Temperament and character in patients with bipolar II disorder and recurrent brief depression.

OBJECTIVES: We compared the temperament and character profiles of 21 patients with bipolar II disorder, 40 patients with recurrent brief depression (RBD; at least monthly depressive episodes meeting the diagnostic criteria for major depressive episode except for duration that is less than 2 weeks, typically 2-3 days, without fixed relation to menstrual cycle) of which 21 had no history of hypomania and 19 had experienced hypomanic episodes, and 21 age- and sex-matched controls. METHODS: Assessments included the Montgomery-Åsberg Depression Rating Scale, Hypomania Checklist, and Temperament and Character Inventory-125. Patients with cluster A and B personality disorders were excluded. RESULTS: Bipolar II and RBD patients had higher harm avoidance (HA) and lower self-directedness (SD) compared with controls. Excluding panic disorder comorbidity effaced this difference in HA and SD (bipolar II only) and harm avoidance. No other differences were found. CONCLUSIONS: In this first study comparing personality profiles of patients with bipolar II vs RBD, when controlling for confounders, neither bipolar II nor RBD patients differed significantly from healthy controls. The lower SD scores among RBD patients may reflect sampling bias (a higher rate of Axis 2 cluster C disorders).

An investigation of the prototype validity of the borderline DSM-IV construct.

OBJECTIVE: To investigate the prototype validity of the borderline personality disorder (BPD) DSM-IV construct. METHOD: Patients (n = 930) from the Norwegian Network of Psychotherapeutic Day Hospitals. Exploratory/confirmatory factor analyses, correlation and reliability statistics, chi-square, and frequency distributions. RESULTS: Number of BPD criteria showed no distinct threshold between No-BPD and BPD patients among whom 136 different combinations of criteria occurred. Both factor analyses supported that one component/latent variable accounted for the variance of the BPD criteria, showing a high convergent and discriminant validity. The criterion of unstable relationships displayed the highest diagnostic efficiency, and that of chronic feelings of emptiness the lowest. CONCLUSION: The prototype theoretical model for BPD fitted the data well and appeared to be satisfactory described by the current criteria. The emptiness criterion needs a more appropriate definition and the hierarchy of the criteria in DSM-IV should be revised.

[Palliative sedation to dying patients in Norway]. / Lindrende sedering til døende i Norge.

BACKGROUND: In May 2000, the Norwegian Medical Association appointed a working group to propose guidelines for the practice of palliative sedation to dying patients (terminal sedation). The present study is part of this work. The aim of the study was to register to what extent this form of palliation is used in Norwegian hospitals, on what indications, how decisions are reached, and whether the treatment is considered necessary. The definition of palliative sedation given was: induction and maintenance of sleep for the relief of pain or other types of suffering in a patient close to death. The intention is exclusively to relieve intractable pain, not to shorten the patient's life. MATERIAL AND METHODS: An anonymous questionnaire was sent to 364 Norwegian hospital departments that might have experience with palliative sedation. Results are reported partly as free text comments and partly as frequencies of predetermined response alternatives. RESULTS: 58% of the questionnaires were returned. 22% of the respondents had given palliative sedation to a dying patient during the last 12 months, and more than half of the physicians found this intervention sometimes necessary. Pain was the most frequent indication; none of the respondents claimed to haven given sedation exclusively based on depression/anxiety. Lack of resources still seems to be an obstacle to optimal palliative care in Norway. CONCLUSION: Though it has some methodological weaknesses, this study confirms the need for national guidelines.

Paternalism, patient autonomy, and moral deliberation in the physician-patient relationship. Attitudes among Norwegian physicians.

Sixteen statements on physician attitudes in the physician-patient relationship were presented to a representative sample of Norwegian physicians (N=990). Three moderately correlated theoretical dimensions were identified in a principal component analysis: paternalism, patient autonomy, and moral deliberation. The paternalism scores increased significantly with age, and psychiatrists scored significantly lower than physicians in somatic specialties. Psychiatrists had the highest scores on the patient autonomy dimension, whereas surgeons scored the lowest. Moral deliberation scores increased slightly with age. To explore the pattern of scores across the three dimensions, the scores were dichotomized and combined in eight different ways. The resulting typology included five different physician profiles: (1) classical paternalists (high scores on paternalism, low scores on both patient autonomy and moral deliberation), (2) modern paternalists (high scores on both paternalism and deliberation, low scores on patient autonomy), (3) autonomists ( high scores on patient autonomy, low scores on both paternalism and deliberation), (4) deliberationists (high scores on deliberation and patient autonomy, low scores on paternalism), and (5) ambivalents (high or low scores on all dimensions, or high or low scores on both paternalism and patient autonomy). The four groups of physicians with 'consistent' attitudes contained between 12 and 19% of the total sample, whereas 37% belonged to the 'ambivalent' group. Laboratory doctors and surgeons belonged significantly more often in the group of classical paternalists than did general practitioners, whereas male physicians were more often modern paternalists than were female physicians. Among the autonomists, women were more numerous than men, doctors in their 40s clearly more numerous than those in their 60s, and psychiatrists clearly more numerous than residents.

