The current status of psychological assessment training in graduate and professional schools.

Test-based psychological assessment is threatened by the policies of managed care organizations; however, research has demonstrated that test-based psychological assessment is quite valuable and economically justified when conducted by well-trained psychologists. This surfaces the question of the current status of graduate training in test-based psychological assessment. Results of this study indicate that clinical and counseling students currently receive almost equivalent training in test-based assessment. However, in a larger context, results indicate a lack of sound preparation in test-based assessment training for a large proportion of clinical and counseling students. These findings are discussed in terms of their implications for the field and, more specifically, for graduate and internship training.

Anger and hostility in tension-type headache.

A battery of standardized psychometric tests was administered to a group of 47 episodic tension-type headache sufferers and 47 headache-free controls. Compared to controls, headache subjects showed higher levels of anxiety, depression, and anger/hostility. The groups did not differ significantly on a measure of anger expressed toward persons or objects, but headache subjects showed significantly greater levels of suppressed anger. The results provide objective data that are in general agreement with predictions derived from psychosomatic theories about the interrelationships among anxiety,

A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain.

A number of treatments are widely prescribed for chronic back pain, but few have been rigorously evaluated. We examined the effectiveness of transcutaneous electrical nerve stimulation (TENS), a program of stretching exercises, or a combination of both for low back pain. Patients with chronic low back pain (median duration, 4.1 years) were randomly assigned to receive daily treatment with TENS (n = 36), sham TENS (n = 36), TENS plus a program of exercises (n = 37), or sham TENS plus exercises (n = 36). After one month no clinically or statistically significant treatment effect of TENS was found on any of 11 indicators of outcome measuring pain, function, and back flexion; there was no interactive effect of TENS with exercise. Overall improvement in pain indicators was 47 percent with TENS and 42 percent with sham TENS (P not significant). The 95 percent confidence intervals for group differences excluded a major clinical benefit of TENS for most outcomes. By contrast, after one month patients in the exercise groups had significant improvement in self-rated pain scores, reduction in the frequency of pain, and greater levels of activity as compared with patients in the groups that did not exercise. The mean reported improvement in pain scores was 52 percent in the exercise groups and 37 percent in the nonexercise groups (P = 0.02). Two months after the active intervention, however, most patients had discontinued the exercises, and the initial improvements were gone. We conclude that for patients with chronic low back pain, treatment with TENS is no more effective than treatment with a placebo, and TENS adds no apparent benefit to that of exercise alone.

Can trials of physical treatments be blinded? The example of transcutaneous electrical nerve stimulation for chronic pain.

Therapeutic trials often attempt to "blind" patient and investigator to the true nature of treatments received, reducing the influences of conscious or subconscious prejudices. In drug trials, this is accomplished with placebo tablets, but blinding in trials of physical treatments is more problematic. This issue arose in a clinical trial of transcutaneous electrical nerve stimulation (TENS) for patients with chronic low back pain. Several study design features were incorporated to promote blinding: use of sham TENS units visually identical with real units, exclusion of potential subjects with previous TENS experience, avoidance of a crossover design and use of identical visit frequency, instructions and modifications in electrode placement. Subjects were asked not to discuss treatments with the clinicians who performed outcome assessments. Both patients and clinicians were asked to guess actual treatment assignments at the trial's end. Every patient in the true TENS group believed the unit was functioning properly, but the degree of certainty varied. In the sham TENS group, 84% also believed they had functioning units, but their certainty was significantly less than in the active treatment group. Differences in patient perceptions did not affect compliance, as the two groups had similar dropout rates, appointment compliance, days of TENS use and daily duration of TENS use. Clinicians guessed treatments correctly 61% of the time (as opposed to 50% expected by chance), again suggesting partial success in blinding. These efforts at blinding may partly explain the negative trial results for TENS efficacy. We conclude that complete blinding is difficult to achieve because of sensory difference in treatment and unintended communication between patient and examiner.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychosexual study of women with detrusor instability.

Clinical impression suggests that many cases of detrusor instability are psychosomatic. We evaluated 63 women with urinary incontinence and 27 continent controls using the Minnesota Multiphasic Personality Inventory, Uplift and Hassle Scales, and a structured questionnaire screening sexual dysfunction. All incontinent women underwent diagnostic urodynamic studies including uroflowmetry, subtracted water cystometry with provocation, and urethral closure pressure profilometry. Thirty-five women had genuine stress incontinence and 28 had detrusor instability, including nine with mixed incontinence. No differences in psychological test results were noted between the detrusor-instability and genuine-stress-incontinence groups. On the Minnesota Multiphasic Personality Inventory, subjects with detrusor instability scored significantly higher than controls on the hypochondriasis (P = .006), depression (P = .01), and hysteria (P = .0009) scales. Compared with continent controls, the detrusor-instability group reported a lower frequency of uplifts (P less than .05) and a greater intensity of hassles (P less than .05). Both incontinent groups reported more sexual dysfunction than did controls. We conclude that many women with urinary incontinence have abnormal psychological and sexual test results reflecting moodiness, feelings of helplessness and sadness, pessimism, general hypochondriasis/somatization, and sexual dysfunction. These abnormalities appear to be associated with urinary incontinence in general rather than with specific diseases of the urinary tract.

Diagnostic epidural opioid technique.

