Predictive validity of acute stress disorder in children and adolescents.

Adult research suggests that the dissociation criterion of acute stress disorder has limited validity in predicting post-traumatic stress disorder (PTSD). We addressed this issue in child and adolescent survivors (n=367) of road accidents. Dissociation accounted for no significant unique variance in later PTSD, over and above other acute stress disorder criteria. Furthermore, thresholds of either three or more re-experiencing symptoms, or six or more re-experiencing/hyperarousal symptoms, were as effective at predicting PTSD as the full acute stress disorder diagnosis.

Dissociative symptoms and the acute stress disorder diagnosis in children and adolescents: a replication of the Harvey and Bryant (1999) study.

Acute stress disorder (ASD) is a good predictor of posttraumatic stress disorder in adult populations, although the emphasis on dissociation symptoms within the diagnosis has been questioned. Recent studies suggest that ASD may also have application to children and adolescents. The present study examined properties of ASD within youth. A large (N = 367) multisite sample of 6- to 17-year-old children and adolescents exposed to motor vehicle accidents completed interviews or self-report questionnaires regarding their acute stress symptoms. The study found evidence supporting the suggestion that the dissociative criterion of ASD is excessively strict in youth, and that there is less overlap between dissociative symptoms than in adults. The implications of these findings for how ASD is applied to youth are discussed.

Developing a rapid access chest pain clinic: qualitative studies of patients' needs and experiences.

OBJECTIVE: The aims of this study are to understand the needs and experiences of rapid access chest pain clinic attenders and to determine the acceptability and effectiveness of simple procedural changes. METHODS: Two qualitative studies of clinic attenders before and after procedural changes which were guided by the first study. RESULTS: Study 1: Patients wanted to be reassured, by knowing what was causing their pain, understanding the cause, and feeling able to help themselves. Often, these needs were not met, and uncertainties left some patients feeling ill-equipped to help themselves. Communication problems were identified. Study 2: The changes were acceptable to patients, and almost all were reassured. Most valued receiving extra verbal and written advice and information. Many felt more aware of cardiac risk factors and intended to change their lifestyle. CONCLUSION: There were clear opportunities for improvements in care. Changes in procedures helped patients to understand their pain, to practice self-management, and to consider altering their lifestyle.

The relationship of disordered eating habits and attitudes to clinical outcomes in young adult females with type 1 diabetes.

OBJECTIVE: To describe the clinical outcomes of adolescent and young adult female subjects with type 1 diabetes in relation to the disturbance of eating habits and attitudes over 8-12 years. RESEARCH DESIGN AND METHODS: Patients were recruited from the registers of pediatric and young adult diabetes clinics (including nonattenders) and interviewed in the community. A total of 87 patients were assessed at baseline (aged 11-25 years), and 63 (72%) were reinterviewed after 8-12 years (aged 20-38 years). Eating habits and attitudes were assessed by a semistructured research diagnostic interview (Eating Disorder Examination). RESULTS: Clinical eating disorders ascertained from the interview and/or case note review at baseline or follow-up were found in 13 subjects (14.9% [95% CI 8.2-24.2]), and an additional 7 subjects had evidence of binging or purging, bringing the total affected to 26%. Insulin misuse for weight control was reported by 31 (35.6% [25.7-46.6]) subjects. Overall outcome was poor; serious microvascular complications were common and mortality was high. There were significant relationships between disordered eating habits, insulin misuse, and microvascular complications. CONCLUSIONS: Although the cross-sectional prevalence of clinical eating disorders in young women with diabetes is modest, the cumulative incidence of eating problems continues to increase after young adulthood, and this is strongly associated with poor physical health outcomes. The combination of an eating disorder and diabetes puts patients at high risk of mortality and morbidity. Better methods of detection and management are needed.

Poor prognosis of young adults with type 1 diabetes: a longitudinal study.

