Albert M. van Hemert

A validation study of the Whitely Index, the Illness Attitude Scales, and the Somatosensory Amplification Scale in general medical and general practice patients

The aim of this study was to assess the reliability and validity of the Whitely Index (WI), the Illness Attitude Scales (IAS), and the Somatosensory Amplification Scale (SAS). The study population consisted of 130 general medical outpatients, 113 general practice patients, and 204 subjects from the general population. The factorial structure of the IAS appeared to consist of two subscales, namely Health Anxiety and Illness Behaviour. The internal consistency and stability of the three questionnaires were satisfactory, and their scores were highly intercorrelated. Scores on the WI and Health Anxiety subscale of the IAS declined significantly from general medical outpatients, through general practice patients to subjects from the general population. This might imply that medical care utilisation is related to hypochondriasis. A prospective study is needed to determine whether health anxiety contributes to the decision to seek medical care or the consultation of a general practitioner or consultant gives rise to worry about possible illness.

Psychiatric disorders in relation to medical illness among patients of a general medical out-patient clinic

In many patients clinical care in general medical settings is complicated by the presence of psychiatric disorders in addition to the presenting physical symptoms. In the present study the prevalence and type of psychiatric disorders was assessed in relation to the medical diagnostic findings in a general internal medicine out-patient clinic. The Present State Examination, a standardized psychiatric interview, was used to detect psychiatric disorders in 191 newly referred patients. Psychiatric disorders were found to be particularly prevalent among patients with medically ill-explained or unexplained symptoms. The prevalence of psychiatric disorders was 15% for patients with a medical explanation for their presenting symptom, 45% for patients with ill-explained and 38% for those with unexplained symptoms. Approximately 40% of the patients with psychiatric disorders met DSM-III-R criteria for somatization disorder or hypochondriasis, suggesting that these disorders contributed in particular to general medical out-patient referrals.

Anxious–Retarded Depression: Relation with Plasma Vasopressin and Cortisol

Dysregulation of the hypothalamus–pituitary–adrenal (HPA) axis is related to melancholic or endogenous depression; however, the strength of this relationship depends on the definition of the specific depression subcategory. A two-dimensionally defined subcategory, anxious–retarded depression, is related to melancholic depression. Since arginine vasopressin (AVP) activates the HPA axis, and both major depression and the melancholic subcategory are associated with elevated plasma AVP levels, we investigated whether the plasma AVP level is also elevated in anxious–retarded depression, melancholic depression and anxious–retarded melancholic depression, and whether plasma AVP and cortisol levels are correlated in these subcategories. A total of 66 patients with major depression not using oral contraception were investigated. Patients with anxious–retarded depression had a highly significant AVP–cortisol correlation, while no such correlation was found in patients with nonanxious–retarded depression. Log-transformed mean plasma AVP values were higher in patients with anxious–retarded depression than in patients with nonanxious–retarded depression. Patients with anxious–retarded melancholic depression also had a significantly elevated level of plasma AVP and a highly significant correlation between plasma AVP and cortisol levels. The correlation was low in patients with melancholic depression. Anxious–retarded depression may be a useful refinement of the melancholic subcategory with regard to dysregulation of the HPA axis and plasma AVP release.

SEX HORMONE BINDING GLOBULIN IN POSTMENOPAUSAL WOMEN: A PREDICTOR OF OSTEOPOROSIS SUPERIOR TO ENDOGENOUS OESTROGENS

To quantify the role of endogenous oestrogen activity in osteoporosis we measured relative metacarpal cortical area (RCA), body mass, serum oestrone, oestradiol, androstenedione, and sex hormone binding globulin (SHBG) in 746 postmenopausal women aged 53 to 76 years, sampled from the general population. The occurrence of fractures and the rate of loss of RCA (delta‐RCA) were determined over the previous 9 years. Both RCA and delta‐RCA were significantly related to body mass, serum oestrone, oestradiol, and SHBG. The influence of the first three variables appeared to be bone preserving, whereas the latter appeared to be bone wasting. Serum oestradiol, SHBG and body mass proved to have an independent relationship with RCA in multivariate regression analysis. The relationship to delta‐RCA was statistically independent for serum SHBG only. Serum androstenedione was unrelated to either RCA or delta‐RCA. In the total study population, body mass, serum oestrone, oestradiol and SHBG were not related to the occurrence of fractures over the previous 9 years. In the subgroup of 249 elderly women, aged 65‐76 years, SHBG levels were significantly higher for women with type I osteoporotic fractures (vertebral and forearm fractures) as compared to controls. The results suggest a bone wasting influence of SHBG in postmenopausal women, possibly resulting in an increased risk of type I osteoporotic fractures in elderly women.

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.