Diagnostic epidural blocks were performed on 27 chronic pain patients sequentially using saline, fentanyl, and lidocaine solution. The patients were divided into one of four groups based on their response to the epidural solutions: placebo response group--pain relief with placebo solutions; fentanyl response group--pain relief with epidural fentanyl; lidocaine response group (LRG)--pain relief with lidocaine but not fentanyl; and no response group--no pain relief with any of the solutions used. The four groups were compared on the basis of age, sex, site of pain, duration of pain, narcotic use, pain assessment index, and workmen's compensation claims. The comparisons resulted in the conclusion that LRG patients had a much longer average duration of pain than the other groups. On the basis of the information gathered, it was theorized that, despite their response to epidural lidocaine, LRG patients may actually be a group of operant pain patients. Their failure to receive analgesia from epidural fentanyl may be a learned response such that they associate any sensory input from the affected area as painful. If follow-up studies support these findings, then the diagnostic opioid technique may be a more sensitive tool in diagnosing chronic pain.

Evaluation of neurolytic blocks using phenol and cryogenic block in the management of chronic pain.

This study compared the use of phenol and cryogenic blocks for neurolysis in 28 patients. Patients were assigned randomly to receive peripheral nerve blocks with either phenol or cryoanalgesia. Significantly more patients in the phenol group received 20% or greater relief at 2, 12, and 24 wk than patients in the cryogenic group. Only 27% of patients received significant relief, however, indicating that neurolytic blocks were not particularly effective even though local anesthetic blocks produced significant but temporary pain relief.

Studies of the Modified Somatic Perceptions Questionnaire (MSPQ) in patients with back pain. Psychometric and predictive properties.

The Modified Somatic Perceptions Questionnaire (MSPQ) was designed to measure heightened somatic awareness among patients with chronic pain. It was hoped that this questionnaire would help predict therapeutic responses for back pain patients. The reliability, validity, and predictive characteristics of this scale were tested among 97 patients with chronic low-back pain enrolled in a clinical trial of transcutaneous nerve stimulation and stretching exercises. Internal consistency was good (alpha = 0.78), and correlations with the Zung depression scale and certain MMPI scales were significant. Correlations with a baseline functional scale (the Sickness Impact Profile) were stronger than those with the MMPI. Unfortunately, the MSPQ did not correlate with functional outcomes, and was only weakly associated with pain outcomes. Thus, the MSPQ appears to be reliable and valid, but the somatic perceptions it measures may have little relation to patient outcomes.

Sociodemographic and clinical correlates of P-A-I-N.

Rules to clarify MMPI profiles into four types (P-A-I-N) observed commonly in chronic pain patient populations were tested to determine if resulting average profiles matched computer-algorithm derived prototypes. Close matches were obtained, suggesting that the rules could be used in the ordinary pain clinic setting to look for type x treatment interactions. Seven clinical variables differentiated the types. Type P and N were most different from one another, and Types A and I represented poles on an optimism-pessimism dimension.

Prognostic variability among chronic pain patients: implications for study design, interpretation, and reporting.

Chronic pain patients share many characteristics, but there is important prognostic variability among them. By selecting for certain characteristics, different recruitment methods and entry criteria for clinical or research programs may influence the likelihood of success regardless of treatment efficacy. This was demonstrated when subjects (n = 55) were recruited through lay publicity for a clinical trial of therapy for chronic back pain. In comparison to routine pain clinic patients (n=61), subjects in the clinical trial were better educated, were more often employed, had more favorable personality profiles, and were less likely to have had surgery or narcotic use (all p less than 0.004). Pain relief was significantly better for clinical trial subjects, apparently due to baseline prognostic differences rather than uniquely efficacious therapy. We conclude that chronic pain patients vary in prognostically important ways; that recruitment methods and criteria strongly influence these characteristics; and that greater attention to these details is needed when interpreting and reporting clinical research.

Mental health attitudes and treatment expectations as treatment variables.

Evaluated 60 patients just before their initial assessment in a community mental health clinic. A series of questions about mental health attitudes and treatment expectation were asked each patient. The Psychiatric Evaluation Form was administered both before evaluation and after five treatment visits. Patients with harsh, pessimistic views about mental illness had more severe psychopathology and did less well over the period of follow-up. Expectation of medication was associated strongly with lower education, greater severity of illness, lower satisfaction with treatment, greater frequency of dropping out of treatment, and less improvement.

A correlation between dropout status and improvement in a psychiatric clinic.

Sixty psychiatric outpatients were independently evaluated before treatment in a mental health center and again after they had either completed five treatment visits or dropped out. Dropouts were older, more likely to be female, more severely ill, and more likely to expect medications. They improved less on scales of drug use, denial of illness, and grandiosity. Dropouts who did improve were more likely to have situational reactions. Better-educated patients had better outcomes. Patients who were satisfied with the treatment they received were the most likely to have improved.

The costs of an institutional review board.

The Institutional Review Board (IRB) at the University of Texas Health Science Center at San Antonio is charged with the responsibility of review of all protocols involving human subjects in research. A large medical institution has many clinical protocols requiring review. The review of hundreds of protocols per year requires much time from the IRB staff, the committees which review the protocols, and the investigators who prepare them. This cost is borne by the institution. Additional federal regulations add to the complexity of review and require additional time on the part of all concerned. An attempt has been made to document the costs of operation of the IRB in a single group of institutions. About 850 new or renewal applications are reviewed each year for $100,000 or about $100 per application. This is a sizable financial burden to be placed on the average medical school. Legislation is now proposed to support IRB activities by direct grants from the federal government.

Absence of glomerular renal tubular epithelial antigen in membranous glomerulonephritis.

Renal biopsies from 24 patients with membranous glomerulonephritis were examined by indirect immunofluorescence for the presence of autologous renal tubular epithelial antigen (RTE). Staining of the luminal layer of proximal tubular epithelium was found in all cases, as with normal human kidney, but granular staining along glomerular capillary walls was not observed. The role of RTE in the genesis of human membranous glomerulonephritis has not been confirmed.