Stress and coping strategies in the general population of Greece and Cyprus in response to the COVID-19 pandemic: A cross-sectional study.

The COVID-19 pandemic and the lockdown policy had a profound psychological impact on the general population worldwide. The aim of this study was to assess the level of stress and coping strategies used during the initial stage of the COVID-19 outbreak and their association. Secondary aims were to a) identify the most important coping strategies and b) investigate predictors of stress. A cross-sectional study was conducted by using an anonymous online questionnaire. The study was carried out from April 23 to May 4 2020. A snowball sampling method was conducted to recruit potential participants from the general population of Greece and Cyprus. Participants over 18 years old who were familiar with the Greek language were included. The psychological impact was assessed by the Impact of Event Scale-Revised (IES-R). Coping strategies were assessed using 15 statements detected from a review of the literature. Participants were asked to rate each one of the coping strategies according to how important it was to them, on a four-point likert scale. The sample consisted of 3941 participants (74.2% women, N=2926), with a mean age of 36.9 years old. The most important coping strategies adopted were 1) "Dealing the situation with a positive attitude" (96.5%), 2) "Follow strict personal protective measures" (95,9%), 3) "Acquiring knowledge about coronavirus" (94.6%), 4) "Engaging in health-promoting behaviors" (89.6%), 5) "Limiting the time spent on media" (75.5%). The highest and positive coefficients were recorded for the association of IES-R scales with 1) "Talking with family and friends to reduce stress", 2) "Seeking help from a mental health professional", 3) "Limiting the time spent on media", 4) "Relieving and managing emotions", 5) "Practicing relaxation techniques". 26.5% showed severe psychological impact. Conclusion: Addressing stress levels with the use of functional coping strategies can be beneficial to protect the general population from adverse psychological outcomes.

[The contribution of the relationship between therapist-patient and the context of the professional relationship].

The therapeutic relationship is the common place of all medical specialties in therapeutic practice. It is a professional relationship and consists of two components: the work component and the interpersonal component. The focus of the studies aims to show the contribution of the dynamics of the therapist - patient interpersonal relationship as a therapeutic factor in achieving the therapeutic outcome. The issue of doctor-patient relationship has been studied since antiquity, in particular by Socrates and beyond. Hippocrates promotes and systematizes medical philosophy, bioethics and medical ethics, as seen in the well-known "Hippocratic Oath". In the new era, S. Freud continued the work of inductive dialectics of Socrates, while formulating the concept of transference and countertransference. The development of psychotherapies has provided enough evidence for the parameters that interact into a therapeutic relationship, as their techniques were merely dialectical. M. Balint supports the value of counter-transference and transference to the therapeutic relationship. G. Bibring & R. Kahana suggest that psychoanalytic techniques and personality types contribute to the understanding of the physical patient. C. Rogers suggested that the attitudes and the empathic understanding of the therapist, not the techniques, contribute primarily to therapeutic success. G. Engel (1970) promotes the patient's biopsychosocial approach. Since 1980, systematic studies have begun to support the value of the therapeutic relationship, believing that it is itself an autonomous therapeutic factor, confirming the views of M. Balint and C. Rogers. They conclude that the therapeutic effect is a function of the quality of the therapeutic relationship, regardless of any therapeutic technique, and that the therapeutic alliance has a significant effect on the clinical outcome for psychotherapies as well as for pharmacotherapy. Empathy, non-possessive warmth, positive respect and authenticity have a significant effect on the treatment results. The common factor model supports the dynamics of the interpersonal relationship contributing 85% to the therapeutic effect whereas the therapeutic techniques contribute 15%. It therefore seems that the dynamics of the interpersonal relationship, the therapist-patient, is an important therapeutic factor. Studies continue and more questions arise as to whether education is available, the dynamics of interpersonal relationships in the context of therapeutic relationships at undergraduate and postgraduate levels. Also, the development of dialectical techniques, as a response to the empathic therapeutic relationship, which contributes at the clinical level to the patient's approach and information within the general health area and not only to mental health.

Informing cancer patient based on his type of personality: the suspicious (paranoid) patient.

