Development and User Experiences of a Biopsychosocial Interprofessional Online Course on Persistent Somatic Symptoms.

Background: Communication between healthcare providers and patients with persistent somatic symptoms (PSS) is frequently hampered by mutual misunderstanding and dissatisfaction. Methods: We developed an online, interprofessional course to teach healthcare providers the knowledge, skills, and attitude they need to diagnose and treat PSS in a patient-centered manner based on the biopsychosocial model. The course consisted of six modules of 45-60 min. Each module contained different types of assignments, based on six cases: videos, discussion boards, reading assignments, polls, and quizzes. For this study, we included (1) medical residents, following the course as part of their residency training, and (2) healthcare providers (general practitioners, medical specialists, physiotherapists, nurses, and psychologists), following the course as continuing vocational training. Throughout the course, participants were asked to fill out online surveys, enquiring about their learning gains and satisfaction with the course. Results: The biopsychosocial approach was integrated across the modules and teached health care workers about recent insights on biological, psychological and social aspects of PSS. In total, 801 participants with a wide variety in clinical experience started the course; the largest groups of professionals were general practitioners (N = 400), physiotherapists (N = 124) and mental healthcare workers (N = 53). At the start of the course, 22% of the participants rated their level of knowledge on PSS as adequate. At the end of the course, 359 participants completed the evaluation questionnaires. Of this group, 81% rated their level of knowledge on PSS as adequate and 86% felt that following the course increased their competencies in communicating with patients with PSS (N = 359). On a scale from 1 to 10, participants gave the course a mean grade of 7.8 points. Accordingly, 85% stated that they would recommend the course to a colleague. Conclusion: Our course developed in a co-design process involving multiple stakeholders can be implemented, is being used, and is positively evaluated by professionals across a variety of health care settings.

How to assess communication skills? Development of the rating scale ComOn Check.

BACKGROUND: Good communication is a core competency for all physicians. Thus, medical students require adequate preparation in communication skills. For research purposes, as well as for evaluation in teaching, there is a clear need for reliable assessment tools. We analyzed the shortcomings of existing instruments and saw a need for a new rating scale. The aim of this publication is to describe the development process for, and evaluation of, a new rating scale. METHODS: First, we developed the rating scale in 10 steps. Then, two raters evaluated the newly developed rating scale by rating 135 videotaped consultations of medical students with standardized patients. Additionally, standardized patients evaluated students' performance, which was used as an outside criterion to validate ratings. RESULTS: Our rating scale comprises six domains with 13 specific items evaluated on a five-point Likert scale: initiating conversation, patient's perception, structure of conversation, patient's emotions, end of conversation, and general communication skills. Item-total correlation coefficients between the checklist items ranged from 0.15 to 0.78. Subscale consistency was calculated for domains comprised of more than one item and Cronbach's α ≥ 0.77, indicating acceptable consistency. Standardized patients' global evaluation correlated moderately with overall expert ratings (Spearman's ρ = .40, p < .001). CONCLUSION: Our rating scale is a reliable and applicable assessment tool. The rating scale focuses on the evaluation of general communication skills and can be applied in research as well as in evaluations, such as objective structured clinical examinations (OSCE). ABBREVIATIONS: CST: Communication skills training; ICC: Intra-class correlation coefficient; OSCE: Objective structured clinical examination; SP: Standardized patients; SD: Standard deviation; M: Mean.

Do deficits in the magnocellular priming underlie visual derealization phenomena? Preliminary neurophysiological and self-report results in first-episode schizophrenia patients.

