Basal activity of the hypothalamic-pituitary-adrenal axis in patients with the chronic fatigue syndrome (neurasthenia).

BACKGROUND: Impairments in both basal activity and activation of the hypothalamic-pituitary-adrenal axis (HPA) have been reported in chronic fatigue syndrome (CFS; neurasthenia). We sought to replicate these findings and examined basal activity of the HPA in a carefully selected sample of patients with CFS. METHODS: Basal activity of the HPA was assessed using salivary and urinary cortisol collection over a 24-hour period in 22 (12 male; 10 female) patients meeting criteria for CFS and appropriate controls. RESULTS: Salivary and urinary cortisol measures did not differ between CFS patients and controls. CONCLUSIONS: Basal activity of the HPA was not reduced in CFS patients. Reasons for the failure to replicate previous findings are discussed.

Cognitive behavioural therapy for medically unexplained physical symptoms: a randomised controlled trial.

OBJECTIVE: To examine the additional effect of cognitive behavioural therapy for patients with medically unexplained physical symptoms in comparison with optimised medical care. DESIGN: Randomised controlled trial with follow up assessments six and 12 months after the baseline evaluation. SETTING: General medical outpatient clinic in a university hospital. SUBJECTS: An intervention group of 39 patients and a control group of 40 patients. INTERVENTIONS: The intervention group received between six and 16 sessions of cognitive behavioural therapy. Therapeutic techniques used included identification and modification of dysfunctional automatic thoughts and behavioural experiments aimed at breaking the vicious cycles of the symptoms and their consequences. The control group received optimised medical care. MAIN OUTCOME MEASURES: The degree of change, frequency and intensity of the presenting symptoms, psychological distress, functional impairment, hypochondriacal beliefs and attitudes, and (at 12 months of follow up) number of visits to the general practitioner. RESULTS: At six months of follow up the intervention group reported a higher recovery rate (odds ratio 0.40; 95% confidence interval 0.16 to 1.00), a lower mean intensity of the physical symptoms (difference -1.2; -2.0 to -0.3), and less impairment of sleep (odds ratio 0.38; 0.15 to 0.94) than the controls. After adjustment for coincidental baseline differences the intervention and control groups also differed with regard to frequency of the symptoms (0.32; 0.13 to 0.77), limitations in social (0.35; 0.14 to 0.85) and leisure (0.36; 0.14 to 0.93) activities, and illness behaviour (difference -2.5; -4.6 to -0.5). At 12 months of follow up the differences between the groups were largely maintained. CONCLUSION: Cognitive behavioural therapy seems to be a feasible and effective treatment in general medical patients with unexplained physical symptoms.

The acceptability of psychological treatment in patients with medically unexplained physical symptoms.

Patients with unexplained physical symptoms are considered to benefit from psychological treatment, but are believed to be reluctant to accept a referral to a psychiatrist or psychologist. As a part of a treatment study, we had the opportunity to examine to what extent somatising patients are willing to accept psychological treatment and how patients who are willing to accept it differ from those who are not. The study was introduced to the patient by the attending physician, and the treatment took place in the general medical outpatient clinic itself. Of 229 patients who had presented with unexplained physical symptoms to a general hospital medical outpatient clinic, 172 (75%) were interviewed at about three months after their initial visit to the clinic. Fourty-five (26%) patients appeared to have either improved or recovered from their presenting symptoms, and 26 (15%) were already receiving psychiatric or psychological treatment. Of 98 patients eligible for treatment, 79 (81%) were willing to participate. Compared with the patients who agreed to take part, the nonparticipants reported lower levels of physical symptoms and less functional impairment. In conclusion, most of the patients who might have benefitted from additional psychological help were willing to accept it. Somatising patients who rejected psychological treatment were those with the least serious problems.

A prospective long-term follow-up study of patients evaluated for erectile dysfunction: outcome and associated factors.

The aim of this study was to investigate the long-term outcome of erectile dysfunction (ED) assessed in a routine clinical setting. The original population consisted of 209 patients who were consecutively referred to either the Urology Clinic or the Sexual Dysfunction Clinic of a University Hospital. At follow-up, 22 patients had died and 32 could not be found. Of the remaining 155, 107 (69%) patients participated in the study. The mean follow-up period was 4.1 years. Of these, 21 had had a prosthesis implanted, 34 had received self-injection therapy. 31 had sex therapy and 28 patients had not received any treatment. Overall, the rate of penetration increased, whereas coital frequency did not change. Despite the fact that sexual functioning in terms of penetration rate improved, more than of the patients reported that they were dissatisfied with the overall quality of their sex-lives.

