Chiara Rafanelli

Well-Being Therapy of Generalized Anxiety Disorder

Background: There is increasing awareness that the goal of treatment in generalized anxiety disorder (GAD) should not simply be a response, but restoration of normal function. The aim of this study was to apply a novel psychotherapeutic approach for increasing the level of remission in GAD. Methods: Twenty patients with DSM-IV GAD devoid of comorbid conditions were randomly assigned to 8 sessions of cognitive behavioral therapy (CBT) or the sequential administration of 4 sessions of CBT followed by other 4 sessions of well-being therapy (WBT). Assessment methods included the Anxiety and Depression Scales of Paykel’s Clinical Interview for Depression, Ryff’s Psychological Well-being Scales and Kellner’s Symptom Questionnaire. A one-year follow-up was undertaken. Results: Significant advantages of the CBT-WBT sequential combination over CBT only were observed with both observer and self-rated methods after treatment. Such gains were maintained at follow-up. Conclusions: These preliminary results suggest the feasibility and clinical advantages of adding WBT to the treatment of GAD. They lend support to a sequential use of treatment components for achieving a more sustained recovery.

Psychometric Theory Is an Obstacle to the Progress of Clinical Research

Psychometric theory is the basis for the development of assessment instruments in psychiatric research. However, the psychometric model appears to be largely inadequate in the clinical setting because of its lack of sensitivity to change and its quest for homogeneous components. Clinimetrics offers a viable alternative to psychometrics, both from a conceptual and a methodological viewpoint. Current diagnostic entities (DSM) are based on clinimetric principles, but their use is still influenced by psychometric models. Suggestions for switching gears in assessment research are offered.

The Relationship of Psychological Well-Being to Distress and Personality

Background: The concept of psychological well-being has been neglected for a long time in scientific literature. Over the last decades, however, many psychometric instruments have been developed to measure it. The aim of the present study was to analyze the concept of psychological well-being and its relationship to distress and personality traits. It is clinically and empirically important to establish where the measures of well-being are located in relation to symptomatology indices and personality traits. Methods: A sample of 450 subjects in the general population completed three self-rating scales for the assessment of symptomatology (Kellner’s Symptom Questionnaire), psychological well-being (Ryff’s Psychological Well-Being Scales, PWB), and personality traits (Cloninger’s Tridimensional Personality Questionnaire). The assessment was repeated after 1 month. Pearson’s coefficient was used to analyze PWB test-retest reliability and correlations between well-being, distress and personality indicators. Exploratory factor analysis was performed for both assessments. Results: Test-retest Pearson’s coefficients were satisfactory for all six PWB scales. Exploratory factor analyses showed a 4- or 5-factor structure, where well-being, distress and personality remained separated. PWB scales were negatively and significantly correlated with all symptom scales, but only with one personality dimension, TPQ Harm Avoidance. Mean-level differences by gender showed that in general women significantly presented with lower levels of well-being (except in Positive Relations) and higher levels of distress and personality disturbances. Conclusions: The results suggest that the relationship of well-being to distress and personality is complex. Psychological well-being could not be equated with the absence of symptomatology or with personality traits. PWB scales measure an attitude toward optimal functioning that is crucial for a comprehensive consideration of individuals in clinical settings.

Long-term outcome of panic disorder with agoraphobia treated by exposure

BACKGROUND There is a paucity of long-term outcome studies of panic disorder that exceed a 2-year follow-up. The aim of the study was to evaluate the long-term follow-up of patients with panic disorder with agoraphobia treated according to a standardized protocol. METHODS A consecutive series of 200 patients satisfying the DSM-IV criteria for panic disorder with agoraphobia was treated in an out-patient clinic with behavioural methods based on exposure homework. One hundred and thirty-six patients became panic free after 12 sessions of psychotherapy and 132 were available for follow-up. A 2- to 14-year (median = 8 years) follow-up was performed. Survival analysis was employed to characterize the clinical course of patients. RESULTS Thirty-one of the 132 patients (23%) had a relapse of panic disorder at some time during follow-up. The estimated cumulative percentage of patients remaining in remission was 93.1 after 2 years, 82.4 after 5 years, 78.8 after 7 years and 62.1 after 10 years. Such probabilities increased with younger age, and in the absence of a personality disorder, of high pre-treatment levels of depressed mood, of residual agoraphobic avoidance after exposure, and of concurrent use of benzodiazepines and antidepressant drugs. CONCLUSIONS The findings suggest that exposure treatment can provide lasting relief to the majority of patients with panic disorder and agoraphobia. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy.

