[Unused knowledge? A useful result of research from the funded Investigative Medicine program]. / Kennis op de plank? Het nuttig effect van onderzoeken uit het programma van het fonds Ontwikkelingsgeneeskunde.

Many policy-makers believe that the translation of research findings into daily practice is poor. Examples of projects from the research programme 'Investigative medicine' over the period 1990-1995 show that this opinion is not correct. Findings from medical technology assessments that focus on clinical decision making were usually translated into clinical practice very quickly, sometimes even before clinical guidelines had been produced or revised. In almost all cases, the formulation of governance policies concerning the financing and distribution of medical services and interventions required considerably more time.

[Diseases and the diseased--scientific and alternative medicine]. / Over ziekten en zieken--wetenschappelijke en alternatieve geneeskunde.

Exposing alternative medicine as quackery and unscientific is necessary, but one should be aware of the limitations of scientific medicine as far as the care of individual patients is concerned. Medicine is primarily about people, not about science. Current regular medicine uses a rational approach and carries out actions of which the effectiveness has been demonstrated in controlled trials. But some questions cannot be translated into a testable hypothesis, e.g., what is the best treatment for the individual incurable cancer patient sitting in my surgery right now? However, this question is a relevant one, especially for the patient involved. In daily clinical practice, there is no clear distinction between scientifically-based and not-scientifically-based acts. The task of medicine is to cure, but also to encourage and to console. When exposing alternative medicine, one should be able to offer the patient a different approach; otherwise the exposure is nothing more than a nihilistic exercise. Alternative medicine does not cure diseases, but it sometimes helps diseased people.

[Chekhov as a doctor]. / Tsjechow als dokter.

Anton Chekhov (1860-1904) was not only a writer, but also a doctor. One might think that he was primarily concerned with writing, but he also dedicated himself fully to being a doctor. When he had to give up his practice in 1897 upon urgent medical advice, he experienced it as a great loss. As a medic he often felt unsure and believed that he failed in his duties. This did not change the fact that many patients called upon him for assistance. They were probably also fond of him because of his genuine interest in their living conditions and because of his compassion. In terms of his scientific activities, his attempt to have his visit in 1890 to the Russian penal colony Sakhalin recognised as a dissertation failed. In many ways, Chekhov was a hard-working idealist, but one without illusions. Doctors appear as the main character or one of the main characters in 25 of Chekhov's hundreds of stories as well as in various plays. Although Chekhov undoubtedly will have incorporated his own experiences into his works, he did not give a picture of his own medical activities in the doctors he portrayed. A large number of the doctors he describes are depressed, nervous or irritable. Others are naïve and clumsy, while others still are skeptic, cynical or disillusioned. In some of the descriptions the image of Chekhov as a doctor may be observed.

[Report of the Dutch Health Council on the cost-effectiveness of long-term psychotherapy]. / Gezondheidsraadadvies over de doelmatigheid van langdurige psychotherapie.

A recent report from the Health Council of the Netherlands considers the cost-effectiveness of long-term psychotherapy (more than 25 sessions over a period of more than one year). It is concluded that knowledge about the efficacy and effectiveness of this form of therapy is scarce, and the cost-effectiveness is largely unknown. A plea is made for further research and for restraints in the administration of such therapy. However, research into the efficacy of long-term psychotherapy requires a controlled design, with the selection and randomisation of patients. This precludes definitive conclusions with regard to the cost-effectiveness in open patient groups. Moreover, psychotherapy is not only aimed at a cure, but also to a fairly large extent at care. Finally, if it is difficult to determine the efficacy of psychotherapy then this is even more so the case for long-term psychotherapy, as the success may be attributable to a wide range of intervening events that occur during the course of treatment.

Gilles de la Tourette's syndrome with and without obsessive-compulsive disorder compared with obsessive-compulsive disorder without tics: which symptoms discriminate?

