[Increased sensitivity to pain in long-term opioid treatment]. / Erhöhte Schmerzempfindlichkeit unter Dauerbehandlung mit Opiaten.

Recent years have seen a rise in the prescription of strong opioids for chronic and even subthreshold forms of pain. Animal and human experiments and clinical observations have shown that, compared to placebos, chronic opioid administration results in not only tolerance to its analgesic effects but also in heightened pain sensitivity. Therefore chronic, especially high-dose, opioid treatment can not be recommended for chronic pain but is instead contraindicated. Patients on long-term opioids will often reject proposals to withdraw the drug. Important elements of treatment are patient education, empathy and unconditional acceptance by the patient, motivation enhancement and psychological support, collaboration with other prescribers and therapists, detoxification, measures to increase pain tolerance, encouragement of general health behavior and salutotherapy, treatment of the primary illness, and prescription of participation oriented alternative analgesics.

Pain management in the opioid-dependent patient.

The opioid-dependent patient presents great challenges for pain management. These challenges are not limited to potential addictive behaviors. In contrast to the profound pain relieving effects of acute opioid intake, chronic opioid intake can promote a counterintuitive state of enhanced pain sensitivity. Multiple biologic mechanisms inducing opioid tolerance and hyperalgesia have recently been elucidated. The potential hyperalgesic state accompanying opioid dependence complicates pain management somewhat for acute pain and cancer pain, but it especially does so for chronic pain. Guidelines for treatment of opioid dependence in the pain patient are proposed. Treatment oriented toward the long term requires limit setting and psychologic support that go beyond simple medication management.

Chronic pain disorder following physical injury.

Pain disorders that are primarily associated with psychological factors are of great clinical concern, but they are difficult to study because of the inability to make valid or reliable diagnoses by structured interview alone. The authors confront this difficulty by using an injured subject population that had extensive psychiatric and medical evaluations. Those who developed somatoform pain disorder (SPD) were compared with a control group who did not. The SPD group had distinctive associated factors: more sites of pain, spread of pain beyond area of original injury, and substantially more opiate and benzodiazepine use. Compensation/litigation influenced symptoms more in the SPD group. Psychotherapists often supported the patient's viewpoint that the pain was physical and to be endured.

St. John's wort for depression: a meta-analysis of well-defined clinical trials.

Studies concluding that St. John's wort (Hypericum perforatum) is an effective antidepressant can be challenged due to questionable methodology. We attempt to correct this by a meta-analysis utilizing only well-defined clinical trials. Controlled, double-blind studies using strictly defined depression criteria were analyzed by the rate of change of depression and by the number of "treatment responders." Rates of side effects and dropouts were also analyzed. Hypericum was 1.5 times more likely to result in an antidepressant response than placebo and was equivalent to tricyclic antidepressants (TCAs). The meta-analysis also showed that there was a higher dropout rate in the TCA group and that the TCAs were nearly twice as likely to cause side effects, including those more severe than hypericum. Hypericum perforatum was more effective than placebo and similar in effectiveness to low-dose TCAs in the short-term treatment of mild to moderately severe depression. However, design problems in existing studies prevent definitively concluding that St. John's wort is an effective antidepressant.

Effectiveness of a psychiatric pain clinic.

Medical charts were reviewed for 101 consecutive outpatients seen between January 1, 1993 and July 1, 1996 at a unidisciplinary, psychiatric pain clinic, which exists within a hospital-based, university-run, outpatient service with primary and specialty care clinics. Mean duration of pain was 7 years. Multiple sites of pain were present in 69% of patients. Eighty-eight percent fulfilled DSM-IV criteria for pain disorder. The patients had significantly fewer medical visits and diagnostic tests 6 months after attending the pain clinic, compared with 6 months before (P < 0.0001). Interventions frequently included detoxification and reduction and substitution of medication, and always included psychotherapeutic approaches, particularly support and suggestions.

Assisted suicide and AIDS patients. A survey of physicians' attitudes.

