Sleep experiences, dissociation, imaginal experiences, and schizotypy: the role of context.

Watson (2001) reported moderate correlations between the Iowa Sleep Experience Survey (ISES) and self-report measures of dissociation and schizotypy. Subsequent investigations (Fassler, Knox, & Lynn, 2003; Watson, 2003) reported similar, although somewhat more modest, correlations between the ISES and measures of dissociation and schizotypy, as well as with measures of absorption and negative affect. The present study tested subjects in conditions in which the measures of sleep experiences were administered with other measures in either the same (N=86) or a different (N=87) test context. We determined that sleep experiences were associated with measures of dissociation, absorption, and schizotypy. We closely replicated Watson (2001) and found that the ISES correlations with other measures were not affected by the test context. We suggest that Watson's (2001) hypothesized common domain of unusual cognitive and perceptual experiences (e.g., sleep experiences) may be underpinned by common ties to imaginative experiences.

Inhibitory control test for the diagnosis of minimal hepatic encephalopathy.

BACKGROUND & AIMS: Minimal hepatic encephalopathy (MHE) is difficult to diagnose. The Inhibitory Control Test (ICT) measures response inhibition and has diagnosed MHE with 90% sensitivity and specificity in a selected population; high lure and low target rates indicated poor ICT performance. We studied the reliability and validity of ICT for MHE diagnosis. METHODS: ICT was compared with a psychometric battery (standard psychometric tests [SPT]) for MHE diagnosis and overt hepatic encephalopathy (OHE) prediction. ICT was administered twice for test-retest reliability, before/after transvenous intrahepatic portosystemic shunting (TIPS), and before/after yogurt treatment. The time taken by 2 medical assistants (MA) to administer ICT was recorded and compared with that of a psychologist for cost analysis. RESULTS: One hundred thirty-six cirrhotic patients and 116 age/education-matched controls were studied. ICT (>5 lures) had 88% sensitivity for MHE diagnosis with 0.902 area under the curve for receiver operating characteristic. MHE-positive patients had significantly higher ICT lures (11 vs 4, respectively, P = .0001) and lower targets (92% vs 97%, respectively, P = .0001) compared with MHE-negative patients. The test/retest reliability for ICT lures (n = 50, r = 0.90, P = .0001) was high. ICT and SPT were equivalent in predicting OHE (21%). ICT lures significantly worsened after TIPS (n = 10; 5 vs 9, respectively; P = .02) and improved after yogurt supplementation (n = 18, 10 vs 5, respectively; P = .002). The MAs were successfully trained to administer ICT; the time required for test administration and the associated costs were smaller for ICT than for SPT. CONCLUSIONS: ICT is a sensitive, reliable, and valid test for MHE diagnosis that can be administered inexpensively by MAs.

The high prevalence of restless legs syndrome symptoms in liver disease in an academic-based hepatology practice.

STUDY OBJECTIVES: Survey-based epidemiologic studies suggest that restless legs syndrome (RLS) affects approximately 10% of the general population and can cause significantly reduced quality of life due to sleep disturbance. This condition is more prevalent in certain disease states, such as iron deficiency anemia, neuropathy, and renal insufficiency. No such prevalence data exists for RLS in liver disease. The aim of the present project was to assess the self-reported prevalence of RLS using an RLS symptom specific questionnaire in patients presenting to a tertiary hepatology clinic with chronic liver disease (CLD). This was a convenience cohort study of established chronic liver disease patients being seen at a tertiary referral center. A one-page survey querying RLS symptoms was administered in hepatology clinic to patients with chronic liver disease. Restless legs syndrome (RLS) symptoms as agreed upon by the International RLS Study Group were incorporated as 5 key questions. Of 141 completed surveys, 88 were positive yielding a questionnaire based prevalence of RLS of 62% in this select population. RLS risk factors were further assessed through chart review and self-report and using a logistical regression analysis. Comparison between those reporting RLS symptoms and those who did not revealed only self-reported neuropathy to be significantly higher in those with RLS. RLS associated with risk factors accounted much of the total prevalence. Of those with RLS symptoms, 23 surveyed were without known RLS risk factors. This yields a convenience sample prevalence of unexplained RLS symptoms of 16.3% (CI: 10.6-23.5) in this population. There did not appear to be a correlation between the severity of liver dysfunction including the presence of cirrhosis or the etiology and the prevalence of RLS symptoms. Quality of Life (QoL) surveys specific to RLS completed suggest RLS symptoms result in significantly diminished QoL, with an average QoL score of 68 on a 0-100 scale. CONCLUSION: This study is the first investigation of RLS prevalence in liver dysfunction. This select population of medically complex patients who all have some degree of liver dysfunction appear to have a surprisingly high prevalence of RLS symptoms. While much of this prevalence may be the result of known secondary causes further investigation is warranted to explore the relationship between RLS and liver dysfunction.

