Development of a measure of childhood information learning experiences related to dental anxiety.

OBJECTIVE: The aim of this study was to develop a measure of childhood information learning experiences related to dental anxiety according to Rachmnan's theory of fear acquisition entitled "Dental Information Learning History Questionnaire (DILHQ)" and to determine its test quality with regard to factorial validity, reliability, divergent, discriminant, and predictive validity. METHOD: Sample 1 included 228 dental patients, answering a 17-item-pool of the DILHQ, the Dental Anxiety Scale (DAS: Corah, 1969), and the Self-Consciousness Scale by Fenigstein et al. (1975). A second sample of 197 patients filled in the final 12-item test version, the DAS and the state version of the State-Trait Anxiety Inventory (Spielberger et al., 1970). Ninety-five participants constituting the third sample answered the DILHQ twice with a 14-days interval. RESULTS: An exploratory study using the first sample resulted in two dimensions underlying the DILHQ-answers after removal of the unique loading items. The two-factorial structure was confirmed in the second sample. The factor-analytically derived Danger Information and Acceptance Information subscales showed sufficient internal consistency (Alpha = 0.87 and 0.72) and temporal stability (r(tt) = 0.77 and 0.76). Dentally fearful patients remembered being exposed to more danger information and less acceptance information about dentistry during childhood than low-fearful patients did (p < 0.001 each). Danger information and acceptance information predicted anxious response to the following dental procedure in opposite directions (r = 0.29 and r = -0.29). CONCLUSION: The results suggest that the DILHQ fulfils criteria of good construct validity. Exposure to threatening information about dentistry during childhood may increase the risk for dental fear acquisition and for exaggerated anxious response to treatment, while acceptance information might have a protective effect.

Development of a questionnaire measuring treatment concerns in regular dental patients.

OBJECTIVES: The aim of this study was to develop an instrument measuring core concerns about dental treatment guided by Reiss' expectancy theory of fear. This would include the content domains of injury, somatic reaction and interpersonal concerns, to study the underlying factorial structure, and to determine the test quality of the resulting subscales. METHODS: A total of 555 regular dental patients answered the item pool. Subsamples filled in the Dental Anxiety Scale (DAS) (n = 346) and the Anxiety-Present Scale of the state-form of the State-Trait Anxiety Inventory (STAI-S) (n = 187). A second sample (n = 89) was used to determine test-retest reliability and bias for social desirability [Self Disclosure Scale of the Freiburg Personality Inventory (FPI)]. RESULTS: Exploratory and confirmatory factor analyses identified a stable three-dimensional structure underlying the items convergent to the content domains of interpersonal, injury and somatic reaction concerns. Internal consistencies of the resulting subscales were between alpha = 0.84 and alpha = 0.87, test-retest reliabilities were from r(tt) = 0.72-0.78. No evidence for a social desirability response bias was found. All subscales discriminated between patients with low and high dental trait anxiety at a level of P < 0.00001. Dental treatment concerns predicted 36% of variations in actual anxiety during treatment. CONCLUSIONS: The results suggest that the proposed instrument, namely the Dental Treatment Concerns Inventory, shows good test qualities according to construct, discriminant and predictive validity, and may be a promising tool for research and clinical applications.

[Multidisciplinary treatment rheumatoid arthritis. Statistical and clinical change in pain experience]. / Multidisziplinäre Behandlung chronischer Polyarthritis Statistisch und klinisch signifikante Veränderungen des Schmerzerlebens.

INTRODUCTION: To date only few studies have been reported on the effect of multidisciplinary inpatient treatment on pain experience in patients with rheumatoid arthritis (RA). Aims of the present research were: to asses the development of different pain qualities at the beginning, at the end of treatment and at a follow-up three months later in a RA-patient sample as a whole, to determine statistically and clinically significant changes on individual base, and to study pain coping behaviors as predictive and pain-change associated variables. METHODS: Subjects were 66 patients with a diagnosis of RA. They were treated with non-steroidal antiphlogistic and disease modifying drugs as well as with physical therapy. Measurement instruments were the pain experience scale with 5 subtests, the four-dimensional questionnaire of pain behavior, the functional disability scale, and a joint-index. RESULTS: At follow-up the reduction was strongest in the quality of persistent pain experience (effect size d: 0.54). Among sensory components a marked reduction was found for the experience of thermal pain. A statistically and clinically reliable change was assessed in 18% of he RA-patients, further 26% indicated a statistical only change. 33% remained stable at a functional level of pain experience. 12% did not change a high level of pain, and 11% deteriorated. Change in the coping behaviors of avoidance and support were associated with success in pain reduction. CONCLUSION: In the assessment of patient improvement different qualities of pain experience should be taken into account. It was suggested that inpatient multidisciplinary treatment was beneficial with regard to pain reduction in nearly on half of the RA-patients. The coping behaviors of avoidance and social support deserve attention as pain change associated variables.