[What is burnout?]. / Hva er utbrenthet?

BACKGROUND: Burnout is most often described as a concept with three separate dimensions: emotional exhaustion, depersonalization (lack of empathy), and reduced accomplishments at work. We wanted to study the descriptive validity of the concept, which may be measured by the Maslach Burnout Inventory. MATERIAL AND METHODS: The Maslach Burnout Inventory was mailed to 1,476 members of the Norwegian Medical Association. The response rate was 73%. The dimensional structure of the instrument was examined by principal component analysis, and the identified factors correlated with validated measures of job satisfaction and depression. The dichotomized factors were combined in eight different ways, and the specificity of the resulting types was studied. RESULTS: The three original dimensions were reproduced, and the internal consistency of the factors was good (Cronbach's alpha ranging from 0.91 to 0.69). There were high correlations between emotional exhaustion and both job satisfaction (r = -0.54) and depression (r = 0.72). INTERPRETATION: Emotional exhaustion seems to be the least specific of the burnout dimensions. For the purpose of reasonable descriptive validity, the burnout notion should be based on both emotional exhaustion and depersonalization. With the applied dichotomization thresholds, this implies that 3% of Norwegian physicians are "burned out".

[The foundation for psychiatric treatment--from belief to science]. / Grunnlaget for psykiatrisk behandling--fra tro til vitenskap.

Like other clinical disciplines, psychiatry has been met with increasing demands to document the scientific foundations for its treatments. The introduction of evidence-based medicine has contributed to this. Psychiatry holds a unique position compared to other medical specialties because it deals not only with physical or biological matters, but also with questions of meaning and mental phenomena. The scientific and clinical approach to psychiatry must incorporate both these aspects. This cannot be accomplished through a purely hermeneutic or a purely relativistic position. In isolation, these approaches cannot contribute to bridging the gap between research and clinical practice. Evidence-based medicine, on the other hand, through a stronger emphasis on empirical scientific evidence as the basis of treatment methods, enables us to secure better and safer therapies for our patients and augment the professional status of psychiatry. A critical attitude towards established "truths" will prevent stagnation in static or dogmatic positions, and thereby promote continuous development. Quality assurance and scientific validation is basically a question of ethics, hence we cannot avoid attending to these issues.

Self-criticism, dependency and depressive symptoms in a nationwide sample of Norwegian physicians.

This cross-sectional study examines the associations between dysfunctional beliefs concerning self-criticism and dependency and self-reported depressive symptoms in a nationwide representative sample of Norwegian physicians (N = 836). The dysfunctional beliefs were measured by the Dysfunctional Attitudes Scale (DAS), and depressive symptoms by the "severe depression" subscale of the General Health Questionnaire. Women reported more depressive symptoms than men, whereas men reported more dysfunctional attitudes, especially concerning self-criticism. Both self-criticism and dependency were significantly associated with level of depressive symptoms in male doctors when age and their medical speciality were controlled, whereas no such relationship was demonstrated in female doctors, except for a bivariate association between depressive symptoms and two single indicators of dependency.

[Health, medicine and population development in Norway]. / Helse, medisin og befolkningsutvikling i Norge.

If health, medicine and medical services in Norway throughout the millennium are seen through a demographer's eyes, it is obvious that the health situation and the preconditions for medical work have changed profoundly, especially in the last two centuries. A relatively stable, young, and geographically dispersed population, living with, and probably to a large extent accepting high morbidity and high mortality, has gradually been transformed into a more middleaged, urbanized population where absence of disease and untimely death is perceived as a normal situation, which it is the goal of the health services to achieve. The population growth was especially accelerated during the 19th century, when mortality rates declined rapidly before a corresponding decrease took place in the birth rates. The demographic effects of medicine in Norway in the 19th century should mostly be ascribed to efforts in preventive and social medicine. The life saving and life prolonging effects of curative medicine belong to the the 20th century, a period when specific treatment of infections had become available. However, further achievements in demographic effects of medicine have to take into account the demands set by the perceptions of health and welfare in the population, and the ever increasing social and economic constraints.

[What shapes people's notions of health and illness?]. / Hva former befolkningens oppfatninger om helse og sykdom?

