David A. Katerndahl

Predictors of development of adult psychopathology in female victims of childhood sexual abuse

The purpose of this study is to identify predictors of resilience and adult mental disorders in women with a history of childhood sexual abuse. This cross-sectional study was conducted in a family practice center using adult female (age 18–40) patients. Outcome measures assessed the prevalence of major depressive episode, panic disorder, agoraphobia, substance abuse, posttraumatic stress disorder, borderline personality disorder, bulimia, and suicidality. Seventy-six percent of the 90 women with sufficient data met criteria for at least one adult disorder. Mental health was related to high SES, lack of family alcohol abuse, lower frequency of first perpetrator abuse, and few perpetrators. Specifics of the abuse were associated with development of borderline personality disorder, substance abuse, major depressive episode, suicidality, bulimia, agoraphobia, and panic disorder. Maternal violence against the father, substance abuse within the household of origin, and maternal care and overprotection were also important. The specifics about the abuse and the family environment during childhood are important predictors of adult psychopathology.

Psychosocial Effects of Physical and Verbal Abuse in Postmenopausal Women

PURPOSE The purpose of this study was to examine the psychological effects of physical and verbal abuse in a cohort of older women. METHODS This observational cohort study was conducted at 40 clinical sites nationwide that are part of the Women’s Health Initiative (WHI) Observational Study. We surveyed 93,676 women aged 50 to 79 years using the mental health subscales and the combined mental component summary (MCS) score of the RAND Medical Outcomes Study 36-item instrument. RESULTS At baseline, women reporting exposure to physical abuse only, verbal abuse only, or both physical and verbal abuse had a greater number of depressive symptoms (1.6,1.6, and 3 more symptoms, respectively) and lower MCS scores (4.6, 5.4, and 8.1 lower scores, respectively) than women not reporting abuse. Compared with women who had no exposure to abuse, women had a greater increase in the number of depressive symptoms when they reported a 3-year incident exposure to physical abuse only (0.2; 95% confidence interval [CI], −0.21 to 0.60), verbal abuse only (0.18; 95% CI, 0.11 to 0.24), or both physical and verbal abuse (0.15; 95% CI, −0.05 to 0.36); and they had a decrease in MCS scores when they reported a 3-year incident exposure to physical abuse only (−1.12; 95% CI, −2.45 to 0.12), verbal abuse only (−0.55; 95% CI, −0.75 to −0.34), and both physical and verbal abuse (−0.44; 95% CI, −1.11 to −0.22) even after adjustment for sociodemographic characteristics. CONCLUSION Exposure to abuse in older, functionally independent women is associated with poorer mental health. The persistence of these findings suggests that clinicians need to consider abuse exposure in their older female patients who have depressive symptoms. Clinicians caring for older women should identify women at risk for physical and verbal abuse and intervene appropriately.

A Randomized Trial of the Effects of Remote Intercessory Prayer: Interactions with Personal Beliefs on Problem-Specific Outcomes and Functional Status

OBJECTIVES Investigate the relevance of interpersonal belief factors as modifiers of the effectiveness of intercessory prayer. DESIGN Randomized clinical trial. SETTING/LOCATION Community-dwelling adults recruited from seven local church groups. SUBJECTS Eighty-six (86) male and female participants 18-88 years of age were randomly assigned to either treatment (n = 45) or control groups (n = 41). INTERVENTIONS Several volunteers committed to daily prayer for participants in the intervention group. Intercessory prayer commenced for 1 month and were directed toward a life concern or problem disclosed by the participant at baseline. Participants were unaware of being prayed for. OUTCOMES MEASURES Degree to which their problem had been resolved and the current level of concern they had about a specific life problem they described at baseline. Four component scores from the Medical Outcomes Study SF-20 were also used. RESULTS No direct intervention effect on the primary outcomes was found. A marginally significant reduction in the amount of pain was observed in the intervention group compared to controls. The amount of concern for baseline problems at follow-up was significantly lower in the intervention group when stratified by subjects baseline degree of belief that their problem could be resolved. Prayer intervention appeared to effectively reduce the subjects level of concern only if the subject initially believed that the problem could be resolved. Those in the intervention group who did not believe in a possible resolution to their problem did not differ from controls. Better physical functioning was observed in the intervention group among those with a higher belief in prayer and surprisingly, better mental health scores were observed in the control group with lower belief in prayer scores. CONCLUSIONS The results of the current study underscore the role of interpersonal belief in prayer efficacy and are consistent with the literature showing the relevance of belief in health and well-being in general. The relevance of interpersonal belief factors of the participants is recommended in future investigations.

