A randomized clinical trial of cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no intervention for patients with hypochondriasis.

BACKGROUND: Hypochondriasis is common in the clinic and in the community. Cognitive behavioural therapy (CBT) has been found to be effective in previous trials. Psychodynamic psychotherapy is a treatment routinely offered to patients with hypochondriasis in many countries, including Denmark. The aim of this study was to test CBT for hypochondriasis in a centre that was not involved in its development and compare both CBT and short-term psychodynamic psychotherapy (STPP) to a waiting-list control and to each other. CBT was modified by including mindfulness and group therapy sessions, reducing the therapist time required. STPP consisted of individual sessions. METHOD: Eighty patients randomized to CBT, STPP and the waiting list were assessed on measures of health anxiety and general psychopathology before and after a 6-month treatment period. Waiting-list patients were subsequently offered one of the two active treatments on the basis of re-randomization, and assessed on the same measures post-treatment. Patients were again assessed at 6- and 12-month follow-up points. RESULTS: Patients who received CBT did significantly better on all measures relative to the waiting-list control group, and on a specific measure of health anxiety compared with STPP. The STPP group did not significantly differ from the waiting-list group on any outcome measures. Similar differences were observed between CBT and STPP during follow-up, although some of the significant differences between groups were lost. CONCLUSIONS: A modified and time-saving CBT programme is effective in the treatment of hypochondriasis, although the two psychotherapeutic interventions differed in structure.

Pain in somatoform disorders: is somatoform pain disorder a valid diagnosis?

OBJECTIVE: Investigate the validity of DSM-IIIR somatoform pain disorder (SPD) by comparing subgroups of somatoform disorder patients on several measures of psychopathology. METHOD: A total of 144 patients with unexplained physical symptoms were referred from non-psychiatric departments. Among these, 127 patients with somatoform disorders were identified, classified according to the Structured Clinical Interview for DSM (SCID) diagnostic interview, and rated with scales for somatization, anxiety, depression and personality traits. RESULTS: Patients presenting pain did not differ significantly from patients presenting non-pain symptoms on measures of symptoms and personality traits. Correspondingly, patients with SPD did not differ significantly from patients with conversion disorder (CD), while patients with Somatization disorder (SD) had higher scores on most scales for psychopathology and personality disorder. CONCLUSION: Significant diagnostic and symptomatic overlap was found between SPD and CD, and although the statistical power of the study was modest, the study questions the validity of the current definition of SPD.

Somatization and chronic pain.

The experience of pain is related not only to tissue damage and physical illness, but also to mental phenomena including depression, anxiety and somatization. Somatization is common among chronic pain patients and presents special problems in management and treatment. Somatoform patients are often given inappropriate diagnoses, treated for non-existent depressive disorders, and exposed to multiple, superfluous investigations. Psychological models of chronic pain and somatization are presented, and treatment issues including psychotherapy and the use of antidepressants are discussed.

[Somatoform disorders. What is wrong when there is "nothing" wrong?]. / Somatoforme tilstande. Hvad fejler man, når man "ingenting" fejler?

Patients with somatoform and dissociative disorders complain of symptoms suggesting physical disease. These patients are high utilizers of health services but seldom receive relevant treatment. Recently empirical data have been obtained concerning epidemiology, familiar distribution, and relation to personality in these disorders. Somatoform patients often have comorbid depression and anxiety disorder. These complications are often overlooked, but accessible to psychopharmacological treatment. A number of psychotherapeutic techniques have been developed for treatment in general practice and in hospital settings.

Electrodermal lability in anxiety disorders.

Twenty-eight anxiety patients, aged below 50 years, were diagnosed according to DSM-III-R criteria (panic disorder with and without agoraphobia, generalised anxiety disorder, and anxiety disorder not otherwise specified). The patients were characterised by high levels of state and trait anxiety and neuroticism, compared with the controls. However, there were no differences between patients and controls in electrodermal habituation rate, non-specific activity, or skin resistance level. When the patients were divided into electrodermally labile and stable subjects, significant differences were found between patients and controls in both electrodermal activity and Eysenck's personality dimensions. The labile patients were more introverted and attained higher psychoticism scores than either the stable patients or controls. Duration of anxiety symptoms removed the difference found in extroversion, but not in any other variable. The results are discussed in relation to the utility of electrodermal measurements in validation of diagnostic entities. It is concluded, that from the psychophysiological point of view, anxiety disorders may be examined within a dimensional framework.

Electrodermal activity in anxiety disorders.

Forty anxiety patients diagnosed according to DSM-III-R criteria were included: panic disorder (n = 12), agoraphobia (n = 11), generalized anxiety disorder (n = 9), anxiety disorder not otherwise specified (n = 8) and compared with 12 controls. Millon Clinical Multiaxial Inventory and Symptom Checklist-90R symptom and personality scales did not separate the diagnostic groups. Electrodermal activity showed delayed habituation and high spontaneous skin resistance fluctuations in the panic and agoraphobia groups compared with the non-panic groups. The generalized anxiety disorder patients could not be separated from the controls, and the anxiety disorder not otherwise specified patients showed less electrodermal activity than the controls on most variables. In contrast to self-report instruments, electrodermal activity discriminated between diagnostic groups of patients with DSM-III-R anxiety disorders, more specifically between patients with and without panic attacks.