BACKGROUND: Early visual impairments probably partially caused by impaired interactions between magnocellular (M) and parvocellular (P) pathways (M priming deficit), and disturbances of basic self-awareness or self-disorders (SDs) are core features of schizophrenia. The relationships between these features have not yet been studied. We hypothesized that the M priming was impaired in first-episode patients and that this deficit was associated with visual aspects of SDs. AIM: To investigate early visual processing in a sample of first-episode schizophrenia patients and to explore the relationships between M and P functioning and visual aspects of SDs addressed by the Examination of Anomalous Self-Experience (EASE) interview. METHOD: Nine stimulating conditions were used to investigate M and P pathways and their interaction in a pattern reversal visually evoked potential (VEP) paradigm. N80 at mixed M- and P-conditions was used to investigate magnocellular priming. Generators were analyzed using source localization (Brain Electrical Source Analysis software: BESA). VEPs of nineteen first-episode schizophrenia patients were compared to those of twenty matched healthy controls by a bootstrap resample procedure. Visual aspects of SDs were analyzed through a factor analysis to separate symptom clusters of derealization phenomena. Thereafter, the associations between the main factors and the N80 component were explored using linear mixed models. RESULTS: Factor analyses separated two EASE factors ("distance to the world", and "intrusive world"). The N80 component was represented by a single dipole located in the occipital visual cortex. The bootstrap analysis yielded significant amplitude reductions and prolonged latencies in first-episode patients relative to controls in response to mixed M-P conditions, and normal amplitudes and latencies in response to isolated P- and M-biased stimulation. Exploratory analyses showed significant negative correlations between the N80 amplitude values at mixed M-P conditions and the EASE factor "distance to the world", i.e. relatively higher amplitudes in the patient group were associated with higher subjective perceived derealization ("distance to the world"). CONCLUSIONS: The early VEP component N80 evoked by mixed M-P conditions is assumed to be a correlate of M priming, and showed reduced amplitudes and longer latencies in first-episode patients. It probably reflects a hypoactivation of the M-pathway. The negative association between visual SDs (derealization phenomena characterized by visual experiences of being more distant to the world), and the M priming deficit was counterintuitive. It might indicate a dysregulated activity of the M-pathway in patients with SDs. Further research is needed to better understand this preliminary finding.

[Treatment of non-specific, functional and somatoform bodily complaints]. / Umgang mit Patienten mit nicht-spezifischen, funktionellen und somatoformen Körperbeschwerden.

In primary and secondary medicine "non-specific, functional, and somatoform bodily complaints" are common and often take a chronic course, with the patients' quality of life usually markedly impaired, and give rise to high direct and indirect costs. They are challenging as they can deteriorate in case of inappropriate behavior on the physician's part. Coordinated by both German professional associations of Psychosomatic Medicine a new evidence based guideline was developed, aiming to transfer relevant diagnostic and therapeutic knowledge to all physicians who are in charge of these patients. After establishing a stable therapeutic alliance a symptom- and coping-oriented attitude could be demonstrated to be helpful. A biopsychosocial diagnostic evaluation combines a thorough assessment of bodily complaints and early introduces a sensitive discussion of signs of psychosocial stress, which can be extended carefully in case problems of this type are present. In less severe courses, physical/social activation is recommended and the patient's explanatory disease model should be extended towards a psychological dimension. More severe and complicated courses require a more structured approach consisting of regular appointments (as opposed to ad-hoc appointments whenever the patient feels worse) and an active cooperation of the patient. A coordinated, multimodal management includes additional measures as graded activation, psychotherapy, relaxation training or--if indicated--temporary medication.

Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: randomised controlled trial.

BACKGROUND: Multisomatoform disorder is characterised by severe and disabling bodily symptoms, and pain is one of the most common and impairing of these. Furthermore, these bodily symptoms cannot be explained by an underlying organic disorder. Patients with multisomatoform disorder are commonly found at all levels of healthcare and are typically difficult to treat for physicians as well as for mental health specialists. AIMS: To test whether brief psychodynamic interpersonal therapy (PIT) effectively improves the physical quality of life in patients who have had multisomatoform disorder for at least 2 years. METHOD: We recruited 211 patients (from six German academic outpatient centres) who met the criteria for multisomatoform disorder for a randomised, controlled, 12-week, parallelgroup trial from 1 July 2006 to 1 January 2009 (International Standard Randomised Controlled Trial Number ISRCTN23215121). We randomly assigned the patients to receive either 12 weekly sessions of PIT (n = 107) or three sessions of enhanced medical care (EMC, n = 104). The physical component summary of the Short Form Health Survey (SF-36) was the pre-specified primary outcome at a 9-month follow-up. RESULTS: Psychodynamic interpersonal therapy improved patients' physical quality of life at follow-up better than EMC (mean improvement in SF-36 score: PIT 5.3, EMC 2.2), with a small to medium between-group effect size (d = 0.42, 95% CI 0.15-0.69, P = 0.001). We also observed a significant improvement in somatisation but not in depression, health anxiety or healthcare utilisation. CONCLUSIONS: This trial documents the long-term efficacy of brief PIT for improving the physical quality of life in patients with multiple, difficult-to-treat, medically unexplained symptoms.