Systems and Complexity Thinking in the General Practice Literature: An Integrative, Historical Narrative Review

PURPOSE Over the past 7 decades, theories in the systems and complexity sciences have had a major influence on academic thinking and research. We assessed the impact of complexity science on general practice/family medicine. METHODS We performed a historical integrative review using the following systematic search strategy: medical subject heading [humans] combined in turn with the terms complex adaptive systems, nonlinear dynamics, systems biology, and systems theory, limited to general practice/family medicine and published before December 2010. A total of 16,242 articles were retrieved, of which 49 were published in general practice/family medicine journals. Hand searches and snowballing retrieved another 35. After a full-text review, we included 56 articles dealing specifically with systems sciences and general/family practice. RESULTS General practice/family medicine engaged with the emerging systems and complexity theories in 4 stages. Before 1995, articles tended to explore common phenomenologic general practice/family medicine experiences. Between 1995 and 2000, articles described the complex adaptive nature of this discipline. Those published between 2000 and 2005 focused on describing the system dynamics of medical practice. After 2005, articles increasingly applied the breadth of complex science theories to health care, health care reform, and the future of medicine. CONCLUSIONS This historical review describes the development of general practice/family medicine in relation to complex adaptive systems theories, and shows how systems sciences more accurately reflect the discipline’s philosophy and identity. Analysis suggests that general practice/family medicine first embraced systems theories through conscious reorganization of its boundaries and scope, before applying empirical tools. Future research should concentrate on applying nonlinear dynamics and empirical modeling to patient care, and to organizing and developing local practices, engaging in community development, and influencing health care reform.

Perceived Complexity of Care, Perceived Autonomy, and Career Satisfaction Among Primary Care Physicians

Background: The purpose of this study was to examine relationships of both perceived autonomy and perceived complexity of care with career satisfaction. Methods: This secondary analysis used 3 consecutive surveys of family physicians, internists, and pediatricians from the Community Tracking Survey. Two-way analysis of variance assessed interaction effects of perceived complexity of care and perceived autonomy on satisfaction. Logistic regression analysis identified physician characteristics, practice characteristics, practice improvement strategies, perceived complexity, and perceived autonomy that accounted for variance in career satisfaction among physicians. Results: Although 24% to 27% of physicians felt perceived complexity of care expected was greater than it should be, 83% to 86% felt free to make clinical decisions. Approximately 80% of physicians were satisfied with their careers. Differences in probability of career satisfaction were highly significant (P < .001) for both perceived complexity of care and perceived autonomy as well as their interaction. A multiphysician practice; the ability to obtain high quality ancillary services (such as physical therapy, home health care, and nutritional counseling); managed care revenue, lower levels of perceived complexity of expected care; and perceived autonomy were consistently associated with satisfaction. Conclusion: Higher perceived autonomy and lower perceived patient complexity as higher than desirable were associated with high career satisfaction among primary care physicians.

A Method for Estimating Relative Complexity of Ambulatory Care

PURPOSE We wanted to demonstrate a method for calculating the relative complexity of ambulatory clinical encounters. METHODS Measures of complexity should reflect the complexity of the typical encounter and across encounters. If inputs represent the information transferred from the patient to the physician, then inputs include history, physical examination, testing, diagnoses, and patient demographics. Outputs include medications prescribed and other therapies used, including education and counseling, procedures performed, and disposition. The complexity of each input/output is defined as the mean input/output quantity per clinical encounter weighted by its inter-encounter diversity (range of possibilities used) and variability (visit-to-visit change). In complex systems, as the information in the input increases linearly, the complexity of the system increases exponentially. To assess the impact of the complexity of the encounter on the physician, we adjusted the estimated complexity by the duration-of-visit. RESULTS Using the 2000 NAMCS database, we calculated input and output complexities for 3 specialties. Construct validity was affirmed by comparing the relative rankings of complexity against relative rankings using other complexity-related measures. Although total relative complexity was similar for family medicine (44.04 ± 0.0024 SE) and cardiology (42.78 ± 0.0004 standard error [SE]), when adjusted for duration-of-visit, family medicine had a greater complexity density per hour (167.33 ± 0.0095 SE) than either cardiology (125.4 ± 0.0117 SE) or psychiatry (31.21 ± 0.0027 SE). CONCLUSIONS This method estimates complexity based on the amount of care provided weighted by its diversity and variability. Such estimates could have broad use for interphysician comparisons as well as longitudinal applications.