Stereotyped repetitive behaviors occur in Gilles de la Tourette's Syndrome (GTS) and obsessive-compulsive disorder (OCD). The present study was undertaken to compare the distribution of obsessive-compulsive and Tourette-related impulsive behaviors in GTS with (+) OCD, GTS without (-) OCD, tic-free OCD, and control subjects. Fourteen GTS + OCD, 18 GTS-OCD, 21 OCD-tic, and 29 control subjects were evaluated using a semistructured interview designed to assess GTS and OCD-related repetitive behaviors. Each reported item was evaluated on the presence of anxiety and goal-directedness. This information was subsequently used to define whether the repetitive behavior was an (anxiety-related) obsession or compulsion, or a (non-anxiety-related) OC-like behavior, impulsion. GTS + OCD subjects reported more overall Tourette-related impulsions than OCD-tic subjects, i.e., more mental play, echophenomena, and touching behaviors but similar frequencies of typical obsessive-compulsive behaviors. Further, GTS + OCD subjects exhibited more overall repetitive behaviors than GTS-OCD subjects, i.e., more Tourette-related impulsions as well as more obsessive-compulsive behaviors. The distribution of symptoms is similar in GTS with and without OCD, and differs from tic-free OCD. These differences suggest that GTS with OCD constitutes a form of GTS, not of OCD, although the possibility that GTS + OCD patients constitute a subgroup distinct from GTS and from OCD can not be excluded by this phenomenological study. Specific non-anxiety-related impulsions seem to discriminate between GTS and OCD-tic individuals. These impulsions possibly reflect differences in underlying mechanisms between GTS and OCD-tics.

Repetitive behaviors in Tourette's syndrome and OCD with and without tics: what are the differences?

Gilles de la Tourette Syndrome (GTS) and obsessive-compulsive disorder (OCD) share obsessive-compulsive phenomena. The aims of this study were to compare the OC symptom distribution between GTS and OCD and to investigate whether a subdivision of these phenomena into obsessions, compulsions and 'impulsions' is useful in distinguishing GTS and OCD patients. Thirty-two GTS, 31 OCD (10 with tics, 21 without tics) and 29 control subjects were studied using the Leiden repetitive behaviors semi-structured interview to assess GTS as well as OCD-related behaviors. Each reported repetitive thought or action was evaluated on the presence of anxiety and on goal-directedness. This information was used to define whether the behavior was an obsession, compulsion, or 'impulsion'. Both the GTS and OCD study groups showed higher scores than control subjects on rating scales measuring depression, OC behavior and anxiety. In GTS, Y-BOCS severity scores and trait anxiety were lower than in the OCD groups. Furthermore, GTS patients differed from OCD patients in the distribution of symptoms. Aggressive repetitive thoughts, contamination worries and washing behaviors were reported more frequently by tic-free OCD, while mental play, echophenomena, touching and (self)-injurious behaviors were reported more frequently by GTS. OCD individuals with tics were intermediate, but closer to tic-free OCD. GTS individuals reported significantly more 'impulsions' and fewer obsessions and compulsions than OCD individuals with and without tics. Factor analysis revealed three factors accounting for 44% of the variance, resulting in an 'impulsive' factor related to GTS, a 'compulsive' factor related to OCD and an 'obsessive' factor related to tic-free OCD. In conclusion, OCD individuals reported more anxiety and goal-directedness associated with their behaviors than did GTS subjects. The distinction between obsessions, compulsions and impulsions is of importance in identifying Tourette-related vs. non-Tourette-related repetitions.

Nocturnal re-experiencing more than forty years after war trauma.

The aim of this study was the examination of Posttraumatic Nightmares (PTNM) and Posttraumatic Anxiety Dreams (PTAD) in Dutch combat veterans and World War II victims. Participants (outpatients; n = 223) were administered a standardized psychiatric interview, the Impact of Event Scale, the SCL-90, the Clinician Administered PTSD Scale, and an interview on posttraumatic nocturnal re-experiencing. Prevalence of PTNM was 56%. Patients with PTNM, even those who were not diagnosed with PTSD, had significantly more psychiatric complaints than patients with no PTNM. Analysis of PTNM demonstrated that they were often experienced as exact replications of the original traumatic events. Replicative PTNM often implicated dream recurrence. Traumatic experiences before the age of 5 resulted in nonreplicative PTNM only. Unlike nonreplicative PTNM, replicative PTNM seemed to be correlated with several intrusion subscales.