Stressful Life Events, Depression and Demoralization as Risk Factors for Acute Coronary Heart Disease

Background: While the effect of psychological stress and depression on the course of heart disease is commonly recognized, the relationship between recent life events, major depression, depressive symptomatology and the onset of acute coronary heart disease (CHD) has been less considered. The aim of this study was to investigate the presence of stressful life events, major and minor depression, recurrent depression and demoralization in the year preceding the occurrence of a first acute myocardial infarction (AMI) and/or a first episode of instable angina and to compare stressful life events, also related with mood disorders, in patients and healthy controls. Methods: 97 consecutive patients with a first episode of CHD (91 with AMI and 6 with instable angina) and 97 healthy subjects matched for sociodemographic variables were included. All patients were interviewed with Paykel’s Interview for Recent Life Events, a semistructured interview for determining the psychiatric diagnosis of mood disorders (DSM-IV), a semistructured interview for demoralization (DCPR). Patients were assessed while on remission from the acute phase. The time period considered was the year preceding the first episode of CHD and the year before the interview for controls. Results: Patients with acute CHD reported significantly more life events than control subjects (p < 0.001). All categories of events (except entrance events) were significantly more frequent. 30% of patients were identified as suffering from a major depressive disorder; 9% of patients were suffering from minor depression, 20% from demoralization. Even though there was an overlap between major depression and demoralization (12%), 17% of patients with major depression were not classified as demoralized and 7% of patients with demoralization did not satisfy the criteria for major depression. Independently of mood disorders, patients had a higher (p < 0.001) mean number of life events than controls. With regard to life events, the same significant difference (p < 0.001) compared to controls applied to patients with and without mood disorders. Conclusions: Our findings emphasize, by means of reliable methodology, the relationship between life events and AMI. These data, together with those regarding traditional cardiac risk factors, may have clinical and prognostic implications to be verified in longitudinal studies.

Psychological Assessment in Cardiac Rehabilitation

Background: While there has been an upsurge of interest in the psychiatric correlates of myocardial infarction, little is known about the presence of psychological distress in the setting of cardiac rehabilitation. Methods: A consecutive series of 61 patients with recent myocardial infarction who participated in a cardiac rehabilitation program was evaluated by means of both observer-rated (DSM and DCPR) and self-rated (Psychosocial Index) methods. A follow-up of this patient population was undertaken (median = 2 years). Survival analysis was used to characterize the clinical course of patients. Results: Twenty percent of patients had a DSM-IV diagnosis (in half of the cases minor depression). An additional 30% of patients presented with a DCPR cluster, such as type A behavior and irritable mood. Only high levels of self-perceived stressful life circumstances and psychological distress approached statistical significance as a psychological risk factor for cardiovascular events after myocardial infarction. Conclusions: Psychological evaluation of patients undergoing cardiac rehabilitation needs to incorporate both clinical (DSM) and subclinical (DCPR) methods of classification. Type A behavior was present in about a quarter of patients and can be studied in specific subgroups of cardiovascular patients defined by DCPR.