Impact of Spiritual Symptoms and Their Interactions on Health Services and Life Satisfaction

PURPOSE Recent work suggests that the biopsychosocial model should be expanded to include the spiritual dimension as well. The purpose of this study was to assess the independent effects of spiritual symptoms and their interactions with biopsychosocial symptoms on health care utilization, extreme use of services, and life satisfaction among primary care patients. METHODS Three hundred fifty-three adult waiting room patients at 2 primary care clinics completed the Biopsychosociospiritual Inventory (BioPSSI) as well as measures of life satisfaction and health care use. Hierarchical logistic regression analysis was performed with each outcome to determine whether adding spiritual symptoms and their interaction terms better accounted for outcomes than demographics, functional status, and chronic medical problems alone. RESULTS Spiritual symptoms (alone or in interaction) were associated with 7 of the 10 outcomes and were particularly important to extreme use of health care services and life satisfaction. Among best-fit models, spiritual symptoms alone were significantly associated with any mental health use (β =0.694, P ≤ .05), fair-poor health status (β =0.837, P ≤ .05), and life lacking meaning (β =1.214, P ≤ .001). CONCLUSIONS This study has shown the relevance of spiritual symptoms and their interactions to understanding health outcomes. Extreme utilization outcomes were related to the number of chronic problems, as well as to the social-spiritual interaction. Satisfaction outcomes were associated with physical and spiritual symptoms. These findings may have important implications for providing comprehensive, outcome-based care, as well as for modeling of research findings.

Panic and prolapse: Meta-analysis

Studies concerning the association of panic disorder and mitral valve prolapse have produced mixed results. Meta-analysis was used to quantitatively review the literature and explain conflicting results. Only 19 published and two unpublished studies have documented both panic and mitral valve prolapse in addition to including a control group, and were therefore included. The strength of association between panic disorder and mitral valve prolapse was measured as the odds ratio and study variables were included in the analysis. The overall weighted relative risk was 2.3 (confidence interval, 1.6 to 3.5). Important study variables were often not addressed in the literature and stepwise multiple regression found that auscultatory criteria, control group diagnosis, and sample size predicted relative risk (F=11.34, p<.001). p-Values differed with publication status (t=2.32, p=.033). Although the quality of literature is uneven, there appears to be a significant association between panic disorder and mitral valve prolapse. However, the suggestion of publication bias indicates that the published literature may present a biased view.

Chemical intolerance in primary care settings: prevalence, comorbidity, and outcomes.

PURPOSE This study extends previous community-based studies on the prevalence and clinical characteristics of chemical intolerance in a sample of primary care clinic patients. We evaluated comorbid medical and psychiatric disorders, functional status, and rates of health care use. METHODS A total of 400 patients were recruited from 2 family medicine clinic waiting rooms in San Antonio, Texas. Patients completed the validated Quick Environmental Exposure and Sensitivity Inventory (QEESI) to assess chemical intolerance; the Primary Care Evaluation of Mental Disorders (PRIME-MD) screen for possible psychiatric disorders; the Dartmouth–Northern New England Primary Care Cooperative Information Project (Dartmouth COOP) charts for functional status; and the Healthcare Utilization Questionnaire. RESULTS Overall, 20.3% of the sample met criteria for chemical intolerance. The chemically intolerant group reported significantly higher rates of comorbid allergies and more often met screening criteria for possible major depressive disorder, panic disorder, generalized anxiety disorder, and alcohol abuse disorder, as well as somatization disorder. The total number of possible mental disorders was correlated with chemical intolerance scores (P <.001). Controlling for demographics, patients with chemical intolerance were significantly more likely to have poorer functional status, with trends toward increased medical service use when compared with non–chemically intolerant patients. After controlling for comorbid psychiatric conditions, the groups differed significantly only regarding limitations of social activities. CONCLUSIONS Chemical intolerance occurs in 1 of 5 primary care patients yet is rarely diagnosed by busy practitioners. Psychiatric comorbidities contribute to functional limitations and increased health care use. Chemical intolerance offers an etiologic explanation. Symptoms may resolve or improve with the avoidance of salient chemical, dietary (including caffeine and alcohol), and drug triggers. Given greater medication intolerances in chemical intolerance, primary care clinicians could use the QEESI to identify patients for appropriate triage to comprehensive nonpharmacologic care.

Factors affecting the threshold for seeking care: the Panic Attack Care-Seeking Threshold (PACT) Study.

Background: This study was conducted to explore the phenomenon of seeking medical care for panic attacks and to identify factors associated with seeking care. Methods: A community sample of adults was screened using the Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition. Subjects who had experienced panic attacks participated in a structured interview concerning their health care access and utilization, panic characteristics, comorbidity, illness attitudes and perceptions, and family characteristics. Results: Forty-one percent of the subjects had not sought medical care for their panic attacks. Having to get someone to drive (RR [relative risk] = 1.8; P = 0.0026), inability to work because of panic (RR = 1.6; P = 0.0054), and a high treatment experience score on the Illness Attitude Scales (RR = 1.5; P = 0.034) independently predicted seeking care. Seeking support was also significantly associated with seeking care (t = –4.05; P = 0.0001). Care seekers tended to have more severe symptoms, stronger symptom perceptions, and more bodily preoccupation and to abuse drugs more frequently. Seeking care was not influenced by sex, race or ethnicity, stress, psychiatric comorbidity, family function, social support, or access to health care. Conclusions: Nearly one-half of persons with panic attacks do not seek care for their attacks. Those who seek care differ from those who do not in ways that have important implications for the understanding of this illness.