The spectrum of anxiety disorders in the medically ill.

OBJECTIVE: The purpose of this cross-sectional study was to assess the prevalence and characteristics of anxiety disorders in the medically ill. METHOD: A sample of 1,660 medical patients was recruited from different medical settings in different periods from 1996 to 2007. All patients underwent detailed semistructured interviews with the Structured Clinical Interview for DSM-IV (SCID) and the Structured Interview for Diagnostic Criteria for Psychosomatic Research (DCPR). RESULTS: Generalized anxiety disorder was the most frequent anxiety disturbance (10.3%) and was associated with DCPR somatization syndromes, Type A behavior, and irritable mood. Panic disorder with agoraphobia and agoraphobia without history of panic disorder had almost identical prevalence (about 4.5%), but differed in some patterns of somatization. Agoraphobia without panic attacks was related to illness denial, persistent somatization, anniversary reactions, and demoralization. Much lower prevalence rates were reported for social phobia and obsessive-compulsive disorder. CONCLUSIONS: The findings indicate that anxiety disorders are common in the setting of medical disease and are associated with several types of psychosomatic presentations. The links between agoraphobia without history of panic disorder and illness denial may provide an explanation for some discrepancies that have occurred in the literature as to the prevalence of agoraphobia in clinical samples compared to epidemiologic studies.

Assessing somatization with various diagnostic criteria.

BACKGROUND: Somatization is a widespread clinical phenomenon that cuts across diagnostic categories, both psychiatric and medical. OBJECTIVE: This study investigates whether somatization can be assessed with a comprehensive diagnostic system, the Diagnostic Criteria for Psychosomatic Research (DCPR) in gastroenterology and cardiology (myocardial infarction) patients. METHOD: Authors assessed a group of 343 outpatients, 190 gastroenterology and 153 cardiology outpatients, with functional gastrointestinal disorders and recent first myocardial infarction. RESULTS: A total of 146 patients were diagnosed by the DCPR Somatization cluster and 106 by the DCPR Abnormal Illness Behavior cluster; 27 patients who met DSM-IV criteria for somatoform disorders were not classified with any DCPR somatization syndromes, whereas 120 with DCPR Somatization cluster did not satisfy the criteria for DSM-IV somatoform disorders. CONCLUSION: Findings suggest that the DCPR is able to identify clinical and subthreshold psychosomatic syndromes and that it can used jointly with the DSM-IV.

Psychosomatic characterization of adjustment disorders in the medical setting: some suggestions for DSM-V.

BACKGROUND: Adjustment disorders have been found to be the most frequent psychiatric diagnosis in the medically ill. Problems have been raised, however, as to their clinical value. The aim of the study was to characterize the psychosomatic features of adjustment disorders. METHODS: One hundred patients with medical illness and a diagnosis of adjustment disorder according to DSM-IV criteria were interviewed according to the Diagnostic Criteria for Psychosomatic Research (DCPR) system, consisting of 12 clusters. RESULTS: A considerable overlap was shown between adjustment disorders and DCPR clusters related to abnormal illness behavior (health anxiety, tanatophobia, nosophobia and illness denial) (54%), somatization (functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms and anniversary reaction) (37%) and demoralization (33%). Only 13 of the patients with adjustment disorders did not present any DCPR syndromes. LIMITATIONS: The study is cross-sectional and does not allow to determine the prognostic features of DCPR categorization. CONCLUSION: The clinical information which derives from the concomitant application of the DCPR might improve and make more specific the treatment of patients with adjustment disorders.

Irritable mood in Italian patients with medical disease.

Irritability may be a mood state independent of other moods and anxiety disorders, even though it may be symptomatic of several psychiatric disorders, such as major depression. The aims of this exploratory study were to verify the presence of irritable mood in a group of medical outpatients with a variety of clinical conditions (functional gastrointestinal disorders, cardiovascular disorders, endocrine diseases and cancer) and to examine its relationship with major depression. A total of 609 consecutive outpatients recruited from different medical settings were assessed according to DSM-IV and Diagnostic Criteria for Psychosomatic Research using semistructured research interviews. Irritable mood was identified in 163 (27%) patients, while major depression was present in 113 (19%) patients. Even though there was a considerable overlap between the two diagnoses, 76 (67%) patients with major depression were not classified as irritable, and 126 (77%) patients with irritable mood did not satisfy the criteria for major depression. The findings suggest a high prevalence of irritability in the medically ill, which in most cases is independent of mood disorder. Further research may determine whether irritability, alone or in association with major depression, entails prognostic and clinical implications.

Use of the Diagnostic Criteria for Psychosomatic Research (DCPR) in a community sample.

The authors assessed the prevalence of Diagnostic Criteria for Psychosomatic Research (DCPR) clusters in a community sample and the association between these syndromes and psychosocial variables. A group of 347 consecutive subjects from the general population were administered the semistructured interview for DCPR and a self-rating scale (the Psychosocial Index). A DCPR syndrome was identified in 59% of subjects. These subjects showed more stress and distress and less well-being than those without a DCPR syndrome. Some DCPR syndromes (alexithymia, Type A behavior, irritable mood) are frequently encountered in a community sample and are associated with impairment in quality of life. Other syndromes (demoralization, persistent somatization) that have been frequently found in medically ill persons were uncommon in this general-population sample.

Assessing demoralization and depression in the setting of medical disease.