The relationship between types and severity of repetitive behaviors in Gilles de la Tourette's disorder and obsessive-compulsive disorder.

BACKGROUND: This study investigated which categories of obsessive-compulsive and Tourette-related behaviors in Gilles de la Tourette's disorder and obsessive-compulsive disorder (OCD) without tics are experienced as most severe across the study groups and what the differences are in symptom distribution between the study groups. METHOD: Fourteen subjects with both Tourette's disorder and OCD, 18 subjects with Tourette's only, 21 subjects with OCD (no tics), and 29 control subjects were studied using a semistructured interview designed to equally assess Tourette- and OCD-related behaviors according to DSM-III-R criteria. Each reported repetitive behavior was evaluated on the presence of anxiety and on goal-directedness. Anxiety-related items were categorized as obsessions or compulsions and non-anxiety-related items as impulsions. Severity of each reported item was assessed with respect to time per day consumed and amount of distress and interference induced by the item. Following these criteria, each reported item was classified as a symptom, a subthreshold symptom, or just as being present. RESULTS: Across the study groups, obsessions were experienced as more severe than (Tourette-related) impulsions and compulsions. Within the study groups, patients with both Tourette's disorder and OCD reported more symptomatic Tourette-related impulsions, such as mental play, echophenomena, and impulsive or self-injurious behaviors; less overall symptomatic obsessions; and less symptomatic washing than patients with OCD (no tics). The differences among individuals with Tourette's with or without OCD reflected differences in symptom severity rather than differences in symptom distribution. CONCLUSION: Obsessions are more time consuming, distressing, and interfering than compulsions and impulsions. Furthermore, the symptomatic repetitive behaviors were distributed differently among patients with both Tourette's disorder and OCD and patients with OCD (no tics). Patients with Tourette's and OCD are phenomenologically more similar to Tourette's than to OCD. These differences possibly represent differences in underlying pathophysiology between Tourette's and tic-free OCD.

Patients' illness perceptions and coping as predictors of functional status in psoriasis: a 1-year follow-up.

In a longitudinal study (two measurements with a 1-year interval), 69 patients with psoriasis completed the Illness Perception Questionnaire, the Medical Outcomes Study SF-20 Health Survey, and the Hospital Anxiety and Depression Scale. Data on coping (Utrecht Coping List) and severity of illness (body surface scores) were also collected. The results of regression analyses indicated that a strong illness identity was associated with more visits to the outpatient clinic, and worse outcome on physical health, social functioning, mental health, health perceptions and depression. Strong beliefs that the disease is controllable/curable and that the disease has disabling consequences were also related to more clinic visits and more negative perceived health, respectively. Patients who initially engaged in coping characterized by more expression of emotions, seeking more social support, seeking more distraction, and less passive coping were prescribed a lower number of different therapies, were less anxious, less depressed, and had a better physical health 1 year later. These results have implications for the management of patients with psoriasis, which reinforces current views on integrating psychosocial aspects into clinical care.

[Chronic, unexplained pain: from complaint to action]. / Chronische, onverklaarde pijn: van klacht naar doel.

Every physician encounters patients with physical symptoms that remain unexplained, despite appropriate investigations. Medical curricula and textbooks fail to provide guidance about the management of such problems. Particularly specialists tend to feel helpless; this often leads to more referrals and unnecessary operations. Three patients, referred to a neurologist for a second opinion, had chronic, unexplained, crippling pains: a woman aged 53 with low back pain radiating to the right leg for 27 years, a man aged 31 with neck pain for 3 years and a woman aged 31 with pain in the left arm for 1.5 years. They had no recognisable features of depression. Their illness behaviour reversed after the neurologist reassured the patients and advised them to embark upon a strict programme of gradually increasing activities. In two of the patients, the scheme was supervised by the general practitioner. A follow-up interview (after a median interval of 3 years) of 27 similar patients referred for a second opinion showed some success with this approach in about half of them. In retrospect no predictive factors at baseline could be identified other than age and duration of symptoms. An indispensable first step in patients with unexplained, chronic pain is unqualified recognition of the symptoms, reassurance, and an explanation that avoids the mind-body division.