Physicians' attitudes about assisted suicide were assessed by using a vignette of an acquired immune deficiency syndrome (AIDS) patients who requests a lethal injection. Of the 389 respondents, 34% received at least 1 request for assisted suicide; 9% had requests from an AIDS patient; and 41% had at least indirectly assisted a terminal patient to die in actual practice. Thirty-three percent of the respondents agreed to the authors' hypothetical patient's request for a lethal injection. Medical and personal experiences did not determine attitudes that were somewhat influenced by ethical beliefs and religious commitment. The study confirms previous findings that many physicians underestimate the effect of depressive illness on rational decision making concerning assisted suicide the effect of depressive illness on rational decision making concerning assisted suicide requests.

"Honeymoon psychosis" in Japanese tourists to Hawaii.

Although Japanese tourists in Hawaii are infrequently treated for acute psychiatric emergencies, we observed several cases among Japanese honeymooners. To investigate this phenomenon, we retrospectively and prospectively collected such cases of honeymooners. Sixteen cases of acute psychiatric disturbance in Japanese honeymooners in Hawaii are described. This phenomenon occurs more frequently than in other Japanese tourists or non-Japanese honeymooners. The tradition of arranged marriage and other cultural factors may be associated with the potential for "honeymoon psychosis."

Pilot study of explicit grading criteria in the American Board of Psychiatry and Neurology. Part II. Examination.

OBJECTIVE: The purpose of this study was to identify specific competencies that differentiated passing from failing performance on the American Board of Psychiatry and Neurology Part II oral board certification examination. METHOD: A total of 363 candidates were rated in 18 areas of competence defined by behavioral criteria. Data were analyzed to determine which areas best discriminated between passing and failing candidates. RESULTS: In both parts of the examination, the ability to develop a comprehensive treatment plan was most influential. After that, specific interview and observational skills discriminated best. Failing candidates had most difficulty detecting and following informational and affective cues in their interview of a patient and presenting a biopsychosocial formulation and comprehensive treatment plan. CONCLUSIONS: Specific candidate competencies related to passing and failing performances can be identified and assessed by a rating scale of observable behaviors on the board certification examination in psychiatry.

Does acculturation influence psychosocial adaptation and well-being in Native Hawaiians?

Native Hawaiians have suffered higher disease rates and achieved lower educational and economic levels than other ethnic groups living in Hawaii. This study tests the hypothesis that cultural affiliation protects against psychosocial pathology in Hawaiians. Subjects included 172 Hawaiians of varying blood quantum and 92 non-Hawaiians. The Na Mea Hawai'i, a rationally derived, empirically validated measure of Hawaiian acculturation was administered to all subjects in addition to psychological tests which included 19 visual analogue scales that measure both state and trait variables. The Na Mea Hawai'i proved excellent at differentiating Hawaiians from non-Hawaiians (p = .0001), and it correlated well with blood quantum (r = 0.31, p = .0001). Low acculturation scores among Hawaiians did not correlate with any measure of discontent or psychosocial pathology irrespective of blood quantum. We conclude that Na Mea Hawai'i is a valid measure of Hawaiian acculturation, and that adaptation of the Hawaiians in our sample has been unaffected by level of acculturation.

The role of "stress" in workers' compensation stress claims.

Twenty-six cases of workers' compensation "stress" claims were examined to delineate the nature and causes of psychiatric illness in relation to psychological stress in the workplace. Correlations were made among demographic data, psychiatric diagnoses, categories of complaints, psychological themes, and role of litigation. Findings showed that most subjects sorted into two major groups. For the largest group (56%), symptoms were precipitated by interpersonal issues. Within this group, 86% of subjects believed that unfair treatment caused their symptoms, 79% fulfilled criteria for a personality disorder diagnosis, and 71% were more focused on issues related to their claim than on symptom relief. A smaller group (24%) encountered significant stress at work. This group had more severe psychiatric illness and fewer personality disorders.

Noncompliant hemodialysis patients. A biopsychosocial approach.

Noncompliance to fluid restrictions is remarkably common and difficult to treat in hemodialysis patients. Psychosocial variables have not been convincingly demonstrated to correlate with fluid noncompliance. Fluid overloading tends to begin early in the course of dialysis treatments and remains remarkably stable over time. This maladaptive behavior on the part of so many dialysis patients could be promoted by abnormalities in the renin-aldosterone-angiotensin system or other abnormalities in the homeostatic mechanisms that regulate water metabolism. Hypotheses related to addictive behavior and milieu variables are also discussed. Recommendations include using a nonmoralistic approach, flexibility in dialysis schedules, and psychological intervention at the onset of dialysis.