OBJECTIVE: The aim of this study was to assess the presence of demoralization and major depression in the setting of medical disease. METHOD: 807 consecutive outpatients recruited from different medical settings (gastroenterology, cardiology, endocrinology, and oncology) were assessed according to DSM-IV criteria and Diagnostic Criteria for Psychosomatic Research, using semistructured research interviews. RESULTS: Demoralization was identified in 245 patients (30.4%), while major depression was present in 135 patients (16.7%). Even though there was a considerable overlap between the 2 diagnoses, 59 patients (43.7%) with major depression were not classified as demoralized, and 169 patients (69.0%) with demoralization did not satisfy the criteria for major depression. CONCLUSIONS: The findings suggest a high prevalence of demoralization in the medically ill and the feasibility of a differentiation between demoralization and depression. Further research may determine whether demoralization, alone or in association with major depression, entails prognostic and clinical implications.

Assessing the community prevalence of bipolar spectrum symptoms by the mood disorder questionnaire.

BACKGROUND: The goal of this study was to assess the frequency and spectrum of symptoms related to bipolar disorders in a community sample by means of a self-rating questionnaire. METHOD: The Mood Disorder Questionnaire, a self-rating scale which evaluates DSM-IV manic/hypomanic symptoms, was administered to a community sample of 1,034 individuals recruited through advertisements. Symptom interrelationships were studied by factor analysis. RESULTS: 275 individuals (26.6%) reported moderate or severe impairment due to the symptoms. Manic/hypomanic symptoms were present in a high proportion of individuals. Factor analysis found a two-factor structure of bipolar spectrum symptoms (an elevated mood overactivity factor, and an irritable behavior factor). CONCLUSION: The findings of this study highlight the need of complementing clinical investigations on the bipolar spectrum with community studies. Subclinical manic-hypomanic symptoms may be present also in allegedly unipolar patients and may have implications on the course of illness.

Well-being therapy of generalized anxiety disorder.

BACKGROUND: There is increasing awareness that the goal of treatment in generalized anxiety disorder (GAD) should not simply be a response, but restoration of normal function. The aim of this study was to apply a novel psychotherapeutic approach for increasing the level of remission in GAD. METHODS: Twenty patients with DSM-IV GAD devoid of comorbid conditions were randomly assigned to 8 sessions of cognitive behavioral therapy (CBT) or the sequential administration of 4 sessions of CBT followed by other 4 sessions of well-being therapy (WBT). Assessment methods included the Anxiety and Depression Scales of Paykel's Clinical Interview for Depression, Ryff's Psychological Well-being Scales and Kellner's Symptom Questionnaire. A one-year follow-up was undertaken. RESULTS: Significant advantages of the CBT-WBT sequential combination over CBT only were observed with both observer and self-rated methods after treatment. Such gains were maintained at follow-up. CONCLUSIONS: These preliminary results suggest the feasibility and clinical advantages of adding WBT to the treatment of GAD. They lend support to a sequential use of treatment components for achieving a more sustained recovery.

Psychological assessment in cardiac rehabilitation.

BACKGROUND: While there has been an upsurge of interest in the psychiatric correlates of myocardial infarction, little is known about the presence of psychological distress in the setting of cardiac rehabilitation. METHODS: A consecutive series of 61 patients with recent myocardial infarction who participated in a cardiac rehabilitation program was evaluated by means of both observer-rated (DSM and DCPR) and self-rated (Psychosocial Index) methods. A follow-up of this patient population was undertaken (median = 2 years). Survival analysis was used to characterize the clinical course of patients. RESULTS: Twenty percent of patients had a DSM-IV diagnosis (in half of the cases minor depression). An additional 30% of patients presented with a DCPR cluster, such as type A behavior and irritable mood. Only high levels of self-perceived stressful life circumstances and psychological distress approached statistical significance as a psychological risk factor for cardiovascular events after myocardial infarction. CONCLUSIONS: Psychological evaluation of patients undergoing cardiac rehabilitation needs to incorporate both clinical (DSM) and subclinical (DCPR) methods of classification. Type A behavior was present in about a quarter of patients and can be studied in specific subgroups of cardiovascular patients defined by DCPR.

Psychological well-being in rheumatoid arthritis: relationship to 'disease' variables and affective disturbance.

BACKGROUND: Resilience is likely to be important in understanding psychological responses to chronic physical illnesses. This study aimed to examine one measure of resilience--Ryff's operationalized measure of psychological well-being (PWB)--in rheumatoid arthritis. It was hypothesized that PWB would be influenced by age and gender in the same way as in community samples, and that the absence of current mood disorder would be associated with high PWB. METHODS: Rheumatology clinic outpatients (n = 104) were assessed for pain, disease activity, disability, depression and anxiety. PWB was assessed using Ryff's six-subscale model. The measured variables were used in a logistic regression analysis to model the absence of clinically important mood disorder. RESULTS: The expected variations in PWB according to age and gender were largely absent, with the overall findings suggesting that chronic illness in general, rather than arthritis in particular, affects PWB. Significant bivariate correlations were found between depression and pain, disease activity, disability and all six PWB subscales. However, in the regression analysis, only the PWB environmental mastery subscale and self-rated disability made significant contributions to the absence of mood disturbance, and their inclusion in the regression model correctly classified 81% of the total sample. CONCLUSIONS: These results require replication in a longitudinal study, but indicate the potential value of using PWB among people with rheumatoid arthritis to screen for individuals who may be particularly vulnerable to developing depression. It might be appropriate to target such people with focused psychological interventions.