Physical and psychological correlates of functioning in patients with chronic obstructive pulmonary disease.

We studied the contribution of coping and illness perceptions to outcome in patients with chronic obstructive pulmonary disease (COPD). In a longitudinal study, 64 patients completed the Medical Outcomes Study Instrument and the Illness Perception Questionnaire. Data on coping and severity of illness (spirometry) were also collected. Regression analyses showed that first-time illness perceptions and coping significantly contributed to the prediction of social functioning, mental health, health perceptions, total functioning score, and prediction of visits to the outpatient clinic and prescribed medication 1 year later. These results have important implications for the medical management of patients with COPD.

[Bizarre advertisements by hospitals in the Dutch Journal of Medicine]. / Wonderlijke reclame voor ziekenhuizen in het Nederlands Tijdschrift voor Geneeskunde.

The advertisements in this journal show that hospitals in the Netherlands are using increasingly bizarre texts to recruit physicians. Not only do they unflinchingly exaggerate phrases to describe their achievements--'top-clinical care', 'customer-orientation', 'quality improvement'--but they even emphasize their attractive surroundings and the fervor of their policy. One wonders whose interests are being served by these inflated advertisements. They are, however, clearly at odds with the advertising restrictions imposed upon individual physicians.

Is alexithymia a risk factor for unexplained physical symptoms in general medical outpatients?

OBJECTIVE: Alexithymia is presumed to play an important predisposing role in the pathogenesis of medically unexplained physical symptoms. However, no research on alexithymia has been done among general medical outpatients who present with medically unexplained physical symptoms as their main problem and in which anxiety and depression have been considered as possible confounding factors. This study investigated whether patients with medically unexplained physical symptoms are more alexithymic than those with explained symptoms and whether, in patients with unexplained symptoms, alexithymia is associated with subjective health experience and use of medical services. METHODS: We conducted a cross-sectional study among patients attending an internal medicine outpatient clinic. All patients were given a standardized interview and completed a number of questionnaires. RESULTS: After complete physical examinations, 169 of 321 patients had unexplained physical symptoms according to two independent raters. Patients with medically unexplained symptoms more often had a mental disorder, but overall they were not more alexithymic. In patients with unexplained physical symptoms, alexithymia was not associated with subjective health experience or use of medical services. However, patients with both unexplained symptoms and a mental disorder who also denied any possible connection between emotional problems and their physical symptoms did have more alexithymic traits. CONCLUSIONS: In the majority of patients with medically unexplained physical symptoms, alexithymia does not play a role of clinical significance. Patients with unexplained physical symptoms are heterogeneous with respect to psychiatric syndrome pathology and probably also with respect to personality pathology.

Predicting functional status in patients with rheumatoid arthritis.

OBJECTIVE: To determine whether coping strategies and illness perceptions would be predictive of outcome in a longitudinal study of patients with rheumatoid arthritis (RA). METHODS: A group of 71 patients with RA was examined on 2 occasions, one year apart. Multiple regressions were used to examine which of the illness perceptions and coping strategies explained variance on the outcome variables: visits to the outpatient clinic, number of hospital admissions, Health Assessment Questionnaire, pain, tiredness, the Hospital Anxiety and Depression Scale. RESULTS: Belief in adverse consequences of the disease was associated with more visits to the outpatient clinic. more tiredness, and higher anxiety scores. Less perceived control and less expression of emotion were associated with more hospital admissions. High scores on coping involving fostering reassuring thoughts were associated with more functional disability. More passive coping was associated with more functional disability and higher anxiety scores. More perceived symptoms were associated with more pain, more tiredness, and more depression. More avoidant coping was associated with more tiredness. Belief that the illness will last a long time was associated with higher anxiety scores. CONCLUSION: Our longitudinal data show that, after statistically controlling for the potential effects of intervening medical variables, coping strategies and illness perceptions contribute to health outcome in patients with RA. Implications for patient management are discussed.

