Åsa Lilja

Pain, coping, emotional state and physical function in patients with chronic radicular neck pain. A comparison between patients treated with surgery, physiotherapy or neck collar : a blinded, prospective randomized study

Purpose: To describe and explore the relationships between pain, emotional state and coping strategies in patients with chronic radicular neck pain before and after surgery or conservative treatments. Methods: We randomize 81 conseutive patients with cervical radicular pain and nerve root compression, verified by MRI, to either surgical decompression with fusion or physiotherapy or neck collar. Emotional state was both measured with Mood Adjective Check List, Hospital Anxiety and Depression Scale and with a Coping Strategies Questionnaire. Pain was measured with VAS and function with Disability Index Rating. Measurements were made before treatment, and follow ups after 3 and 12 months post treatment. Results: We found generally a low emotional state with anxiety, depression and sleep-disturbances not only connected to pain. Pain improved faster in the surgery group but after one year no differences were seen. Surgery and physiotherapy improved function with heavy work compared to collar after 3 months. Many patients used active coping before treatment, but after treatment more passive coping strategies were found. Conclusion: We recommend a multidisciplinary rehabilitation with cognitive behavioural therapy and psychological interventions.PURPOSE To describe and explore the relationships between pain, emotional state and coping strategies in patients with chronic radicular neck pain before and after surgery or conservative treatments. METHODS We randomize 81 conseutive patients with cervical radicular pain and nerve root compression, verified by MRI, to either surgical decompression with fusion or physiotherapy or neck collar. Emotional state was both measured with Mood Adjective Check List. Hospital Anxiety and Depression Scale and with a Coping Strategies Questionnaire. Pain was measured with VAS and function with Disability Index Rating. Measurements were made before treatment, and follow ups after 3 and 12 months post treatment. RESULTS We found generally a low emotional state with anxiety, depression and sleep-disturbances not only connected to pain. Pain improved faster in the surgery group but after one year no differences were seen. Surgery and physiotherapy improved function with heavy work compared to collar after 3 months. Many patients used active coping before treatment, but after treatment more passive coping strategies were found. CONCLUSION We recommend a multidisciplinary rehabilitation with cognitive behavioural therapy and psychological interventions.

Mindfulness group therapy in primary care patients with depression, anxiety and stress and adjustment disorders: randomised controlled trial

BACKGROUND Individual-based cognitive-behavioural therapy (CBT) is in short supply and expensive. AIMS The aim of this randomised controlled trial (RCT) was to compare mindfulness-based group therapy with treatment as usual (primarily individual-based CBT) in primary care patients with depressive, anxiety or stress and adjustment disorders. METHOD This 8-week RCT (ClinicalTrials.gov ID: NCT01476371) was conducted during spring 2012 at 16 general practices in Southern Sweden. Eligible patients (aged 20-64 years) scored ≥10 on the Patient Health Questionnaire-9, ≥7 on the Hospital Anxiety and Depression Scale or 13-34 on the Montgomery-Åsberg Depression Rating Scale (self-rated version). The power calculations were based on non-inferiority. In total, 215 patients were randomised. Ordinal mixed models were used for the analysis. RESULTS For all scales and in both groups, the scores decreased significantly. There were no significant differences between the mindfulness and control groups. CONCLUSIONS Mindfulness-based group therapy was non-inferior to treatment as usual for patients with depressive, anxiety or stress and adjustment disorders.

Increased monoaminergic neurotransmission improves compliance with physical activity recommendations in depressed patients with fatigue.