[Continuing clinical education in adult psychiatry is not sufficient--a questionnaire study on training and participation]. / Klinisk videreuddannelse i voksenpsykiatri er mangelfuld--en spørgeskemaundersøgelse af tilbud og deltagelse.

In June 1990 the Section of Younger Psychiatrists affiliated to the Danish Psychiatric Society conducted a survey among junior doctors (JD) regarding clinical and theoretical training during attachments to psychiatric departments. The aim was to evaluate clinical and theoretical training and compare the results with the goals given by the Danish Psychiatric Society. Sixty-two percent (n = 362) answered a questionnaire including personal data, classification of the department, and participation in the organized training and supervision in the psychiatric departments. The introduction to the department at appointment was insufficient for 97% of the JDs. Fifty percent had been offered and 24% had participated in the advised number of clinical conferences. Sixty-nine percent had been offered and 13% had attended the theoretical conferences, while 43% respectively 41% had been offered and had attended the theoretical sessions. Two-thirds of the JDs participated in 50% or more of the organized training. Reasons for not attending were day-offs and pressing duties in the department. The results are discussed in relation to ongoing changes of the educational structure and of doctors appointments in the departments.

The Nordic concept of reactive psychosis--a multicenter reliability study.

Reactive psychosis is a common diagnosis in the Nordic countries (Norway, Sweden, Denmark, Finland and Iceland) and in several other parts of the world. In ICD-9 and DSM-III-R, the concept is defined more narrowly than in the Nordic tradition. In this study we examined the interrater reliability of the Nordic concept by the case-summary method between clinicians from 9 university departments in the Nordic countries. The results show that Nordic psychiatrists have a reasonably reliable concept of reactive psychosis, and that this psychosis can be diagnosed as reliably as schizophrenia and affective psychosis.

Minor head injury: impact on general health after 1 year. A prospective follow-up study.

A prospective follow-up study of 51 patients hospitalized due to minor head injury (MHI) was performed. After one year 28 patients answered the General Health Questionnaire, the Impact of Event Scale and a symptom checklist. A significant impact on general wellbeing attributed to head injury, was indicated. Half of the patients reported some sequelae from head injury, only 25% to a degree that resulted in a case score on General Health Questionnaire. Incidence of prominent post-traumatic stress symptoms was around 20%. Outcome seemed without correlation to trauma severity. Patients with sequelae after one year reported more symptoms at one week after trauma, and the results point to the magnitude of the health problems due to sequelae throughout follow-up. Aspects of prevention and treatment are discussed.

A double blind comparative multicentre study of remoxipride and haloperidol in schizophrenia.

Seventy-two patients fulfilling the DSM-III criteria for schizophrenia and schizophreniform psychosis were admitted to a multicentre, double-blind controlled study to evaluate the efficacy and safety of remoxipride in comparison to haloperidol. The mean daily dose of remoxipride at the end of treatment was 353 mg and of haloperidol, 11 mg. Patients were assessed each week on the Brief Psychiatric Rating Scale (BPRS), the Clinical Global Impression (CGI) and the symptoms checklist. No significant differences in efficacy were found between the two treatments. The median total BPRS score in the remoxipride group was 25 at start of active treatment and 17 at the last valid rating (n = 31). For the haloperidol group the corresponding figures were 24 and 15 (n = 29). According to the CGI, 40% of remoxipride patients and 50% of haloperidol patients were much or very much improved. Treatment-emergent extrapyramidal symptoms, such as akathisia and rigidity, occurred significantly more frequently, and were more severe during treatment with haloperidol than with remoxipride (p = 0.012 and 0.024, respectively). Haloperidol-treated patients reported significantly more drowsiness and increased sleep during treatment (p = 0.026 and 0.012, respectively). No statistically significant differences were seen in endocrine or autonomic symptoms. Remoxipride seemed to be as effective as haloperidol, had a lower frequency of side effects, and was used safely in the dose range 150-600 mg/day.

Life events and social support in prediction of stroke outcome.

A prospective study of 252 patients (average age 73, range 26-95) admitted to a regional general hospital over a 12-month period was carried out. 241 patients had stroke verified by the initial neurological examination and CT scan, and of these baseline data were not available on 27%. 34% died before or were not willing or able to provide data at follow-up. 39% survived and completed the study. Prestroke life events and social support could not predict the outcome of stroke rehabilitation measured as survival, length of stay, functional recovery (Barthel's Index) or placement at the follow-up 12 months after the onset of stroke. Age and arteriosclerotic heart disease predicted poor survival at follow-up. Premorbid hypertension, stroke, diabetes, obesity, tobacco smoking, and alcohol consumption did not significantly influence the outcome. Problems in stroke rehabilitation research are discussed.

Dilatation of pupils in a 'top of the basilar' stroke. Case report.

A case is presented of a 'top of the basilar' stroke followed by a well circumscribed midbrain lesion mainly involving the parenchyma around both third nerve nuclear complexes. Prominent clinical features were: third nerve paralysis including huge pupils unresponsive to light, transient unconsciousness, and slight cerebellar dyscoordination.