Functional and social discomfort during orthodontic treatment--effects on compliance and prediction of patients' adaptation by personality variables.

During the course of treatment orthodontic patients frequently endure a number of functional complaints and are anxious about their appearance. The aims of this longitudinal study were to follow the progress of patients' adaptation to discomfort, to elucidate the putative relationship between the type of appliance worn and functional and social discomfort experienced, to study potential predictability by their attitude to treatment and to evaluate the effects of discomfort as predictors of patients' compliance. Eighty-four patients undergoing either removable, functional, or fixed appliance treatment monitored their complaints during the first 7 days of treatment and rated them retrospectively 14 days, and 3 and 6 months after appliance insertion. The most frequent complaints were impaired speech, impaired swallowing, feeling of oral constraint and lack of confidence in public. A significant reduction in the number of complaints was observed between 2 and 7 days after insertion of the appliance. No further differences were revealed after longer periods of appliance wear. The type of appliance had an effect on impaired speech and swallowing. Patients' expectations of favourable treatment performance and appreciation of dental aesthetics were predictive of reported feeling of oral constraint and lack of confidence in public. There was a relationship between the complaints and acceptance of the appliance, as well as between lack of confidence in public and compliance with treatment. The results of this study highlight the importance of patients' attitudes to treatment and of functional and social discomfort associated with appliance wear for the theory and practice of the management of orthodontic patients, and the necessity for early intervention by clinicians.

Relationship between patient discomfort, appliance acceptance and compliance in orthodontic therapy.

Orthodontic treatment is occasionally a discomfort to patients, due to pain or functional restrictions. In this context, several retrospectively planned studies were performed in the 1980s, but correlations between different aspects of patient discomfort were not investigated. The present study aimed at examining and structuring the psychogenic dimensions of patient discomfort. Furthermore, the impact of the patient's attitude on the intensity of discomfort was to be evaluated in addition to the influences of appliance therapy. The study was performed with 67 patients aged from 9 to 32 years. Prior to insertion of a new appliance, psychogenic scales reflecting their attitude towards orthodontic therapy were submitted to them. They were instructed to keep a discomfort log during the first 7 days after insertion. After 6 months they were given lists for retrospective assessment of discomfort and an appliance-acceptance scale to be filled in. At the same time, the respective orthodontist assessed his patient's compliance on a cooperation scale. The factor analysis revealed 3 levels of patient discomfort: feelings of tension, functional restrictions and aversion to wearing an orthodontic appliance in public. Appliance acceptance after 6 months could be predicted from the attitude towards treatment and the experienced discomfort. Patient compliance also correlated with these factors, so that causal flow diagrams of the investigated variables could be produced. Giving detailed information on any discomfort occurring and explaining how to reduce or eliminate it are vital factors in good treatment cooperation.

Pain and discomfort during orthodontic treatment: causative factors and effects on compliance.

Orthodontic patients experience pain and discomfort to a varying degree during the course of treatment. The aims of the present investigation were to follow the progress of adaptation after insertion of new appliances and to study the relationships between the type of appliance worn and pain or discomfort experienced, between pain sensations and attitude toward the treatment and their effects on patients' compliance. Pain and discomfort experienced by 84 patients undergoing orthodontic treatment, their attitude toward the treatment, and compliance were assessed 7 days, 14 days, 6 weeks, 3 months, and 6 months after appliance insertion, using specially designed protocols, questionnaires, and rating scales. Evaluation of the results showed that an adaptation to pain and discomfort occurred during the first 3 to 5 days after placement of the appliance. The severity of pain and discomfort experienced by the patients wearing functional or fixed appliances was significantly higher than by those treated with upper and/or lower removable plates. Patients who had higher personal perception of the severity of their malocclusion and displayed attitudes characteristic for internal control orientation according to the so-called locus of control theory, seemed to adapt faster and have less pain. The results of this study also indicate that acceptance of orthodontic appliances and treatment in general may be predicted by the amount of initial pain and discomfort experienced.

[Long-term results of therapy of open and closed fractures of the elbow joint]. / Langzeitergebnisse der Therapie offener und geschlossene Frakturen des Ellenbogengelenks.