Clinical studies have shown that moderately intense physical activity effectively treats various types of depression. Beneficial effects have been reported in the acute phase of the disease as well as in a long-term perspective. In addition, epidemiological studies have shown that inactivity increases the risk of depression and that exercise prevents relapse. Depressed patients are often prescribed antidepressants, with or without psychotherapy. Some studies have, however, suggested that the most frequently used antidepressants, selective serotonin reuptake inhibitors (SSRIs), contribute to fatigue, which is a common residual symptom associated with depression and the target of the proposed study. Profound fatigue may in turn decrease the ability and motivation to perform the beneficial physical activity, e.g. via executive dysfunction. Fatigue and impaired executive function are commonly linked to disturbed cerebral dopaminergic and noradrenergic neurotransmission. This kind of dysfunction is hard to overcome, even when the major symptoms of depression are alleviated. Interestingly, physical activity has been suggested to improve the dopamine and norepinephrine neurotransmission. Furthermore, the favorable effects may be reciprocal; improved dopamine and norepinephrine transmission in the brain may hypothetically increase the ability and motivation to exercise, since some parts of the brain (e.g. the prefrontal cortex, striatum and cerebellum) that control movement and initiative receive dopaminergic and noradrenergic projections. Based on these findings and assumptions, our hypothesis is that increased dopaminergic and noradrenergic neurotransmission, via intake of a dopamine- and norepinephrine-enhancing agent, improves the compliance with prescribed physical activity in patients with depression and residual fatigue. We also believe that the increased physical activity can prevent relapse into depression, even after interruption of medication. Since increased physical activity also has been shown to improve executive cognitive function, we suggest that executive function should be examined as a secondary outcome together with other possibly related variables such as quality of life, sick leave and BMI.

Microprocesses in Perception and Personality

This paper utilizes an ontogenetically validated personality test, the Meta-Contrast Technique (MCT). The instrument focuses on the microdevelopment of perception (percept genesis) reflecting the process of individual adaptation to and construction of reality. Empirical evidence for the adequacy of the MCT paradigm in neuropsychological personality research is presented. In all, 45 patients were tested; thirty-three patients with various forms of supra-tentorial brain tumors were examined and compared with a group of 12 cerebrovascular disease (CVD) patients. Without the examiners knowledge of degree of tumor malignancy, the MCT results allowed differentiation among tumors of various histological types. Uninformed of the final diagnosis, patients with highly malignant gliomas showed panic-related anxiety and schizoid-like regressions, in contrast both to patients with low and nonmalignant brain tumors and to the group of CVD patients.

Psychological profile related to malignant tumours of different histopathology

In a previous preoperative study of patients with gliomas, we made the original observation that patients with high grade as opposed to those with low‐grade gliomas have a psychological profile marked by extreme emotional reactivity. In this postoperative study of the psychological profiles of patients with breast cancer, the main funding was unexpectedly analogous with the findings in the brain tumour study. The patients with poorly differentiated ductal carcinomas showed a specific and, compared to the patients with well differentiated carcinomas, outstanding psychological profile marked by extreme emotional reactivity as well as by genuine creativity. Some of the present patients with well differentiated carcinomas showed personality profiles marked by compulsive inhibition, also described earlier in the literature of patients with breast cancer. The psychobiological relations between emotional reactivity and aggressiveness of tumour growth are discussed.

Psychological profile in patients with Stages I and II breast cancer: associations of psychological profile with tumor biological prognosticators.

We have earlier shown that breast cancer patients with moderately or well differentiated tumors seem to be able to inhibit stress evoked from anger in a successful manner, while those with poorer prognosis do not. We now report a study with an enlarged group of patients, investigating associations between tumor biological factors and psychological profile. 129 patients with Stages I and II breast cancer undergoing adjuvant radiation therapy were interviewed and tested with three projective personality tests assessing attitude to aggression and coping with stress and anxiety. Creative functioning was also tested. Patients with Stage I (smaller) tumors reported a “fighting spirit” attitude toward the disease, but they also showed depressive reaction patterns. Moreover, if the patient could successfully avoid or inhibit the stress evoked from perceiving an aggressive motif in the picture shown in the aggression test, the tumor biological situation was better. Patients who did not inhibit stress reactions on the aggression test and also on the anxiety test had a poorer tumor biological situation. Surprisingly, low speed of tumor cell proliferation (DNA S-phase fraction) correlared with high scores on the creativity test. Successful denial or inhibition of stress evoked by aggression combined with a creative, flexible attitude was associated with a better tumor biological situation.

Attitude towards aggression and creative functioning in patients with breast cancer.