Psychosexual functioning of partners of men with presumed non-organic erectile dysfunction: cause or consequence of the disorder?

In the treatment of couples where the male partners have erectile dysfunction (ED) it often becomes apparent that characteristics of the female partners and of the relationship in general have contributed to the problem. However, this has received little research attention. We investigated female partners of men with ED where no organic cause could be found (n = 34) and partners of men with organically based ED (n = 71) to compare their views on their relationships, sexual function, sexual attitudes, and psychological adjustment. Relationship problems and the psychosexual dysfunctions of vaginismus and dyspareunia were more common in the partners of men with nonorganic ED; they also reported higher levels of sexual interest. Female sexual dysfunctions in the nonorganic ED group had usually preceded the onset of the erectile difficulties. While belief in male sexual myths was substantial in both groups of patients, neither the presence of traditional views on sexuality nor psychological complaints distinguished partners of men experiencing nonorganic ED from those with organic ED. Relationship problems, female psychosexual dysfunction, and the possible effect of relatively high levels of female sexual interest may contribute to the onset, exacerbation, and maintenance of ED. These should be addressed during assessment and treatment of couples in which the male partners have erectile difficulties.

Discrimination between psychogenic and organic erectile dysfunction.

The aim of this study was to develop a screening test based on the Leiden Impotence Questionnaire (LIQ) in order to assist in the difficult process of differentiating between psychogenic and organic erectile dysfunction (ED). The main sample consisted of 176 patients with ED, which was classified according to the results of the urological and psychiatric assessment as either organic, in 109 (62%) patients, or psychogenic, in 67 (38%) patients. A logistic regression model including six general items from the LIQ correctly identified psychogenic ED in 62% of the cases, and organic ED in 86%, with an overall correct classification rate of 76%. Adding information regarding sexual intercourse and the relationship in patients who had a partner and were having sexual intercourse the correct classification rates were: psychogenic 77%, organic 94%, and overall 87%. Discrimination between psychogenic and organic ED is improved when more information concerning sexual activity can be assessed.

Comparison of doctors and nurses in the assessment of deliberate self-poisoning patients.

The assessments of deliberate self-poisoning patients carried out by 8 doctors and 8 nurses were compared. Both groups of staff had undergone special training in the assessment procedure. The adequacy of the assessments was determined by blind judges' ratings of transcripts of assessment interviews, comparisons of the types of treatment offered and repetition of self-poisoning The attitudes of the patients and their general practitioners were also investigated. No major differences were found between the assessments of the 2 groups of subjects. It is concluded that nurses under supervision of a senior psychiatrist can safely carry out the assessment of self-poisoning patients, provided they have received appropriate training. The findings suggest that services in which nurses assess most self-poisoning patients could be established in district general hospitals. This would reduce the demands currently placed on psychiatrists and physicians.

A human sexuality course for Oxford University medical students.

A human sexuality course for clinical students in Oxford was held based on the format of similar courses held in the U.S.A. with one-and-a-half days of films and lectures followed by discussion in small groups. The course was largely successful and evaluation of attitudes and knowledge revealed that significant preliminary changes resulted. Students who failed to complete the course had more inhibited attitudes towards sexuality and less sexual information compared with those who attended the whole course. Advice is given to those intending to hold such a course elsewhere, including how more inhibited students, who probably are most in need of such teaching, might be encouraged to participate.

Psychiatric morbidity and referral on two general medical wards.

Psychiatric morbidity among 230 medical inpatients was determined by a two-stage screening procedure, using the General Health Questionnaire and Standardized Psychiatric Interview. Of these patients, 23% were considered psychiatrically ill, affective disorders being the commonest illnesses encountered; and 27 (12%) were psychiatrically referred. While referral was related to severity of psychiatric illness and previous psychiatric illness, the degree to which the psychiatric illness obtruded or created problems in management appeared more crucial in determining referral. In half of those with psychiatric illness the problems did not appear to have been detected or dealt with. It is suggested that medical clerking should routinely include questions about mood and psychological responses to illness.