Psychiatric aspects of oncology: a review of recent research.

Psychiatrists diagnose and treat the mental disorders of cancer patients, but they are also concerned with pain management, the patient's adaptation to the disease, and the attitudes of relatives and health care professionals toward the cancer patient. The author reviews recent research on these areas of concern and discusses the psychiatric complications of cancer such as organic brain syndromes, depression, and anxiety; the pharmacotherapy of such complications; and the role of psychological factors in the etiology of cancer. Approaches to informing patients of their cancer diagnosis and other implications for clinical practice are also covered.

Coping with transplant failure: grief vs. denial.

A major drawback to kidney transplantation as a treatment for end stage renal disease is the common occurrence of rejection and failure of the transplanted kidney. We evaluated twenty-five dialysis patients, all of whom had suffered transplant failure during a ten year period. Of these, twenty-four had good psychological readjustment to chronic dialysis. Fourteen patients successfully grieved the loss of their kidneys. Ten denied any psychological difficulty in returning to dialysis and did not manifest the usual signs of grief. We suggest that the effectiveness of denial as a coping mechanism should be recognized and supported when present; in contrast, "grievers" should be helped through the grieving process and followed up to ensure resolution and proper readjustment to dialysis.

Diagnostic and treatment considerations in depressed dialysis patients.

Depressive symptoms are common in a dialysis population. These symptoms are only infrequently part of a major depressive illness, however, and are more usually related to adjustment disorders associated with the onset of chronic dialysis treatment, or medical complications of end stage renal disease. A substantial proportion of depressive symptoms are also related to problems in living not directly associated with renal failure. Psychotherapeutic support helps the majority of patients with depressive symptomatology. Nurse-patient and physician-patient relationships are potentially powerful factors influencing patient adjustment to dialysis.

The influence of cultural group on the undertreatment of postoperative pain.

Culture is widely recognized to be an important determinant of pain response, yet little is known about the interactions of culture with other variables or about the relationship between culture and the treatment of pain in the clinical setting. This study analyzes the variance in postcholecystectomy narcotic requirements accounted for by racial group in a multiethnic setting. Caucasians and Hawaiians received significantly more analgesics than Filipinos, Japanese, or Chinese. Race and its interactions with age and sex accounted for 11% of the variance. All groups were notably undertreated for pain. While individual factors are probably of greatest importance in the treatment of postoperative pain, cultural factors do contribute to the variability. Whether this reflects ethnic differences in analgesic requirements or reflects cultural bias in treatment remains to be determined. In a milieu of undertreatment of pain, some cultural styles may be more susceptible to undertreatment than others.

Denial in dialysis patients: relationship to compliance and other variables.

Denial has been documented as an important defense mechanism to helping the chronically ill cope with their disease. With respect to a dialysis population, however, the role of denial has been ambiguous. The purpose of this study were 1) to examine the physiological and psychological correlates of denial in a dialysis population and 2)( to examine the relationship between use of denial and compliance to fluid restrictions. Subjects were 46 self- and limited-care dialysis patients. From this subject pool two groups were derived, based upon weight gains between treatments: complies (N=15) and noncompliers(N=16). Both physiological and psychological data were correlated with denial as measured by the Marlow-Crowne Social Desirability Scale. Results indicated that denial is used a great deal in dialysis patients, but there was no difference in denial scores between compliers and noncompliers. For compliers, however, denial was correlated with more adaptive attitudes toward illness. The results have implication for the clinical management of dialysis patients.

Treatment of iatrogenic drug dependence in the general hospital.

Despite the vast literature on drug dependence, little has been written about patients who become addicted while taking medically prescribed drugs for organic pathology. Observations from a psychiatric consultation-liaison service reveal that these patients are frequently middle-aged with no history of drug abuse before the onset of a chronic medical condition. Associated with their medical condition is a dependence on narcotics and/or psychotropic medications for such complaints as pain, headache, insomnia, and anxiety. Thea addiction may persist for years without acknowledgement by a patient, doctor, or family, although there is usually a progressive constriction of social and occupational functioning. The primary physician is highly valued by the patient; this manifest appreciation trends to facilitate the primary physician's continued prescription of large doses of addicting drugs. Treatment involving detoxification typically goes through a series of stages, each of which has characteristic hazards and pitfalls that can lead to failure of treatment.