Psychotherapy in dizziness: a systematic review.

BACKGROUND: About 30-50% of complex dizziness disorders are organically not sufficiently explained or related to a psychiatric disorder. Of patients with such dizziness disorders, 80% are severely impaired by dizziness in their daily and working lives; nevertheless, they are often not diagnosed or treated adequately. OBJECTIVES: This review aims to give a systematic overview of psychotherapeutic approaches and their efficacy regarding the treatment of dizziness that is medically not sufficiently explained or related to a psychiatric disorder. METHODS: A systematic literature search was conducted in Medline, PSYNDEX and PsycINFO. Included in this systematic review were (randomised) controlled trials ((R)CTs) concerning psychotherapy in patients with dizziness, medically not sufficiently explained or associated with a psychiatric disorder. If possible, Hedges' g was used to express the effect sizes (ES) of the treatment. Heterogeneity was assessed using the Q statistic. In addition, the quality of the studies was rated. RESULTS: Three (R)CTs were included. All studies used cognitive-behavioural treatment methods in combination with relaxation techniques or vestibular rehabilitation. All studies suggested that psychotherapy may provide improvement. The mean ES in the treatment groups was 0.46 (95% CI 0.05 to 0.88) for dizziness related outcome, 0.10 (-0.44 to 0.64) for anxiety and 0.17 (-0.24 to 0.58) for depression whereas in the control groups the mean dizziness related ES was -0.04 (-0.44 to 0.37), anxiety related ES was -0.03 (-0.43 to 0.38) and depression related ES was -0.02 (-0.42 to 0.38). The quality of the studies was average. Sample sizes were small, however, and there was a lack of long term studies. CONCLUSION: This systematic review provides some preliminary evidence that psychotherapy may be effective in patients with dizziness that is medically not sufficiently explained or due to a psychiatric disorder. The results should be replicated in larger samples and follow-up RCTs.

Psychosocial outcome following genetic risk counselling for familial colorectal cancer. A comparison of affected patients and family members.

Few studies have reported prospective data on psychosocial outcomes after genetic counselling in families with suspected hereditary non-polyposis colorectal cancer (HNPCC). This prospective study examines the impact of multidisciplinary risk counselling on the psychosocial outcome of 139 affected cancer patients and 233 family members without cancer at risk for HNPCC. Participants completed questionnaires specific to HNPCC before and 8 weeks after attending the familial cancer clinic. Affected patients' levels of distress were closely related to their health status and exceeded that of unaffected individuals, as did worry regarding their relatives' risk. A significant reduction in general anxiety (Hospital Anxiety and Depression Scale), distress specific to familial CRC (Impact of Events Scale) and general cancer worry (Distress Hereditary Disorder) was demonstrated after counselling in both affected patients and unaffected individuals. Reduction in distress was more pronounced in affected patients given a high risk of HNPCC compared with those at intermediate risk. Among unaffected individuals, distress declined regardless of what clinical risk they were assigned. Their perceptions of risk and cancer-related threat declined, while confidence in effective surveillance increased. These results suggest the beneficial effects of multidisciplinary counselling even when high-risk information is conveyed. A patient's previous cancer experience is likely to contribute to clinically relevant distress (15% of those patients), indicating the need for appropriate counselling.

Discrimination of Alzheimer's disease and normal aging by EEG data.

Quantitative EEG results in Alzheimer's disease may be summarized by the term 'slowing', i.e. slow frequencies (delta, theta) are increased and fast frequencies (alpha, beta) are decreased. But how can EEG data be used to discriminate AD patients from controls by means of EEG data? Discriminant analysis may produce false predictions using too many predictors, as is often the case in EEG studies. We studied 4 approaches to this problem: Classification by group means, stepwise discriminant analysis, a neuronal network using back propagation and discriminant analysis preceded by principal components analysis (PCA). A maximum of 86.6% correct classifications was reached using the last mentioned approach with EEG data alone. Including age as a moderator variable in a subgroup, 95.9% correct classifications were reached.

