['I'm in hate with you; epistemic distrust in patients with a severe personality disorder]. / 'Ik haat van jou'; epistemisch wantrouwen bij mensen met een ernstige persoonlijkheidsstoornis.

Background The assessment and treatment of patients with a personality disorder have made considerable progress during the last decades. Unfortunately, this progress is often limited to patients with a personality disorder in general. Patients with a personality disorder who also fulfil criteria for a severe mental illness (SMI-PD) profit less. Aim To describe the relationship between contemporary paradigms about personality disorders and the current treatment practices of patients with SMI-PD, and to assess the added value of the recently introduced paradigm epistemic trust and distrust. Method An expert group of mental health professionals, all members of the Expertise Centre for Personality Disorders, conducted a literature study and in addition organized an invitational conference and consensus meetings, resulting in an analysis and recommendations for treatment of patients with SMI-PD. Results The epistemic trust and distrust paradigm clarifies the learning process of patients with SMI-PD and the way patients benefit from treatment. We conclude with elaborations of this paradigm for five contexts of patients with SMI-PD. Conclusion The epistemic trust and distrust paradigm seems a promising concept to improve the often difficult treatment of patients with SMI-PD.

Does urodynamic investigation improve outcome in patients undergoing prolapse surgery?

AIMS: Without solid evidence, it has been advocated to perform urodynamic investigation in all patients scheduled for prolapse surgery. If urodynamic investigations were to be valuable in the diagnostic work-up, patients with normal and abnormal findings would have different treatment results. Our policy to never combine prolapse surgery and stress-incontinence surgery allowed us to study whether incontinence after surgery can be predicted from urodynamic investigation results. METHODS: A retrospective study was performed in consecutive patients undergoing vaginal prolapse surgery (anterior colporraphy and/or posterior colporraphy, and/or vaginal hysterectomy) between 2002 and 2004. All patients underwent pre-operative urodynamic investigation, including filling cystometry, urethral pressure profile measurement, and free flow cystometry. Data were collected from the files about medical history, findings at pelvic examination, findings at urodynamic investigation and presence of stress- and/or urge-incontinence after surgery. RESULTS: We studied 76 patients, of whom 5 (7%) patients reported stress-incontinence and 5 (7%) patients reported urge-incontinence after surgery. Findings at urodynamic investigation could not predict the presence of stress- or urge-incontinence after surgery. Likelihood ratios (LR) of prior presence of urge and stress-incontinence for the presence of post-operative urge- and stress-incontinence were 4.5 and 1.2, respectively. Of all findings at urodynamic investigation, only negative transmission during cough test was associated with presence of stress-incontinence (LR = 1.5). CONCLUSIONS: The prevalence of incontinence after prolapse surgery is low. None of the investigated parameters of the urodynamic investigation tests was associated with the presence of urinary incontinence after surgery.