Lay conceptions of health are shaped by a variety of demographic, social, and personal factors. Research has focused on psychological and sociological perspectives, and three core models have dominated the field: the cognitive developmental model, the health locus of control model, and the so-called health belief model. Societal factors have been less studied. On the basis of a meta model we discuss how changes in prevalence of disease and disease panorama, social network, the experience of uncertainty, and the medical focus on risk may have impact on lay conceptions of health and disease. The joint effect of the medical focus on risk and disintegrating social networks seems to be the central force behind medicalization.

[The history of the asylum--the history of "the great confinement"?]. / Asylets historie--historien om "den store innesperringen"?

Histoire de la Folie (1961) by the French philosopher Michel Foucault has profoundly influenced the general public's conception of the history of psychiatry, but the book is relatively seldom discussed among psychiatrists. Foucault views the core characteristics of psychiatry in the light of what he terms "the great confinement" of the mad and other outsiders. He maintains that the confinement took place all over central Europe from 1650 until 1800, and that the psychiatric asylum was designed on the basis of the confinement house. This paper discusses whether this great confinement actually took place and critically examines Foucault's interpretational model. There is a further discussion of the main reasons why the humanistic and creative spirit characteristic of the early nineteenth century asylum was replaced by stagnation and disillusionment 150 years later.

[Perception among Norwegian hospital physicians of physician-nurse cooperation]. / Oppfatninger blant norske sykehusleger om samarbeidet mellom lege og sykepleier.

It is generally agreed that a positive and cooperative atmosphere between nurses and doctors is of vital importance to the quality of medical services in hospitals. In this study 1,278 Norwegian hospital doctors were asked how they perceived the working atmosphere between doctors and nurses. 75% replied that the doctors-nurse relationship was characterized by openness and dialogue and half of them felt that there was generally not much competition with regard to medical responsibility. Only 14% found communicating difficult, 20% stated that conflicts between the two groups were seldom discussed openly. Psychiatrists were found to view the relationship in the most positive light, whereas surgeons and non-specialists (mostly residents and interns) perceived the working atmosphere less favourably. Young doctors had a more negative view of the relationship than older ones. Neither gender nor job position were of any significance in predicting the perceptions. A high level of autonomy and a low level of stress were factors which contributed positively to the doctor-nurse relationship.

The ethics of euthanasia--attitudes and practice among Norwegian physicians.

The ethical guidelines of the Norwegian Medical Association strongly condemn physician participation in euthanasia and assisted suicide. A previous study on attitudes towards euthanasia in the Norwegian population, however, indicates that a substantial part of the population is quite liberal. This study explores Norwegian physicians' attitudes towards and experience with end of life dilemmas. Sixty-six percent of a representative sample of 1476 who received postal questionnaires responded. They confirmed that Norwegian physicians actually seem to hold quite restrictive attitudes towards euthanasia. Seventeen percent answered yes to a question of whether a physician should have the opportunity to actively end the life of a terminal patient in great pain who requests this help, while 4% agreed that the same could be done to a chronically ill patient with great pain and a poor quality of life who otherwise would have several more years to live. Six percent of the physicians had performed actions intended to hasten a patient's death, while 76% said that they at least once had treated patients even if they had felt that treatment should have been discontinued. A multiple logistic regression analysis showed that internal medicine specialists, surgeons and psychiatrists were significantly more restrictive than their colleagues in laboratory specialties, and that physicians educated abroad and those with negative attitudes towards patient autonomy had more liberal attitudes towards euthanasia, when gender and time since graduation from medical school were controlled for.

[Time stress among Norwegian physicians]. / Tidspress blant norske leger.

In this paper perceived stress at work is examined in a nationwide representative sample of Norwegian physicians. Four questions were asked about how often the doctors experienced their working conditions as hectic and bothersome, that the work load was unacceptable, that the large number of duties prevented them form working effectively and that they had difficulty in working reasonably undisturbed. 28% of the respondents stated that their work load was often or fairly often unacceptable, while 43% often or fairly often found it difficult to carry out various tasks without being disturbed. While 19% of the physicians perceived their working situation as often hectic and bothersome, the corresponding figure among other academics was 5%. When the four questions were combined to form a measure of stress, about one fifth of the doctors proved to be highly stressed. In a multiple linear regression analysis (N = 2,304) the physician's perceived autonomy was the strongest predictor of stress, i.e. doctors who feel they can substantially influence the planning and organization of their work achieve the lowest scores for stress. Heads of hospital departments are more stressed than physicians who work outside hospital. Stress also increases with increasing frequency of overtime and with increasing amounts of voluntary overtime.

[Positive feedback for good medical work--a short-supply commodity?]. / Anerkjennelse for godt legearbeid--en mangelvare?