OBJECTIVE: To determine the role of early behavioral and psychological factors on later outcomes in young adults with childhood- or adolescent-onset type 1 diabetes. RESEARCH DESIGN AND METHODS: We conducted a longitudinal cohort study of patients recruited from the register of the young adult outpatient diabetes clinic, Oxford, U.K. A total of 113 individuals (51 male subjects) aged 17-25 years completed assessments, and 87 (77%) were reinterviewed as older adults (aged 28-37 years). Longitudinal assessments were made of glycemic control (HbA(1c)) and complications. Psychological state at baseline was assessed using the Present State Examination and self-report Symptom Checklist, with corresponding interview schedules administered at follow-up. RESULTS: There was no significant improvement between baseline and follow-up in mean HbA(1c) levels (8.5 vs. 8.6% in men, 9.3 vs. 8.7% in women). The proportion of individuals with serious complications (preproliferative or laser-treated retinopathy, proteinuria or more severe renal disease, peripheral neuropathy, and autonomic neuropathy) increased from 3-37% during the 11-year period. Women were more likely than men to have multiple complications (23 vs. 6%, difference 17%, 95% CI 4-29%, P = 0.02). Psychiatric disorders increased from 16 to 28% (20% in men, 36% in women at follow-up, difference NS), and 8% had psychiatric disorders at both assessments. Baseline psychiatric symptom scores predicted follow-up scores (beta = 0.32, SE [beta] 0.12, P = 0.008, 95% CI 0.09-0.56) and recurrent admissions with diabetic ketoacidosis (odds ratio 9.1, 95% CI 2.9-28.6, P < 0.0001). CONCLUSIONS: The clinical and psychiatric outcome in this cohort was poor. Psychiatric symptoms in later adolescence and young adulthood appeared to predict later psychiatric problems.

Dissociation and post-traumatic stress disorder: two prospective studies of road traffic accident survivors.

BACKGROUND: Dissociative symptoms during trauma predict post-traumatic stress disorder (PTSD), but they are often transient. It is controversial whether they predict chronic PTSD over and above what can be predicted from other post-trauma symptoms. AIMS: To investigate prospectively the relationship between dissociative symptoms before, during and after a trauma and other psychological predictors, and chronic PTSD. METHOD: Two samples of 27 and 176 road traffic accident survivors were recruited. Patients were assessed shortly after the accident and followed at intervals over the next 6 months. Assessments included measures of dissociation, memory fragmentation, data-driven processing, rumination and PTSD symptoms. RESULTS: All measures of dissociation, particularly persistent dissociation 4 weeks after the accident, predicted chronic PTSD severity at 6 months. Dissociative symptoms predicted subsequent PTSD over and above the other PTSD symptom clusters. Memory fragmentation and data-driven processing also predicted PTSD. Rumination about the accident was among the strongest predictors of subsequent PTSD symptoms. CONCLUSIONS: Persistent dissociation and rumination 4 weeks after trauma are more useful in identifying those patients who are likely to develop chronic PTSD than initial reactions.

Psychiatric consequences of motor vehicle accidents.

Psychiatric complaints are frequent following motor vehicle accidents and may be major predictors of persistent pain and other complaints. Outcomes are not related closely to the nature or severity of any medical injury. Psychiatric problems often are unrecognized and untreated. There is a need for more behaviorally inferred routine care, early recognition of complications, and the use of psychological and pharmacological interventions.

Guideline-based early rehabilitation after myocardial infarction. A pragmatic randomised controlled trial.

OBJECTIVES: To determine the effectiveness of individualised educational behavioural treatment delivered by cardiac nurses in hospital compared to usual care for patients following acute myocardial infarction. METHODS: One hundred and fourteen consecutive patients were randomised to receive the intervention or usual care. Outcome assessment was by self-report questionnaire (the Hospital Anxiety and Depression Scale and Dartmouth COOP Health Status), interview at 1 month, and self-report at 3 and 12 months. The primary outcome was improvement in the Dartmouth COOP total score from baseline to 3 months. RESULTS: Four patients needed to be treated to give an additional patient with improvement in health status at 3 months (number needed to treat [NNT] 4, 95% confidence intervals [CIs] 3 to 12). The intervention group were more confident about returning to activities 1 month after discharge from hospital. Treated patients had fewer further treatment needs. CONCLUSIONS: An individualised educational behavioural treatment delivered by cardiac nurses in hospital may have substantial benefits. A large-scale pragmatic RCT is needed.

The experiences and needs of Gujarati Hindu patients and partners in the first month after a myocardial infarction.

BACKGROUND: South Asian people living in the United Kingdom are at increased risk of coronary heart disease, have higher mortality rates and are less likely to be treated when compared to the white population. There is, however, little information about the experiences and needs of this group after discharge from hospital. AIMS: To explore the experiences and needs of Gujarati Hindu patients and their partners in the first month after a myocardial infarction. METHODS: Using a qualitative research approach, semi-structured interviews were conducted by a Gujarati-speaking researcher with 35 patients and their partners at home during early convalescence. RESULTS: A number of categories emerged from the data which pertained to a lack of information and advice, poor performance of activity, little lifestyle adjustment, poor expectations, lack of future plans, strong family support, dissatisfaction with the family doctor, and a significant belief in fate. CONCLUSION: Experiences and health care needs of Gujarati Hindu patients with myocardial infarction appear different to those of non-Asians. Cardiac aftercare and rehabilitation services should take account of such information