[Degree of disability of demented patients as judged by relatives and experts (disability insurance)]. / Die Pflegebedürftigkeit Demenzkranker im Urteil von Angehörigen und Gutachtern (Pflegeversicherung).

Health insurance companies commission medical expert opinions rating the severity of clinical improvement in order to provide adequate nursing support. We compared these ratings on 28 demented patients with the ratings from carers and with our own examination. The results indicate that the expert opinions underestimated the severity of improvement and adequate support in some of the cases. We discuss whether these discrepancies may be due to the peculiarities of dementia.

[Alzheimer dementia and normal aging. Clinical, neuroradiologic, neurophysiologic and molecular biology follow-up data]. / Alzheimer-Demenz und normales Altern. Klinische, neuroradiologische, neurophysiologische und molekularbiologische Verlaufsdaten.

A total of 30 patients with clinically diagnosed Alzheimer's disease and 55 healthy, age-approximated controls were followed up over a 2-year period to compare the course of functional and cognitive impairment, quantitative morphological and functional brain changes. No remarkable changes were observed within the control group in any of these modalities. There were significant differences between patients and controls at the first examination: Mini-Mental State Examination (MMSE), 16.1 +/- 7.3 compared with 28.7 +/- 1.4; left lateral ventricle 2.7 +/- 1.1% versus 1.6 +/- 0.7% of the total intracranial volume; right lateral ventricle 2.7 +/- 1.4% versus 1.4 +/- 0.4%; absolute delta-power 1.1 +/- 0.3 versus 0.9 +/- 0.2 microV2; and absolute theta-power 1.1 +/- 0.3 versus 0.8 +/- 0.2 microV2 (means +/- standard deviation). In the patient group, scores on the Blessed dementia rating scale deteriorated from 10.6 +/- 6.1 to 17.9 +/- 9.6; the MMSE decreased by 8.0 +/- 3.7; the left lateral ventricle volume increased by 0.9 +/- 0.7%, the right by 0.9 +/- 0.7% of the total intracranial volume; absolute delta-power increased by 0.2 +/- 0.4 microV2 and theta-power by 0.1 +/- 0.3 microV2. We could not confirm a relationship between age, age at onset or apolipoprotein E4 gene dose and the rate of clinical change. High initial Blessed dementia scores were correlated with more severe ventricular enlargement, and delta-theta increase during the follow-up period. High initial theta-power predicted more severe functional and cognitive deterioration. To our knowledge, this is the first longitudinal study reporting quantitative clinical, morphological and EEG-changes measured in two points in time in patients and non-demented controls.

[Self and informant perception of clinical manifestations of Alzheimer dementia: results of a structured interview (CAMDEX)]. / Die Selbst-und Fremdeinschätzung klinischer Störungen bei der Alzheimer-Demenz: Ergebnisse eines strukturierten Interviews (CAMDEX).

The correlations between (a) the patients' memory complaints, (b) the informants' rating of the patients' cognitive impairment, and (c) cognitive performance according to the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX) were examined in 163 patients with probable or possible Alzheimer's disease. The patients' complaints were weakly correlated with informants' view (p < 0.05), closely correlated with depressive mood (p < 0.0001), but not with cognitive performance or the stage of dementia. The results of Clinical Dementia Rating, Mini-Mental State Examination and the Cambridge Cognitive Examination were significantly correlated with the informants' rating of cognitive impairment (p < 0.0001). These results are in line with previous studies and confirm (1) the suitability of CAMDEX for the structured examination of dementia patients and their caregivers, (2) the association between affective disturbances and the perception of cognitive deficits, and (3) the importance informants' rating for the valid evaluation of demented patients.

Longitudinal cognitive, electroencephalographic and morphological brain changes in ageing and Alzheimer's disease.

