Eliana Tossani

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.

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.

Psychological Evaluation after Cardiac Transplantation: The Integration of Different Criteria

Background: The psychological evaluation of patients undergoing cardiac transplantation is currently based on DSM-IV criteria. An alternative diagnostic and conceptual framework has been proposed by an international group of psychosomatic investigators. The aim of this study was to compare these new criteria (Diagnostic Criteria for Psychosomatic Research, DCPR) with DSM-IV in a population where a high prevalence of psychological problems is expected (heart-transplanted patients). Method: 129 consecutive patients who underwent heart transplant surgery were assessed according to DSM-IV and DCPR criteria. Results: The results showed a higher number of diagnoses made using the DCPR than with the use of the DSM-IV. At least one DCPR diagnosis was found in 85 (66%) patients, whereas at least one DSM diagnosis was present in 23 (18%) patients. The number of DCPR diagnoses was almost the triple of DSM criteria. While patients who were given a DSM diagnosis frequently had additional DCPR diagnoses, many patients with DCPR criteria did not fulfill any DSM criteria. Four DCPR syndromes appeared to be particularly frequent: demoralization, type A behavior, irritable mood and alexithymia. Conclusions: The joint use of DSM and DCPR criteria was found to improve the identification of psychological factors which could result in a worsening of quality of life in heart-transplanted patients.

Psychosocial functioning during the treatment of major depressive disorder with fluoxetine

Background: Major depressive disorder (MDD) is associated with significant disability, having a profound impact on psychosocial functioning. Therefore, studying the impact of treatment on psychosocial functioning in MDD could help further improve the standard of care. Methods: Two hundred twenty-two MDD outpatients were treated openly with 20 mg fluoxetine for 8 weeks. The self-report version of the Social Adjustment Scale was administered at baseline and during the final visit. We then tested for the relationships between (1) self-report version of the Social Adjustment Scale scores at baseline and clinical response, (2) nonresponse, response and remission status and overall psychosocial adjustment at end point, (3) the number/severity of residual depressive symptoms and overall psychosocial adjustment at end point in responders, and (4) the time to onset of response and overall psychosocial adjustment at end point. Results: An earlier onset of clinical response predicted better overall psychosocial functioning at end point (P = 0.0440). Responders (n = 128) demonstrated better overall psychosocial adjustment at end point than nonresponders (P = 0.0003), while remitters (n = 64) demonstrated better overall psychosocial adjustment at end point than nonremitted responders (P = 0.0031). In fact, a greater number/severity of residual symptoms predicted poorer overall psychosocial adjustment at end point in responders (P = 0.0011). Psychosocial functioning at baseline did not predict response. Conclusions: While MDD patients appear equally likely to respond to treatment with fluoxetine, regardless of their level of functioning immediately before treatment, the above results stress the importance of achieving early symptom improvement then followed by full remission of depressive symptoms with respect to restoring psychosocial functioning in MDD.

The Concept of Mental Pain

inadequacy. When negative outcomes fall far below one’s standards of the ideal self and aspirations, and outcomes are attributed to the self, that person experiences mental pain. The basic emotion in mental pain is, thus, self-disappointment. Shneidman [5] defined psychache as an acute state of intense psychological pain associated with feelings of guilt, anguish, fear, panic, angst, loneliness and helplessness. The primary source of severe psychache ‘is frustrated psychological needs’ [6] . Psychache is the mental pain of being perturbed [7] . Perturbation refers to one’s inner turmoil, or being upset or mentally disturbed [7] . Bolger [8] defined emotional pain as a state of ‘feeling broken’ that involved the experience of being wounded, loss of self, disconnection, and critical awareness of one’s more negative attributes. Essential characteristics of emotional pain were described as a sense of loss or incompleteness of self and an awareness of one’s own role in the experience of emotional pain [8] . Orbach et al. [9, 10] have defined mental pain as ‘a wide range of subjective experiences characterized as a perception of negative changes in the self and its function that is accompanied by strong negative feelings’. Intense ‘unbearable’ mental (psychological) pain is defined as an emotionally based extremely aversive feeling which can Mental pain is no less real than other types of pain related to parts of the body, but does not seem to get adequate attention. A major problem is the lack of agreement about its distinctive features, conceptualization and operational definition. I will examine some suggested descriptions of mental pain, its association with psychiatric disorders and grief, its assessment and the implications that research in this field may entail.

Depression and renal disease.