Fractures of the elbow joint are quite rare compared with the total incidence of injuries to the extremities. However, elbow fractures often result in significant disability. Therefore in a retrospective study, we have evaluated criteria that are of prognostic value for late functional outcome. Sixty-four (10.3%) of 622 patients with closed elbow fractures and 107 (89%) of 119 patients with open elbow fractures underwent a physical examination. The mean follow-up time was 8.2 years. The functional outcome was recorded by a modified score (0-max. 15) according to Morrey. Epidemiological data from both groups revealed a greater severity and higher degree of injury in open fractures than in closed fractures. In contrast, both groups presented a comparably good functional result. The most significant factor for poor outcome (score < 5) was identified as nerve lesions. Among all nerve lesions in open fractures, 45% resulted in a functional score of < 5; in 42% of closed fractures combined with a nerve lesion a similarly poor result was also noted. A second major factor appeared to be the method of primary therapy. An external joint transfixation resulted in a score of < 5 in 32% of patients that were treated primarily by transfixation. In cases initially treated with open reduction and internal fixation, only 18.5% of open fractures and 3.1% of closed fractures presented a similar low score. According to our results the late functional outcome of elbow fractures depends less on the type of fracture than on the presence of a nerve lesion and the method of primary treatment, which should facilitate early mobilization.

[Prognosis of depression in the elderly]. / Prognose bei Altersdepression.

Depressive syndromes are, with dementia, the most frequent psychiatric disorders in the elderly. The etiology of depressive syndromes can be reactive, endogenous, and neurotic as well as organic. Recent studies could show, that about 60% of the elderly patients clearly improve under treatment. Therefore the earlier opinion of a dramatically poorer outcome has to be revised. The presence of simultaneously occurring somatic illness, positive family history, certain personality traits and severity of disease could exert a bad influence on clinical outcome. Medical treatment should consider the special pharmacological features in higher age, and should be combined with psychotherapy as well as a close involvement of the relatives.

Hepatic encephalopathy presenting as delirium and mania. The possible role of bilirubin.

The case of a woman who suffered from hepatic encephalopathy is described. The psychiatric symptoms presented first as a delirium, changing into a manic syndrome. As the neurotoxic direct fraction of bilirubin was greater than 100 times normal, increasing and decreasing in a parallel fashion with the psychiatric symptoms, direct bilirubin is assumed to play a role in the pathogenesis of this case. This is discussed in the context of bilirubin encephalopathy, very seldom diagnosed in adults.

[Classification of patients with tension headache: irrationality, self-communication, stress reactions and pain.]. / Zur Klassifizierung von Patienten mit Spannungskopfschmerz: Irrationalität, Selbstkommunikation, Streßreagibilität und Schmerz.

INTRODUCTION: A review of the literature suggests that patients with tension headache do not differ from normals as much as from each other in psychological traits. The aim of the present study was to identify psychological subtypes of tension headache patients. METHOD: The subjects were 130 inpatients with a diagnosis of recurrent tension headache who were treated in a pain clinic. Six factors measured the constructs irrationality, positive and negative self-communication, emotionality, affective pain and situational pain. RESULTS: Hierarchical agglomerative cluster analysis allowed the identification of five subtypes of patients. The reclassification rate was 95%. All patients endorsed, to a high degree, pain adjectives that expressed obstinate-refractory pain qualities. Most, i.e. 81%, indicated that they suffered from affective pain: 51.5% reported high situation-dependent and affective pain. They were comprised by two clusters, 30% showing high irrationality/negative self-communication and low positive self-talk communication and 21.5%, the opposite profile. A further 30% of the patients suffered from affective pain but reported no stimulus dependence. They were divided into two groups: 17% reported high, whereas 13% reported low positive self-communication. In 18.5% of cases the patients reported no psychological causation and demonstrated a state of inner placidity and low irrationality. DISCUSSION: The results are discussed with reference to the literature and to indications for psychological treatment interventions.

[Psychological classification of patients with ankylosing spondylitis]. / Zur psychologischen Klassifikation von Patienten mit Spondylitis ankylosans.