BACKGROUND: The natural course of cognitive performance, electrophysiological alterations and brain atrophy in ageing and Alzheimer's disease (AD) has been investigated in numerous studies, but only few attempts have been made to examine the relationship between clinical, electroencephalographic (EEG) and morphological changes with quantitative methods prospectively over longer periods of time. METHOD: Fifty-five patients with clinically diagnosed AD and 66 healthy elderly controls were examined biannually using a cognitive test (CAMCOG), EEG band power and volumetric estimates of brain atrophy. RESULTS: On average cognitive performance deteriorated by 28 points on the CAMCOG in the AD group, the alpha/theta ratio decreased by 0.2, and the proportion of intracranial cerebrospinal fluid volume increased by 3.5% during a 2-year period. Similar changes were observed after a second 2-year interval. A multiple regression model demonstrated a significant influence of age on cognition and atrophy and a significant influence of the estimated duration of symptoms on cognition, alpha/theta ratio and brain atrophy at the initial examination. Cognitive performance at the first examination exerted significant effects on the performance and also on brain atrophy at re-examination after 2 or 4 years, whereas the EEG and neuroimaging findings at the previous examination were exclusively related to the corresponding findings at the follow-up examinations. In the control group no significant cognitive, EEG and morphological changes were observed after 2 and 4 years. CONCLUSION: After 2 consecutive follow-up periods, we were able to verify significant deteriorations of cognition accompanied by neurophysiological and neuroradiological changes in AD, but not in normal ageing. In clinically diagnosed AD, cognitive performance at the followup examination could not be predicted by the previous alpha/theta ratio or by the previous degree of global brain atrophy, whereas the cognitive test score determined not only performance, but also structural findings at follow-up. Performance on cognitive tests appears to be a more sensitive indicator of the degenerative process than EEG band-power and morphological changes in manifest AD. Neuroimaging, neurophysiology and genetic risk markers may be more important for the early differential diagnosis than for the prediction of the course of illness.

[Volumetric brain changes and quantitative EEG in normal aging and Alzheimer's dementia]. / Volumetrische Hirnveränderungen und quantitatives EEG bei normalem Altern und Alzheimer-Demenz.

We studied (1) the differences of volumetric estimates of brain atrophy in normal ageing and Alzheimer's disease (AD); (2) the correlation of these estimates with age and cognitive performance; (3) the differences between absolute EEG power between ageing and AD; (4) the correlation between EEG power and age or cognitive performance; and (5) the correlation between volumetric and EEG data. 84 patients with a clinical diagnosis of AD and 45 age-approximated non-demented controls between 48 and 91 years of age were examined. For statistical comparisons the volumetric estimates of intracranial cerebrospinal fluid (csf) spaces were converted into percentages of total intracranial volume. The EEG was recorded from 17 locations at resting conditions, eyes closed, according to the 10/20 system. Logtransformed absolute band powers were compared between the AD and control groups and correlated with clinical and volumetric findings. The total intracranial csf-space, both lateral ventricles, the third ventricle, anterior, lateral and posterior fissures were significantly larger in AD than in non-demented controls. In normal ageing the csf-volumes were significantly correlated with age, whereas age and cognitive performance were differentially correlated with these variables in AD. In AD, the absolute delta or theta power was significantly higher in all locations, whereas alpha power was lower than in normal controls. These differences were significantly correlated with cognitive performance. There were no significant correlations between the csf-volumes and EEG-power in AD and the control group with one exception: we found a significant inverse correlation between the volumes of the anterior and posterior fissure and the alpha-1 and alpha-2 power independent of electrode location in AD. We conclude that the morphological and EEG-changes in AD are largely independent and suggest that the functional relationship between alpha-power and anterior or posterior fissure volume needs further examination.

Quantitative EEG in frontal lobe dementia.

A study on quantitative EEG in 14 patients with frontal lobe dementia (FLD), 14 patients with Alzheimer's disease (AD), and 14 healthy controls was conducted using a complete set of EEG parameters: band power, coherence and fractal dimension. Contrary to earlier studies, we observed higher theta power and sagittal interactions in higher frequency bands in the FLD than in the control group. Lateral interactions of coherence and two indices of fractal dimension were lower in FLD than in controls. There was greater electrophysiological resemblance between the control group and FLD than between any of these groups and AD. This was documented by the results of a discriminant analysis which led to a correct overall classification of 66% of the subjects with misclassifications occurring primarily between control and FLD group.

Frontal lobe degeneration and Alzheimer's disease: a controlled study on clinical findings, volumetric brain changes and quantitative electroencephalography data.