Rating well‐being and distress

There is insufficient research on rating psychological well-being and distress in clinical populations. The aim of this study was to evaluate the differential characteristics of instruments assessing well-being and distress in 20 remitted patients with affective (mood and anxiety) disorders and 20 healthy control subjects matched for sociodemographic variables. Remitted patients displayed significantly higher levels of psychological distress—as measured by Paykels Clinical Interview for Depression (CID), Van Praags Scale for Personality Disturbances and Kellners Symptom Questionnaire (SQ)—and significantly less well-being—as measured by Ryffs Scales of Psychological Well-Being (PWB) and the SQ—than control subjects. The correlations between scales of psychological distress and well-being were found to be complex in both patients and controls. Psychotherapeutic treatment of residual symptomatology in patients disclosed a differential sensitivity of the scales to changes. The results thus suggest that well-being cannot be equated to lack of distress (as implicitly endorsed by current psychiatric paradigms), and the need for a multidimensional assessment in stress medicine. Copyright

Adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events: individual patient data meta-analysis

BACKGROUND The association between depression after myocardial infarction and increased risk of mortality and cardiac morbidity may be due to cardiac disease severity. AIMS To combine original data from studies on the association between post-infarction depression and prognosis into one database, and to investigate to what extent such depression predicts prognosis independently of disease severity. METHOD An individual patient data meta-analysis of studies was conducted using multilevel, multivariable Cox regression analyses. RESULTS Sixteen studies participated, creating a database of 10 175 post-infarction cases. Hazard ratios for post-infarction depression were 1.32 (95% CI 1.26-1.38, P<0.001) for all-cause mortality and 1.19 (95% CI 1.14-1.24, P<0.001) for cardiovascular events. Hazard ratios adjusted for disease severity were attenuated by 28% and 25% respectively. CONCLUSIONS The association between depression following myocardial infarction and prognosis is attenuated after adjustment for cardiac disease severity. Still, depression remains independently associated with prognosis, with a 22% increased risk of all-cause mortality and a 13% increased risk of cardiovascular events per standard deviation in depression z-score.

Psychological well-being and residual symptoms in remitted patients with panic disorder and agoraphobia

BACKGROUND Little is known about psychological well-being in remitted patients with panic disorder and agoraphobia and its interactions with residual symptoms. METHODS Thirty patients with panic disorder and agoraphobia who displayed a successful response to exposure therapy, and 30 control subject matched for sociodemographic variables, were administered both observer-rated and self-rated scales for assessing residual symptoms and well-being. RESULTS Patients had significantly more residual symptoms -- as assessed by the Clinical Interview for Depression (CID) and the Symptom Questionnaire (SQ) -- than controls. They also had significantly less environmental mastery, personal growth, purpose in life and self-acceptance -- as measured by the Psychological Well-being Scales (PWB) -- and less SQ physical well-being than controls. LIMITATION The findings apply to patients with panic disorders who had been treated by behavioral methods and may be different in drug-treated subjects. CONCLUSIONS The results indicate that successful reduction of symptomatology in panic disorder cannot be equated to a pervasive recovery (encompassing psychological well-being) and may pave the way for sequential therapeutic strategies of more enduring quality.

The clinical process in psychiatry: a clinimetric approach.

OBJECTIVE The aim of this review was to examine the clinical process in psychiatry, with special reference to clinimetrics, a domain concerned with the measurement of clinical phenomena that do not find room in customary taxonomy. DATA SOURCES A MEDLINE search from inception to August 2010 was performed for English-language articles using the keywords clinical judgment, clinimetric, staging, comorbidity, sequential treatment, and subclinical symptoms in relation to psychiatric illness. It was supplemented by a manual search of the literature. STUDY SELECTION Choice of assessment strategies was based on their established or potential incremental increase in clinical information compared to use of diagnostic criteria. DATA EXTRACTION Contributions were evaluated according to the principles of clinimetrics. RESULTS Several innovative assessment strategies were identified: the use of diagnostic transfer stations with repeated assessments instead of diagnostic endpoints, subtyping versus integration of different diagnostic categories, staging methods, and broadening of clinical information through macroanalysis and microanalysis. The most representative examples were selected. CONCLUSIONS Current assessment strategies in psychiatric research do not reflect the sophisticated thinking that underlies clinical decisions in practice. The clinimetric perspective provides an intellectual home for the reproduction and standardization of these clinical intuitions.