Excess mortality in general hospital patients with delirium : a 5-year follow-up of 519 patients seen in psychiatric consultation

Mortality was determined in 519 patients with delirium who were seen in psychiatric consultation in two general hospitals. Among 419 patients with simple delirium (DSM-III: 293.00) in-hospital mortality was 26%. As compared to average hospital patients the age adjusted in-hospital excess mortality ratio varied from 6.2 for patients with malignancies to 2.1 for patients with motor system disease. After hospital discharge the 5-yr cumulative mortality was 51%. As compared to the general population excess mortality was noted in most, but not in all diagnostic subgroups. The age and sex adjusted excess mortality ratio varied from 14.1 for malignancies to 1.3 for motor system disease. The figures underline a general notion that delirium may be an indicator of disorders of grave prognosis, but mortality appears to depend more on the medical condition than on the presence of delirium.

Comorbidity of PTSD in anxiety and depressive disorders: prevalence and shared risk factors

The present study aims to assess comorbidity of posttraumatic stress disorder (PTSD) in anxiety and depressive disorders and to determine whether childhood trauma types and other putative independent risk factors for comorbid PTSD are unique to PTSD or shared with anxiety and depressive disorders. The sample of 2402 adults aged 18-65 included healthy controls, persons with a prior history of affective disorders, and persons with a current affective disorder. These individuals were assessed at baseline (T0) and 2 (T2) and 4 years (T4) later. At each wave, DSM-IV-TR based anxiety and depressive disorder, neuroticism, extraversion, and symptom severity were assessed. Childhood trauma was measured at T0 with an interview and at T4 with a questionnaire, and PTSD was measured with a standardized interview at T4. Prevalence of 5-year recency PTSD among anxiety and depressive disorders was 9.2%, and comorbidity, in particular with major depression, was high (84.4%). Comorbidity was associated with female gender, all types of childhood trauma, neuroticism, (low) extraversion, and symptom severity. Multivariable significant risk factors (i.e., female gender and child sexual and physical abuse) were shared among anxiety and depressive disorders. Our results support a shared vulnerability model for comorbidity of anxiety and depressive disorders with PTSD. Routine assessment of PTSD in patients with anxiety and depressive disorders seems warranted.

A longitudinal study of experiential avoidance in emotional disorders

The aim of this study was to examine the degree in which measurements of trait experiential avoidance (EA) are affected by current emotional disorder and whether EA is a causal factor in the course of emotional disorders (anxiety and depressive disorders) and the development of comorbidity among emotional disorders. In a sample of 2,316 adults aged 18 to 65, consisting of healthy controls, persons with a prior history of emotional disorders, and persons with a current emotional disorder, DSM-IV-based emotional disorders (CIDI: Composite Interview Diagnostic Instrument) were assessed at T2 and 2 (T4) and 4years later (T6) and experiential avoidance (AAQ: Acceptance and Action Questionnaire) at T2 and T4. Results showed that EA scores were stable over a 2-year period notwithstanding state fluctuations because of current emotional disorder. Moreover, EA scores at T2 predicted changes in distress (major depressive disorder, dysthymia, generalized anxiety disorder) and in fear disorders (social anxiety disorder, panic disorder with or without agoraphobia, agoraphobia without panic) at T4. Finally, EA at T4 mediated the longitudinal association of fear disorders at T2 with distress disorders at T6 as well as of distress disorders at T2 with fear disorders at T6. These findings suggest that EA scores are more than epiphenomena of emotional disorders and that EA may be conceptualized as a relevant transdiagnostic factor affecting the course and development of comorbidity of emotional disorders.

Childhood trauma questionnaire: Factor structure, measurement invariance, and validity across emotional disorders

To study the psychometric properties of the Childhood Trauma Questionnaire-Short Form (CTQ-SF), we determined its dimensional structure, measurement invariance across presence of emotional disorders, the association of the CTQ-SF with an analogous interview-based measure (CTI) across presence of emotional disorders, and the incremental value of combining both instruments in determining associations with severity of psychopathology. The sample included 2,308 adults, ages 18-65, consisting of unaffected controls and chronically affected and intermittently affected persons with an emotional disorder at Time 0 (T0) or 4 years later at T4. Childhood maltreatment was measured at T0 with an interview and at T4 with the CTQ-SF. At each wave, patients were assessed for Diagnostic and Statistical Manual of Mental Disorders (4th ed., or DSM-IV; American Psychiatric Association, 1994)-based emotional disorders (Composite Interview Diagnostic Instrument) and symptom severity (Inventory of Depressive Symptomatology, Beck Anxiety Inventory, Fear Questionnaire). Besides the correlated original 5-factor solution, an indirect higher order and direct bifactorial model also showed a good fit to the data. The 5-factor solution proved to be invariant across disordered-control comparison groups. The CTQ-SF was moderately associated with the CTI, and this association was not attenuated by disorder status. The CTQ-SF was more sensitive in detecting emotional abuse and emotional neglect than the CTI. Combined CTQ-SF/CTI factor scores showed a higher association with severity of psychopathology. We conclude that although the original 5-factor model fits the data well, results of the hierarchical analyses suggest that the total CTQ scale adequately captures a broad dimension of childhood maltreatment. A 2-step measurement approach in the assessment of childhood trauma is recommended in which screening by a self-report questionnaire is followed by a (semi-)structured diagnostic interview.

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.