Imparting bad news had always been an unpleasant task for the physician, as shown from ancient years to our days. In the healthcare sector and as far as the cancer patient is concerned, the imparting of bad news is performed by the patient's doctor within a therapeutic relationship of course. The fundamental question is how a therapist could tailor the information to any patient and if "Is it possible to determine who should be told what, when and how ?". The aim of this paper was to describe the suspicious character or type of personality thoroughly so that any physician can make a diagnosis and tailor the information strategy to the patient's needs. As method of research was used the qualitative method through groups with doctors and nurses, while research within groups lasted for 5 years. The degree of informing of the suspicious personality in the range "minimal - small - medium - large - very large" is : the degree of denial varies between large and very large. The degree of informing varies between medium and small and sometimes minimal. Informing the Family: The hardest family to deal with. Pay attention to litigious mania. Avoid confrontation or be drawn into agreeing with the family views.

Informing cancer patient based on his type of personality: the avoidant patient.

Imparting bad news to a cancer patient is considered an arduous task, but it seems to be facilitated by the use of the empathic approach. Indeed, doctors who are trained to adhere to a cancer patient informing protocol argue that the hardest step to take is the empathic approach. The usual questions asked are: To tell the diagnosis or not? How much information should we give? Should the patient know or has the right not to know? Is it possible to determine who should say, what, when, and how. The aim of this article was to describe the avoidant character or type of personality, so that any physician can make a diagnosis and tailor the information strategy to the patient's needs. As method of research was used the qualitative method through groups with doctors and nurses, while research within groups lasted for 5 years. The degree of informing the avoidant personality in the range "minimal - small - medium - large - very large" is : The degree of denial varies between "small" and "medium", while the degree of informing varies between "medium" and "small" in order to reach "large" later. Informing the family: The patient reacts to a common approach with the family as he is concerned about inflicting a blow to his image.

Informing cancer patient in relation his type of personality: the emotional-hypothymic (depressive) patient.

Informing patients with cancer has been a subject of great scientific interest. Initially the research was aimed at quantity evaluation, in other words, the number of doctors who break the news to the patient, the number of patients seeking informing etc. Since the 1980s to present, research has shifted its focus equally on quality evaluation. In other words, serious efforts are being made to answer the question: "Is it possible to determine who should be told what, when and how?" It seems that deepening on the patient s character traits offers the best starting point for understanding the patient. The aim of this paper was to describe the character of personality types based on the question: "How could characters or personality types be used in informing patients with cancer?" As method of research was used the qualitative method through groups with doctors and nurses, while research within groups lasted for 5 years. The degree of informing is similar to the degree of the hyperthymic personality; initially, is "minimal, then "small" until it reaches "medium". The degree of denial varies between "large" and "very large" to sometimes "medium". Family: similar to the emotional-hyperthymic person, with the added difficulty of introversy. There is a discordance between what the patient shows and what the family reports about him, especially when the compensation mechanism is that of a controlling - orderly patient.

Informing cancer patient based on his type of personality: the arrogant (narcissistic) patient.

The task of informing the cancer patient is considered an arduous one as it typically involves breaking bad news to the patient. It appears that the adoption of an empathic approach is vital within a therapeutic relationship. This applies to every character or personality type, perhaps more so to the arrogant patient with a feeling of superiority. The question "Is it possible to determine who should be told what, when and how" basically implies the adoption of an empathic approach and the tailoring of information to each cancer patient. The use of character traits contributes to managing the physically ill patient in the best possible way. Therefore, follows the question: in what way does a character or personality type affect cancer patient informing? The aim of this article was to describe the arrogant (narcissistic) character or type of personality in an analytic way so that any therapist can make a diagnosis and tailor the information strategy to the patient's needs. As method of research was used the qualitative method research through groups with doctors and nurses, while research within groups lasted for 5 years. The degree of informing the arrogant personality in the range "minimal - small - medium - large - very large" is: The degree of denial varies between "large" and "very large" while the degree of informing varies between "medium" and "small". Informing the family: The patient objects to a common approach with the family as he is concerned about inflicting a blow to his image.

Informing cancer patient in relation to his type of personality: the dependent (oral) patient.

