables, differences in mortality between patients with and without aneurysm were no longer significant. To investigate further the role of aneurysm in survival, the 52 patients presenting with left ventricular aneurysm were matched with 52 of the remaining 334 patients according to the following baseline variables: ejection fraction, number of diseased vessels, left ventricular end-diastolic pressure, and bifascicular block. The survival curves of these two subsets were similar (mortality rates of 75% and 82%, respectively). Cox regression analysis of the whole cohort of 104 patients selected bifascicular block and the number of diseased vessels, but not left ventricular aneurysm, as independent predictors of outcome.

Psychogenic pain and depressive disorders: an empirical study.

A sample of 31 patients of both sexes suffering from psychogenic pain disorder (DSM-III) were studied in order to test if their clinical and biological features as well as their response to antidepressant treatment support the hypothesis that relates this syndrome to depressive disorders. Biological variables were basal cortisol and dexamethasone suppression test, and treatment consisted of daily administration of 100-175 mg of imipramine for a period of 5 months. Mood state was evaluated by the Hamilton scale and pain was assessed through visual analogue scales immediately before starting treatment and 3 months later. There was a low prevalence of non-suppressors (9.6%) and all patients significantly improved in mood and pain after antidepressant treatment. However, general results support both the hypothesis linking psychogenic pain to depressive disorders and its possible understanding in terms of failed adjustment processes.

Significance of Q-wave regression after transmural acute myocardial infarction.

A total of 313 consecutive patients was studied to assess the prevalence and prognostic implications of Q-wave loss after transmural acute myocardial infarction. Heart catheterization, including single-plane left ventriculography and selective coronary arteriography, was performed before hospital discharge. After a mean follow-up of 65 (1 to 100) months, 34 patients (11%) lost their Q waves. The time interval from the acute event to the first electrocardiogram showing Q-wave disappearance was 14 (1 to 32) months. Peak creatine kinase value was significantly higher in patients who retained their Q waves than in those who lost them (1,121 +/- 813 vs 779 +/- 464 IU, respectively, p less than 0.05). Severity of coronary artery disease, as judged by the number of diseased arteries and the number of arteries with total or subtotal occlusion, was similar in both groups. However, patients showing Q-wave regression had lower left ventricular end-diastolic pressure, higher ejection fraction and fewer abnormally contracting segments than their counterparts (12 +/- 6 vs 15 +/- 7 mm Hg, p less than 0.05; 53 +/- 11 vs 44 +/- 14%, p less than 0.001; 1 +/- 1 vs 2 +/- 1 segments, p less than 0.001, respectively). In addition, no patient with normalized electrocardiogram presented with left ventricular aneurysm. Although differences in mortality, nonfatal reinfarction and new onset of angina between the 2 groups were not significant, congestive heart failure was prevalent among patients with permanent Q waves (23 vs 6%, p less than 0.05). Our findings suggest that Q-wave loss after AMI may be related to a smaller infarct size.

Psychogenic pain and psychological variables: a psychometric study.

A sample of 41 women suffering from psychogenic pain according to DSM-III diagnostic criteria were psychometrically studied, in order to ascertain if they showed specific psychological traits or mechanisms. Type A behavior, extraversion, neuroticism, psychoticism and dissimulation and hostility-aggressivity traits were the psychological variables studied both in the pain sample and in a matched control group. Psychogenic pain patients were significantly more neurotic and suspicious and less physically aggressive than healthy subjects and also scored significantly higher in dissimulation, which suggests a tendency to use defense mechanisms of denial.

Clinical course and risk stratification of myocardial infarct survivors with three-vessel disease.

Prevalence of three-vessel disease was prospectively analyzed in a series of 462 consecutive infarct survivors aged 60 years or less. Eighty-seven percent (403) of the patients were catheterized within one month of the acute event, and were followed for a mean of 43 months (range 21 to 69). Three-vessel disease was present in 96 cases (24%) and these patients form the study population. The primary goals of this study were to determine the prevalence of three-vessel disease and to identify predictors of survival and new coronary events among this subset of infarct survivors. During follow-up, 15 patients died, 17 had a recurrent nonfatal infarction, and 54 developed angina (4-year probability of each cardiac event being 0.20, 0.22, and 0.59, respectively). Cox's stepwise multivariate analysis identified the ejection fraction (EF) as the only predictor of survival (p less than 0.001). No predictors for nonfatal ischemic events were found among the independent variables considered. Patients were stratified in risk categories according to the EF. Four-year probability of survival was 1.0 in participants with EF = greater than 50% (n = 23), 0.77 for those with EF = 21% to 49% (n = 66), and 0.22 in patients with more severe left ventricular dysfunction, EF = less than 20% (n = 7). Probability of occurrence of nonfatal reinfarction or angina was similar in the three risk categories. Thus, our results indicate that a normal ejection fraction is found in 25% of infarct survivors with three-vessel disease, and that this subset of patients has a low incidence of early and intermediate range coronary events.

Psychometric analysis of behavior pattern A in the Spanish population and its relationship with personality variables.

As a first step in the epidemiological study for CHD prevention among the Spanish population, the authors have analyzed two of the instruments for the assessment of the behavior pattern A (JAS and Bortner questionnaires). From a student sample (n = 302), a factor analysis of items and scales was made, relating pattern A scores to Eysenck's personality variables (EPQ). The importance of an accurate psychometric study of pattern A was emphasized, in order to select A subjects as specifically as possible.