Ten patients with a clinical diagnosis of frontal lobe degeneration (FLD) were compared with a group of patients with probable Alzheimer's disease (AD) and with nondemented controls matched for gender and age. In comparison with AD, the duration of illness was slightly shorter and cognitive performance was better in patients with FLD. The greatest enlargement of cerebrospinal fluid volumes was found in FLD and this effect was most pronounced in the anterior fissure and lateral ventricles. Estimates of EEG band-power and EEG coherence in FLD were not remarkably different from nondemented controls, whereas delta- and theta-power were significantly increased in AD. These observations may indicate different disease processes with a dissociation of volumetric computed tomography and quantitative EEG changes, which may be of differential diagnostic value.

Senile dementia of Alzheimer type and multi-infarct dementia investigated by transcranial Doppler sonography.

Dementia of the Alzheimer type, senile onset (SDAT), and multi-infarct dementia (MID) exhibit differences in cerebrovascular blood flow velocity profiles, which were investigated by means of transcranial Doppler sonography. The pulsatility indices (PI), as angle-independent parameters of peripheral vascular resistance measured in the basal cerebral arteries, were significantly increased in MID patients with respect to SDAT cases. In an analysis of the correlations between several variables and the magnitude of PI, we found strong inverse correlations of the CAMCOG score, and strong direct correlations of the blood pressure and the duration of illness, with the PI of all basal cerebral arteries only in MID patients. In SDAT patients, we found a direct correlation between the Hachinski ischemia score and the PI of all basal cerebral arteries. All 3 ischemia scores (Hachinski, Rosen, Loeb and Gandolfo) were significantly correlated with the PI of the middle cerebral and basilar arteries. By analyzing the correlations of the single items of the 3 different ischemia scores with the PI values obtained, we only found a clearcut correlation with the item focal neurological signs. Thus, our findings stress the relative importance of a concomitant cerebrovascular factor in the development of dementia in old age, even in patients with probable SDAT. A raise of the PI in the basal cerebral arteries allows early suspicion of a cerebrovascular factor even in only slight dementia so that possible risk factors for further aggravation of this type of vascular dementia might be detected and treated early in the course of disease.

Brain atrophy in normal ageing and Alzheimer's disease. Volumetric discrimination and clinical correlations.

BACKGROUND: We examined the differences in volume of the ventricular and extracerebral cerebrospinal fluid spaces in normal ageing and in probable Alzheimer's disease (AD) and we tried to investigate the effects of the severity of illness on the morphometric differentiation of AD and ageing, the principal components underlying brain atrophy in both conditions, and the correlations of these measurements with clinical findings. METHOD: Forty patients with probable AD were matched with 40 non-demented elderly controls. Both groups underwent standardised clinical tests and unenhanced cranial computed tomography for post hoc volumetric analysis. RESULTS: The lateral and third ventricles and the anterior and lateral fissures were significantly larger in AD than in normal ageing. The volumes of the lateral ventricle and lateral fissure permitted a highly efficient differentiation between normal ageing and AD even at the mild stage of dementia, and this differentiation was improved further in the more severe stages of illness. We identified one principal component underlying brain atrophy in normal ageing and two components in AD: a 'grey matter' component accounting for sulcal and third ventricular enlargement, and a 'white matter' component for lateral ventricular enlargement. In AD, most of the volumetric measurements were significantly correlated with cognitive impairment, but in the group of non-demented elderly controls they were correlated with age. CONCLUSION. Volumetric indices of brain atrophy permit a highly efficient differentiation between normal ageing and AD even in the mild stages of illness and this demonstrates that substantial structural brain changes have developed in the preclinical phase of illness. We suggest that there is an uncoupling between lateral ventricular enlargement and cortical brain atrophy in AD.

Parameters of EEG dimensional complexity in Alzheimer's disease.

The dimensional complexity or fractal dimension of the EEG recorded at 17 locations from the 10-20 system was studied using a very fast new algorithm. The paper contains 2 parts. First, the influence of several parameters (embedding dimension, delay time, high and low frequency cutoff, ADC precision and sweep length) on the estimation of dimensional complexity is investigated. Then it is shown that patients with Alzheimer's disease (n = 50) have significantly lower dimensional complexity than age-approximated non-demented controls (n = 42).