Ankylosing spondylitis - (AS-)patients are reported being characterized by marked ego strength and a stable personality. The aim of the present study was to investigate if they can be differentiated into subgroups which suggest different indications for training psychological skills to cope with their disease. Constructs which were thought to be relevant for psychological pain treatment were: disease activity, irrationality, positive and negative self-communication, stress-reactions, and disease impacts. For each construct factorial values were calculated from indicator variables to classify the patients. Subjects were 197 patients with a long-standing diagnosis of AS, who were treated in a specialized theumatological treatment unit in the Karl-Aschoff-Klinic, Bad Kreuznach, Germany. A hierarchical-agglomerative cluster-analyses suggested five subgroups with a reclassification rate of 91%. 10.2% of the patients were marked by elevations on all negative scales (including disease activity) and low values on the positive self-communication scales. Further 28% showed low disease activity but high disease impacts (affective pain, general health condition). For both groups different indications for learning to cope with disease impacts were suggested. 60.8% of the patients demonstrated themselves to be good copers. Of special interest were 11.8% of all patients who reported high disease activity but low disease impacts and low positive self-communication. Two other subgroups differed only in the level of the variables-profile.

Blunted growth hormone response to clonidine in Gilles de la Tourette syndrome.

Noradrenergic mechanisms have been involved in the pathogenesis of Gilles de la Tourette Syndrome (GTS). Since the central alpha 2 adrenergic agonist clonidine is widely used as a therapeutic agent in GTS, the present study aimed at assessing whether GH release after clonidine, representing central alpha 2-adrenergic receptor sensitivity, was altered in GTS. After administration of 2 micrograms/kg body weight clonidine, the GH response was examined in nine drug-free, alcohol-abstinent GTS patients (eight men, one woman) and in nine age- and sex-matched abstinent healthy controls. A blunted response of GH release (< 5 ng/ml) was observed in seven patients and the area under the curve (AUC) of the GH-release was significantly reduced (p < .01) compared to controls. This finding indicates an involvement of the noradrenergic system in GTS.

Cytosolic free [Ca2+] in mononuclear blood cells from demented patients and healthy controls.

There is increasing evidence that the neurodegenerative processes in Alzheimer's disease (AD) may be related to alterations in calcium homeostasis and that these metabolic changes are not necessarily restricted to the central nervous system. However, previous studies investigating [Ca2+]i in fibroblasts, lymphoblasts, platelets and lymphocytes of AD patients gave inconclusive results, since increase, decrease and no alteration in [Ca2+]i were found in AD patients compared with controls. With respect to the importance of establishing altered Ca2+ homeostasis in peripheral cells, we have investigated [Ca2+]i in circulating mononuclear cells of patients with AD, multi-infarct dementia, age-associated memory impairment and healthy controls. [Ca2+]i was evaluated using the fluorescent dye fura-2 before and during stimulation with phythaemagglutinin (PHA). In our study we failed to find major differences in resting [Ca2+]i and in response to stimulation with 25 micrograms/ml and 100 micrograms/ml PHA in cells of AD patients as compared with all other groups investigated. There was only a tendency towards a decrease in [Ca2+]i in AD after stimulation with PHA. Thus the present findings suggest that [Ca2+]i evaluation in mononuclear cells does not have diagnostic value in discriminating AD patients from other demented patients. However, there might be some difference in [Ca2+]i values between early- and late-onset AD, which could have pathophysiological importance.

Influence of the earth's magnetic field on resting and activated EEG mapping in normal subjects.

We found in a former investigation that by measuring sleep parameters, the REM latency is shortened in the E-W position of sleepers compared with the N-S position. This paper reports on a further neurological observation in humans concerning the influence of the earth's magnetic field: there are statistically significant differences in the EEG of normal subjects, depending on whether the subjects sit facing the N-S or E-W direction. The difference is especially pronounced in the alpha-power.

EEG mapping investigations of psychomotor and music perception brain dysfunction in untreated schizophrenic patients.

Twenty-six untreated schizophrenic inpatients and 34 control persons were investigated using 16-channel EEG mapping during resting, manumotor and music perception tasks. Power values of activation tasks were each referenced to a separate, immediately preceding resting condition, using conventional delta, theta, alpha and 2 beta frequency bands. Results in delta and alpha bands, which maximally separated the two groups, are reported only for space reasons. Results indicated a "nonreactivity" (in all frequency bands) on the two activation paradigms in schizophrenic patients as a group. Major gender effects were obtained in normal persons, but not signs of nonreactivity comparable to patients. Subdividing patients exclusively by means of their EEG changes on activation produced meaningful clinical subgroups of "positive/negative" schizophrenics. This latter finding could contribute towards clinical utility of EEG mapping in psychiatry.

[Atypical neuroleptics, pharmacology and clinical importance]. / Atypische Neuroleptika, Pharmakologie und klinische Bedeutung.