Cognitive change following cognitive behavioural therapy for non-cardiac chest pain.

BACKGROUND: Seventeen to 43% of patients with non-cardiac chest pain suffer from anxiety/panic disorders. Cognitive behavioural therapy (CBT) is effective in reducing non-cardiac chest pain. However, no data are available indicating that pain reduction following CBT may be cognitively mediated or whether success of CBT is dependent on the presence of panic. The aim of the study was threefold: (1) does CBT have a differential effect on cognitive measures; (2) does a relationship exist between improvement in non-cardiac chest pain and changes in cognitive measures, and (3) can panic be established as a moderator of the effect of treatment? METHODS: Sixty-five patients with non-cardiac chest pain completed a randomised trial comparing study CBT with 'care as usual'. Dependent measures were: frequency of chest pain, anxiety, the fear of bodily sensations, attributions and catastrophic cognitions. RESULTS: CBT had a differential effect on most of the cognitive measures. Pain reduction was associated with the development of more adequate cognitions with respect to chest pain, independent of anxiety reduction. Although panic patients reported higher baseline scores on the cognitive measures, no differences in treatment results were found between panic and no-panic patients. CONCLUSIONS: Pain reduction following CBT may be cognitively mediated. The presence of panic did not affect the outcome of treatment, implying a broad applicability of the cognitive model for treatment of patients with non-cardiac chest pain.

Cognitive-behavioral therapy for noncardiac chest pain: a randomized trial.

PURPOSE: Patients with nonischemic chest pain frequently experience recurrent symptoms, have persistent functional and occupational disability, and are high utilizers of health-care resources. Our aim was to evaluate the efficacy of a cognitive-behavioral treatment for patients with noncardiac chest pain. PATIENTS AND METHODS: Subjects were recruited from patients with at least weekly episodes of noncardiac chest pain, as diagnosed by a cardiologist. The main outcome measures were frequency and intensity of chest pain at 6 and 12 months. RESULTS: Seventy-two patients were enrolled in the study; 37 were assigned to cognitive-behavior therapy and 35 to usual care. Sixty-five patients completed the study. Intervention patients improved significantly with regard to frequency and intensity of chest pain: 15 (48%) of the 31 patients in the treatment group were pain free at 12-month follow-up compared with 4 (13%) of the 33 patients in the control group (P = 0.002). CONCLUSIONS: Cognitive-behavioral therapy for noncardiac chest pain patients was effective compared with usual care.

[Report of the Health Council on the use of benzodiazepines. The Netherlands Health Council]. / Gezondheidsraad-rapport over gebruik van benzodiazepinen.

The Netherlands Health Council has issued a report on the appropriate use of benzodiazepines, detailing current knowledge on mode of action, indications for use, adverse effects and the prescribed volume in the Netherlands. About 3% of the adult population are chronic users of benzodiazepines. Chronic use is complicated by the risk of falling; the relative risk of hip fractures in chronic benzodiazepine users in about 1.7. Chronic use should be discouraged. However, most chronic users are fragile elderly people for whom a good night's sleep implies temporary escape from a sorry existence with somatic or psychic symptoms. Such circumstances should be kept in mind when treating individual patients.

[Roaming through methodology. IV. Causality]. / Dwalingen in de methodologie. IV. Causaliteit.

If a factor A is often followed by an event B, it may erroneously be concluded that one causes the other. Actually B may have been brought about by a factor C (the true cause), A being only an epiphenomenon of C. If factors other than C (for example D or E) can cause the same effect B, none of those factors is a necessary cause. Causes often are multiple: a single causal factor is often not sufficient for a certain effect to ensue, whereas that effect can result from a number of factors acting together (simultaneously or consecutively).