Is hypnotic suggestibility a stable trait?

The present study examined the trait-like nature of hypnotic suggestibility by examining the stability of hypnotic responsiveness in a test-retest design in which the procedures were administered either live or by audiotape. Contrary to the idea that hypnotizability is a largely immutable, stable trait, scores on the scale of hypnotic responsiveness decreased significantly at the second session. Measures of subjective experiences and expectancies accounted for a sizable portion of the variance in hypnotic responding, both at initial test and at retest. Participants became disengaged with the hypnotic procedures at retest. Participants who received the hypnotic induction by audiotape did not differ from participants who received it live. The results are consistent with sociocognitive and altered state theories of hypnosis, and underline the important role of subjective experiences in hypnotic responding.

Increased rates of early adverse reaction to azathioprine in patients with Crohn's disease compared to autoimmune hepatitis: a tertiary referral center experience.

OBJECTIVES: Idiosyncratic drug hypersensitivity may occur at increased rates in specific patient populations. Azathioprine has a significant early adverse reaction (EAR) profile, which includes an acute syndrome of constitutional symptoms, fever, rash, and acute pancreatitis and often requires discontinuation of drug. EAR precludes azathioprine use in patients with Crohn's disease (CD) and autoimmune hepatitis (AIH). Our aims were to investigate differential rates of EAR to azathioprine in CD compared to AIH in a tertiary referral center population. METHODS: Retrospective chart review of consecutive CD and AIH patients who were initiated on azathioprine in our inflammatory bowel disease (IBD) and hepatology centers was performed. EAR (fevers and constitutional symptoms, severe arthralgias, nausea, and vomiting) were defined as those occurring within 1 month of initiation. EAR rates between AIH and CD patients were compared using the Fisher's exact test. RESULTS: One hundred and forty-three CD (88F/55M; age 39.2 +/- 13 yr) and 40 AIH (35F/5M; age 53.1 +/- 14 yr) patients were studied. All patients were initiated with equivalent azathioprine dosage (50 mg qd). All AIH patients were on prednisone (mean daily dose 7.5 mg) compared to 51% of CD patients (median daily dose 20 mg). EAR rates were significantly higher in CD patients (42/143; 29%) compared to AIH (2/40; 5%) (Fisher's exact test; p= 0.008). EAR excluding nausea and vomiting were still significantly higher in CD patients (27/143; 19%) compared to AIH (1/40; 2.5%) (Fisher's exact test; p= 0.01). All patients with EAR required drug discontinuation and 7% of CD patients required hospitalization for management of these complications. CONCLUSIONS: CD patients represent a unique subgroup at increased risk of EAR to azathioprine. Mechanisms behind these reactions need to be further defined.

An evaluation of Woodard's theory of perceptually oriented hypnosis.