Since the development of clozapine the investigation of atypical neuroleptic compounds has become increasingly relevant. Compared with classic neuroleptics they are distinguished by either fewer or absent (clozapine) extrapyramidal side effects, some of them also by lower increases of serum prolactin concentrations. Pharmacologically they are a group of heterogeneous substances. At the level of transmitter systems a high 5HT2/D2-ratio is regarded as the best criterion to distinguish between atypical and classic neuroleptics. Further differences involve: the preferred effects of atypical neuroleptics on mesolimbic D2 receptors compared to striatal dopaminergic neurotransmission; a higher potency of some atypical neuroleptics to antagonize D1-receptors; the increase of serum corticosterone concentrations by some of the atypical neuroleptics.

Findings of electroencephalographic brain mapping in mild to moderate dementia of the Alzheimer type during resting, motor, and music-perception conditions.

Sixteen-channel electroencephalographic (EEG) brain mapping studies were carried out under resting conditions in 41 patients with mild to moderate dementia of the Alzheimer type, diagnosed according to DSM-III-R criteria. The patients showed diffuse patterns of EEG slowing, as known from the literature. They showed increases of theta power in large bilateral brain areas and bitemporal increases of delta power as compared with both age-matched and younger control subjects. In addition, the patients had increased beta activity in comparison with the younger control group, but not with the age-matched control subjects. Functional brain mapping revealed decreases of EEG power during manual-motor and music-perception tasks in delta frequencies for patients, which was not seen in either of the two control groups. All frequency bands revealed major gender-related differences in EEG activity, which should receive more attention in future research.

Life change, irrational attitudes and disease impacts in patients with ankylosing spondylitis.

The present study is concerned with (1) the question whether patients with ankylosing spondylitis (AS) are different from patients with rheumatoid arthritis (RA) reported previously, with respect to the personality trait of irrational attitudes and to disease impacts, and (2) how the socio-psychological variables of life stress and irrational attitudes relate to disease impacts. Subjects were 197 patients with definite AS from a rheumatic treatment center. AS-patients scored lower in irrationality, pain-intensity, sensory pain, pain avoidance and disability than RA-patients but were not different in affective pain and in general health condition. Relations between negative events and avoidance behavior were stronger in AS-patients. The associations between irrationality versus pain intensity, affective pain and disability were lower (but significant) in AS-patients compared to RA. Of equal strength were correlations between irrationality and avoidance as well as general symptoms. Hierarchical regression analyses with disease activity as control variables revealed 2.2% to 7.1% common variance between life stress and disease impacts (affective pain, avoidance behavior, general symptoms). Irrational attitudes explained 8.9% to 18.3% of disease impact variation. The results suggest influences of social and personality variables on suffering of AS-patients and expect these patients to be good treatment candidates-though they seem stable and non-neurotic in their personality.

On the prediction of dentist-evaluated patient compliance in orthodontics.

The aim of the present study was to determine to what degree social and psychological patient variables can predict orthodontic co-operation evaluated by dentists 3 and 6 months after the beginning of treatment. The subjects were 94 patients from seven orthodontic practices. They received a questionnaire with four subscales: impulsiveness, dominance, anxiety, and orthodontic attitudes. Compliance was assessed by an 11-item instrument based on the studies of Slakter et al. (1980). None of the social indices could predict co-operation, but the psychological scales for orthodontic attitudes, impulsiveness and dominance showed a significant relationship to later co-operation. The combination of all psychological variables (regression equation) could explain co-operation 3 months later to 12.1 per cent and to 16.8 per cent 6 months later. The implications for psychological guidance in orthodontics and future research are discussed.

Relations between verbal behavior of the orthodontist and communicative cooperation of the patient in regular orthodontic visits.

A study of interrelationships between orthodontist and patient communication characteristics on the basis of audiotape recordings is reported. The subjects were 66 patients from an orthodontic outpatient clinic who were treated by seven orthodontists. Strong relationships (partial correlations) were found between clinicians encouraging behavior (listener signals and symmetrical answering) and patient communicative cooperation (speech volume, detailed answering, questions, initiatives); whereas orthodontists guiding behavior showed lower correlations, only the clinicians' direct questions were significantly related to patient participation. For communication content, relations to patient activity depended on how strongly orthodontists discussed social or therapy topics. Discussion characteristics of both parties were not related to the patient's age, sex, and duration of therapy. However, patient communication differed with the personality of the dentist. Results are discussed with reference to literature, orthodontic consulting practice, and future research.