In a nationwide survey of the working environment of Norwegian physicians every second respondent reported seldom or never being appreciated or praised for good work by their superiors. Nurses, colleagues and auxiliaries are more frequent sources of such appreciation. Very little of the variance in doctors' experience of positive feedback is explained by job variables: a doctor who does not receive supportive feedback cannot attribute this to unwise choice of specialty or type of employer, or to age, sex or position in the hierarchy. The experiences of male and female doctors are very much the same. Whether the doctors are appreciated and praised for good work seems to depend rather on certain traits of their personality.

The communication atmosphere between physician colleagues: competitive perfectionism or supportive dialogue? A Norwegian study.

Open and supportive communication is probably one of the most important promotors of learning, coping and satisfaction at the workplace. The aim of this paper is to describe and predict the communication atmosphere between Norwegian physicians. Twenty statements describing communication, as perceived by the physicians themselves, were presented to a random sample of the members of the Norwegian Medical Association of which more than 90% of the physicians in the country are members (N = 2628). In general, this investigation indicates that the communication atmosphere among Norwegian physicians is characterised by support and mutual respect. More than half of the respondents fully agreed that communication between colleagues in the workplace is marked by solidarity, and that experienced colleagues show respect for the less experienced in both personal and professional matters. Physicians working in hospitals described the communication atmosphere as substantially more selfish and competitive than non-hospital physicians, whilst general practitioners considered the atmosphere between colleagues to be more supportive than non-specialists. In addition, high perceived stress was associated with the perception of a less supportive atmosphere. However, the strongest predictor of the communication atmosphere was clearly the physician's perceived autonomy. The comprehensive retrenchment programmes implemented in Norwegian hospitals during recent years have increased stress and restricted professional autonomy among both physicians and other occupational groups. Our findings indicate that the communication atmosphere necessary to secure continuity of knowledge within the medical profession may have been jeopardised by this process. In the long term, this may prove hazardous to the quality of medical care.

Health complaints and job stress in Norwegian physicians: the use of an overlapping questionnaire design.

An extensive research program has been undertaken in Norway on physician health, sickness, working conditions and quality of life. Data are collected from cross-sectional and longitudinal prospective and retrospective surveys, qualitative studies, and vital statistics. This paper presents findings on subjectively experienced health problems, emotional distress, experienced job stress and job satisfaction, based on an extensive cross-sectional postal questionnaire study in 1993. An overlapping questionnaire design was used to allow many relationships to be estimated without exhausting the recipients. 9266 active physicians were included, which comprises close to the total Norwegian physician work-force minus a representative sample of 2100, used for other studies. The primary questionnaire was returned by 6652 (71.8%), the great majority of which also returned three secondary questionnaires. The results indicate that health complaints were significantly more frequent in female physicians and decreased with age. Low job satisfaction, high job stress, and emotional distress were all found to be significant predictors of subjective health complaints, as measured by the Ursin Health Inventory.

Survey of Norwegian doctors' cultural activities.

BACKGROUND: During the past few decades the need for humanities in medical education has been increasingly emphasised. We sought to find out how doctors meet their cultural needs during their spare time, in comparison with other university graduates. We also aimed, in this Norwegian survey, to analyse differences between doctors according to various professional characteristics. METHODS: 1041 Norwegian doctors (71% of those approached) reported their cultural activities through a postal survey. Their replies were compared with those of 224 university graduates who had taken part in a similar survey by Statistics Norway in 1991. FINDINGS: The doctors spent less time than the other graduates on reading newspapers and watching television, though they were more musically active and 18% play at least one instrument regularly. No other differences were apparent. The more time doctors spent on medical reading, the more time they also devoted to non-medical reading. No systematic differences in cultural activity according to medical specialty were found, but women were more culturally active than men. INTERPRETATION: The high work-load and demands of medical practice do not limit doctors' cultural life. Spare-time cultural activities among doctors seem to be determined more by personal than by professional characteristics.

Attitudes toward informing the cancer patient--a survey of Norwegian physicians.

To examine Norwegian physicians' attitudes to informing patients of a diagnosis of cancer, a random sample of 1467 were surveyed. The respondents rated their level of agreement to 14 statements, and the responses were analysed by chi-squared statistics. 990 physicians responded (67%). Only 30.5% of the responding physicians had treated more than 10 cancer patients the previous year, which included 7.8% who had treated more than 50. 40.4% had treated none. The great majority (81%) preferred full information of the diagnosis. Physicians with increasing age preferred relatives not being present and gave priority to factual information and informing patients with the same diagnosis identically. Hospital physicians (39.5%) more often preferred other health professionals being present than physicians in private practice (18%) (P < 0.001). Number of cancer patients treated was not associated with attitudes toward the disclosure of information. Norwegian physicians prefer revealing the cancer diagnosis to patients, but have divergent opinions about how to do so. Some of these indicate suboptimal information-giving.