When a doctor has to break bad news to the cancer patient, he knows that the news will put a strain on his relationship with the patient. Bad news is any information that changes a person's view of the future in a negative way. The questions: "Do you tell the diagnosis or not? How much information do you reveal? Who do you inform about the diagnosis and/or what do you tell" are very frequent during scientific discussions. Must the patients know or do they also have the right not to know? Is it possible to determine who should be told what, when and how? The aim of this paper was to describe the dependent character or type of personality, so that a therapist can make a diagnosis in order to determine the informative approach.

Informing cancer patient in relation to his type of personality: the emotional-hyperthymic (dramatizing) patient.

Informing a cancer patient has been an issue of particular interest to the scientific community over the last 50 years. Since 1989 we have been studying the characters or personality types based on the Kahana and Bibring's approach as part of Consultation-Liaison (C-L) Psychiatry. The question posed was how these characters or personality types could be useful in the process of informing the cancer patient. The aim of this paper was to describe the emotional-hyperthymic character or type of personality thoroughly, so that any physician can make a diagnosis and tailor the information strategy to the patient's needs. The qualitative method of research through groups with doctors and nurses was used, while the research within groups lasted for 5 years. The degree of patients' denial varied between "large" and "very large" and sometimes was "medium". Initially, the degree of information was "minimal", then "small" until it reached "medium". A discordance was evident between what the patient showed and what the family reported about him. The patient presented himself as courageous and extrovert, but the relatives considered him as faint-hearted.

Informing cancer patient in relation to his type of personality: the controlling-orderly (obsessive) patient.

The questions "Do you tell the diagnosis or not? How much information do you reveal? Who do you inform about the diagnosis and/or what do you tell" are very frequent during scientific discussions. Must the patients know or do they also have the right not to know? Is it possible to determine who should be told what, when and how? Is it possible individualizing the informing of a cancer patient according to his character or type of personality? The aim of this paper was to describe the Controlling- Orderly (C-O) character, so any therapist can build up an information strategy to cancer patients. This study took place within the framework of Consulting- Liaison (C-L) psychiatry and included: 1) Training groups in which doctors and nurses participated. 2) The section of C-L Psychiatry of the Psychiatry Department. 3) The training activity in the framework of C-L Psychiatry. 4) The annual seminars of psychooncology for health professionals. How a doctor could use the characteristics of a C-O patient for an empathetic approach and correctly inform him. And how to approach his denial and family in order to tailor the information strategy. Understanding the personality type of C-O patient, his denial mechanisms and the dynamics within his family maximizes the therapist's empathetic approach towards the cancer patient. The therapist can respond at "what, when and how" about to break bad news. A therapist must take into account the main C-O patient characteristics (control and order), as well as the attributes or cognitions: the tendency to use reason, the mechanism of rationalization by which he exercises mental control that leads to doubt. The denial degree is small to minimal, while the degree of information is large to very large.

Informing the cancer patient and family.

One of the questions the therapist poses himself while informing a patient is: whom shall I inform about the diagnosis, treatment and prognosis? If we unconditionally accepted the view that information belongs to the patient from an ethical and legal standpoint, we would automatically exclude the partner and the family. Therefore, the therapist should raise another question: what is the benefit to the patient? To answer the question and the resulting dilemma, we have to leverage the long experience of family therapy and tailor it to the cases we are dealing with. It should be taken into consideration that patient and family are a dynamic system which was balanced before the onset of the disease, but is now disrupted, entering into crisis. Therefore, denial mechanism and personality characteristics we have previously elaborated on, and communication among members play a crucial role in determining the information strategy and the way family should be approached. The steps to approach the patient - family are: 1) Firstly, we evaluate the patient's degree of denial and personality characteristics. Then we receive information about the patient's family so that we can have a rough idea about intrafamily dynamics. 2) Then we gather information from the nurses about the family atmosphere: simple information about the patient's and relatives' relationship like who comes to the hospital, who shows interest in the patient, whether someone is being quarrelsome or not are crucial to assess the dynamics of their relationships. 3) We summon patient and family members in our office. 4) We decide on the steps to inform the patient, and we apply them. Involving family members with the patient seems to improve the results of information and forge concession and therapeutic alliance, which are necessary parameters in the therapeutic follow-up. Usually, doctors and nurses approach patient and family using their experience. Therefore, we need a training that will equip health professionals with the necessary knowledge to approach the family.