This article evaluates Woodard's theory of Perceptually Oriented Hypnosis, a welcome addition to theories of hypnosis that emphasize the centrality of subjective experiences in understanding and studying hypnosis. With a focus on subjective experience. Woodard's account of perceptually oriented hypnosis is based on elements of humanistic, client-centered, and perceptual psychology. However, we contend that improvements in the operational clarity and coverage of the theory are necessary to optimize its utility and heuristic value. We also argue that it is important for Perceptually Oriented Hypnosis to address hypnotic phenomena, e.g., individual differences in suggestibility, involuntary responding to suggestions, stability of responding over time, widely recognized as essential to understanding hypnotic experience and responding. With these refinements, we believe that Woodard's theory would have a greater potential to enrich our understanding of both the unique experiences of individuals who undergo hypnosis and of hypnosis in general.

Leflunomide treatment of Crohn's disease patients intolerant to standard immunomodulator therapy.

BACKGROUND: Immunomodulator therapy with the purine analogs azathioprine and 6-mercaptopurine (6-MP), is efficacious in the treatment of moderate to severe Crohn's disease (CD), but is not tolerated by a significant minority of patients. The pyrimidine analog, leflunomide, has demonstrated efficacy in the treatment of rheumatoid arthritis (RA) patients. Because established RA immunomodulator agents may demonstrate success in the treatment of CD, we reviewed our clinical open-label experience with leflunomide in a refractory CD population. GOALS Assess the effect of leflunomide 20 mg daily, on disease activity, steroid requirement and serologic measures of inflammatory activity in our series of CD patients intolerant to azathioprine/6-MP. STUDY: CD patients intolerant of azathioprine/6-MP were offered leflunomide treatment. The Harvey-Bradshaw (H-B) disease activity index, global assessment, serologic parameters and ability to taper corticosteroids of those who accepted were retrospectively assessed. RESULTS: Leflunomide was well tolerated and resulted in a significant reduction in the H-B score, global assessment and serologic parameters in 8/12 patients. Average follow-up was 38 weeks and a majority of steroid-dependent patients were able to successfully taper following leflunomide initiation. CONCLUSIONS: Our case series demonstrates that the pyrimidine analog leflunomide may be effective for treating moderate to severe CD patients intolerant to standard immunomodulator therapy and warrants further investigation in a randomized controlled trial.

Unsedated transnasal endoscopy: a new technique for accurately detecting and grading esophageal varices in cirrhotic patients.

OBJECTIVES: Endoscopic screening of cirrhotics for large esophageal varices (EV) is advocated before initiation of prophylactic therapy for variceal bleeding. Conscious sedation for conventional endoscopy is problematic in cirrhotic patients because of risk of prolonged encephalopathy. Unsedated transnasal endoscopy (T-EGD) is a new technique, which allows for unsedated examination because it is well tolerated. The aims of this study were to determine whether T-EGD is feasible for screening of cirrhotic patients for presence of EV and to compare the diagnostic yield of T-EGD with conventional endoscopy for detecting and grading of EV. METHODS: Fifteen cirrhotics with no history of variceal bleeding, known EV, severe thrombocytopenia, or recurrent epistaxis were evaluated by unsedated T-EGD using a 5.3-mm outer diameter endoscope. Immediately afterward, a different endoscopist, blinded to T-EGD findings, performed sedated conventional endoscopy in standard fashion. The presence and size of EV, gastric varices, and other findings were recorded. Patient tolerance was also evaluated. RESULTS: Both modalities detected EV in the same 10 and gastric varices in the same two patients and completely agreed on size of EV. No stigmata of recent variceal bleeding were noted. Average time for unsedated T-EGD was 5 min 6 s. All patients found both procedures acceptable overall, with no significant difference in choking, discomfort, and sore throat. One patient developed self-limited epistaxis after T-EGD. CONCLUSIONS: 1) EV are accurately detected and graded by T-EGD in cirrhotic patients. 2) T-EGD is a safe and less costly screening alternative for EV in cirrhotic patients.