Three projective personality tests were used to assess attitude to aggression (The Identification Test), anxiety and defenses (The Meta-Contrast Technique) and creative functioning (The Creative Functioning Test) in 70 patients with breast cancer. Discriminant analyses were applied pro primo to characterize psychologically patients with a better prognosis and patients with a poorer prognosis. A second aim was to characterize psychologically older (postmenopausal) and younger (premenopausal) women. Generally, high scores on the Identification Test indicated maladaptive attitudes towards aggression among all the patients. Patients with a poorer prognosis showed responses that in healthy subjects indicate acknowledgement of aggressive impulses, perhaps suggesting lack of “defenses” against such impulses among those patients. Another way to describe it would be that patients with a better prognosis seem to have (normally nonadaptive) “defenses” against aggressive impulses while those with poorer prognosis have not. Surprisingly, the patients with a better prognosis (but not those with a poorer prognosis) gave responses classified as depression in the Meta-Contrast Technique. Typical of premenopausal patients were responses classified as anxiety as well as reaction formation on the Identification Test. Responses classified as adaptive defenses (isolation) were seen in the Meta-Contrast Technique. A surprising finding was that many of these patients were characterized by high scores on the creativity test. These original statistically significant findings of attitudes towards aggression and creative functioning in breast cancer patients are discussed in relation to the underlying nature of aggression and creativity.

Creativity and breast cancer

ABSTRACT: A study of the relation between creativity and prognosis was performed in a group of 59 premenopausal women with breast cancer. For the majority of these patients it could be shown that high creativity, as measured by the Creative Functioning Test, correlated with a favorable prognosis as evidenced by tumor size, lymph node metastasis, and rate of tumor growth. Because high creativity has been shown to correlate with openness to aggressive impulses, we concluded that suppression of aggression could be a negative factor in the development of cancer growth. However, as in a previous study of 70 pre- and postmenopausal women in a small group of patients with comedo carcinoma, these relations were reversed. Low creativity was now a positive predictor. At the same time, the test results in these people suggested they could not handle their aggression in a constructive manner. Here, creative openness to primitive impulses entailed danger to the stability of the self. To predict cancer growth, one must qualify creativity. A general conclusion would be that there is a covariation between personality profile and type of breast cancer.

Aggression: destructive and constructive aspects.

The concept of aggression was long relegated to the shadow of the libido in psychoanalytic theory, placed among the negative affects by some theoreticians, denied the role of a primary drive among leading writers in clinical psychology, brought to the fore as an adaptive force in ethology, and proved to be a decisive factor in the development of psychosomatic ailments. The second part of the paper reviews experiments using projective techniques, showing that highly creative subjects as opposed to ones low in creativity seem inclined to accept their aggressive impulses. A total denial of these impulses has been typical of women with breast cancer.

White matter lesions and brain atrophy in systemic lupus erythematosus patients: correlation to cognitive dysfunction in a cohort of systemic lupus erythematosus patients using different definition models for neuropsychiatric systemic lupus erythematosus

Aim The aim of this study was to evaluate the extent of white matter lesions, atrophy of the hippocampus and corpus callosum, and their correlation with cognitive dysfunction (CD), in patients diagnosed with systemic lupus erythematosus (SLE). Methods Seventy SLE patients and 25 healthy individuals (HIs) were included in the study. To evaluate the different SLE and neuropsychiatric SLE (NPSLE) definition schemes, patients were grouped both according to the American College of Rheumatology (ACR) definition, as well as the more stringent ACR-Systemic Lupus International Collaborating Clinics definition. Patients and HIs underwent a 3 Tesla brain MRI and a standardized neuropsychological test. MRI data were evaluated for number and volume of white matter lesions and atrophy of the hippocampus and corpus callosum. Differences between groups and subgroups were evaluated for significance. Number and volume of white matter lesions and atrophy of the hippocampus and corpus callosum were correlated to cognitive dysfunction. Results The total volume of white matter lesions was significantly larger in SLE patients compared to HIs (p = 0.004). However, no significant differences were seen between the different SLE subgroups. Atrophy of the bilateral hippocampus was significantly more pronounced in patients with NPSLE compared to those with non-NPSLE (right: p = 0.010; left p = 0.023). Significant negative correlations between cognitive test scores on verbal memory and number and volume of white matter lesions were present. Conclusion SLE patients have a significantly larger volume of white matter lesions on MRI compared to HIs and the degree of white matter lesion volume correlates to cognitive dysfunction, specifically to verbal memory. No significant differences in the number or volume of white matter lesions were identified between subgroups of SLE patients regardless of the definition model used.