Using personality characteristics to individualize information to cancer patient.

Disclosure of information to cancer patients is an issue of continuous and great interest. There is a wide-scale debate underway about the questions "do we disclose diagnosis or not", "what should we tell", "how much information should we reveal". Usually, the answers to those questions are general rules of approaching the patient, instructions and general communication skills. What we are missing here is individualization, tailoring information and communication to each patient according to their own personality characteristics. The purpose of this paper was to provide a guide that will make individualization possible, taking into account personality characteristics. We provide a description of the main personality types and of how we can use character traits to inform a patient or otherwise, how do we tailor information to a patient's personality characteristics. Thus, we address the questions of how much do we inform, what words should we use, what do we say, when do we say it and how can information be in line with the therapeutic relationship and patient follow up. On the whole, there is the view that information within the context of doctor-patient communication should be a subject of training. We agree with this view and that is one of the reasons why training workshops are being held at the Metaxa Cancer Hospital.

Using the denial mechanism to inform the cancer patient.

Denial is a defense mechanism found in interpersonal relationships and behaviors, when a person finds it hard to cope with an unpleasant event or situation and accept that it is true. The success of disclosing information to a patient and indeed its individualization lies on the right use of the patient's character traits. This approach supplies an answer in issues such as when, how much, how we give information and what words we use. We can address these questions more fully, if we combine the approach and use of the denial degree of each patient along with personality traits. Therefore, it is obvious that there is a relationship between characteristics and the expression of the denial mechanism, hence denial per se. It is worth stressing on how family and relatives react to the bad news. In fact, in some cases not only preserve but also exacerbate denial in their patient, whereas many times they press the physician not to disclose the patient's illness. The hardest difficulty in understanding the denial mechanism by therapists is to establish to which extent these denial-induced reactions are conscious or not. As much as this defense mechanism is simple to put down in words, it is difficult to understand it completely and assess how deeply rooted it is. Therefore, the concepts of the denial mechanism should be the subject of training. The best way to understand the denial mechanism is through Consulting-Liaison Psychiatry.

Autonomic nervous system responses to personal stressful events in patients with acute myocardial infarction. Preliminary results.

BACKGROUND: Life events specific for each individual may influence the onset of acute myocardial infarction (AMI), and we wondered whether recall of such events elicits autonomic nervous system responses in patients. METHODS: Thirty-one subjects with AMI, which occurred about 1 month previously (study group), and 22 healthy subjects were interviewed. Whenever the presence of a stressful event was found within the last 2 months before AMI onset, a key phrase of the event was isolated. Each subject was faced with 20 written key sentences (including his/her own sentence if detected) at random order, for 40 s each. At the same time the heart rate (HR) and the galvanic skin response (GSR) were continuously recorded. Pearson r correlations, chi 2 and t tests were employed for comparisons between study and control group as well as within each group. RESULTS: A recent exacerbating event was detected in 30/31 AMI patients and in 0/22 healthy subjects. For the 30 AMI patients the values of HR following the sentence of the suspected event, specific for each patient, were statistically significantly higher than the mean values of HR following the remaining 19 'neutral' statements. The same significant difference appeared with regard to GSR values. The mean values of the AMI patients for the 19 neutral statements did not differ significantly from those of the healthy subjects for the 20 neutral statements, either for HR or GSR. CONCLUSIONS: Findings suggest that recall of personal stressful events elicited autonomic nervous system responses in AMI patients and, therefore, events with personal significance are related to coronary disease onset.

Pain intensity in nondiabetic patients with myocardial infarction or unstable angina. Its association with clinical and psychological features.

Sixty nondiabetic coronary artery disease (CAD) patients submitted to coronary angiography were asked to rate (score 0 to 20) pain intensity (RPI) during their last major anginal episode having occurred prior to coronary angiography. This parameter was examined in relation to other variables of CAD and to psychological features. Stepwise regression analysis revealed that RPI was not related to New York Heart Association (NYHA) classification of angina or to angiographic variables. Yet, RPI was found to be significantly affected by psychological features: higher RPI scores were reported by low state anxiety patients (P=0.008), by Type A coronary-prone behavior patients (P=0.02) and by patients with high depression (P=0.03).