Major depressive disorder (MDD) is a highly prevalent disease, frequently characterized by recurrent or chronic course, and by comorbidity with other medical illnesses. The lifetime prevalence of MDD ranges up to 17% in the general population, and it almost doubles in patients with diabetes (9–27%), stroke (22–50%), or cancer (18–39%). Moreover, MDD worsens the prognosis, quality of life, and treatment compliance of patients with comorbid medical illnesses. Similar to what is observed with other comorbid illnesses, MDD worsens the outcome of kidney disease patients by increasing both morbidity and mortality. Treatment of depressive symptoms in renal failure patients increases medication acceptability and therefore potentially improves the overall patient outcome. The issue of the safety of antidepressant treatment in subjects with renal failure is frequently counterbalanced by the risks associated with depression comorbidity, provided that antidepressants with a low volume of distribution and low protein binding are prescribed, and most important, at low initial doses. Screening for CYP isoenzyme interactions with current medications is also recommended before starting antidepressant treatment.

Prodromal stage of major depression

Aim:  The aim of this review was to survey the available literature on prodromal symptoms of unipolar major depression.

Distance between Patients’ Subjective Perceptions and Objectively Evaluated Disease Severity in Chronic Heart Failure

Background: Chronic heart failure (CHF) is a socially relevant condition carrying an adverse prognosis. Systematic analysis is needed of the relationship between quality of life (QoL) – what patients are most interested in – and objective parameters of CHF severity – which largely determines physicians’ care. Methods: We prospectively investigated QoL, as ascertained by the Minnesota Living with Heart Failure Questionnaire, alongside all the currently used objective clinical/instrumental (electrocardiographic, echocardiographic, hemodynamic and functional capacity) indicators of disease severity in 106 consecutive CHF patients. Results: Besides persistence of sinus rhythm (p = 0.007), the only objective parameters that correlated with QoL were NYHA class (p < 0.001) and distance covered during the six minutes walking test (p < 0.001) (two indications of patients’ ability to attend to their daily needs). Presence of left bundle branch block was associated with a worse QoL only in patients with CHF due to ischemic heart disease (p = 0.032). All the other clinical/instrumental parameters showed no relation with QoL (p > 0.150 in all cases). Conclusions: Objective indicators of disease severity, which largely determine physicians’ care, appear to have little bearing on QoL, suggesting that current treatment for CHF fails to satisfy patients’ perceived needs. The possibility of cost-effective nonpharmaceutical therapeutic protocols (e.g. psychological interventions) specifically designed to improve patients’ QoL deserves investigation as a much needed new approach to the management of CHF.

Agoraphobia is a disease: a tribute to Sir Martin Roth.

The evidence which has accumulated on the course of agoraphobia challenges the DSM view that phobic avoidance is secondary to panic attacks. In particular, a longitudinal study by Wittchen et al. indicates that agoraphobia, as a diagnostic category, is frequently independent of panic disorder and panic attacks, is unlikely to remit spontaneously and entails compromised quality of life. A staging system of agoraphobia is presented. Panic may ensue in the longitudinal development of agoraphobia, as well as of other anxiety disorders, and be conceptualized as a potential outcome in the course of anxiety, phobias and hypochondriasis as more than a specific disease entity. These recent research findings confirm the clinical observations and phenomenological research of Sir Martin Roth (1917–2006) and call for a reassessment of the concept of neurosis.

Personality characteristics and psychological distress associated with primary exercise dependence: An exploratory study

The aim of this study was to assess personality characteristics and psychological distress associated with primary exercise dependence (ExeDepI) in a mixed gender sample. A cross-sectional study was carried out with adult habitual physical exercisers. A total of 79 participants voluntarily completed a package of self-report questionnaires including the Exercise Dependence Questionnaire (EDQ), the Eating Disorder Inventory II (EDI-2), the Temperament and Character Inventory (TCI), the Attitude Toward Self scale (ATS), and the Symptom Questionnaire (SQ). Significant differences were found on the EDQ exercise for weight control subscale with regard to gender, as well as on the EDI-2 total score and five of its subscales, with higher scores for females compared to males. Participants reporting primary exercise dependence (N=32) were more likely to present with disordered eating patterns than controls (N=47). They also showed higher levels of harm avoidance and persistence on the TCI, but lower self-directness and less mature character. Furthermore, ExeDepI group scored higher on the ATS dysmorphophobia subscale, as well as on the anxiety and hostility subscales of the SQ compared to the control group. These findings provide support to the idea that primary exercise dependence can be considered as a clinical syndrome associated with certain personality characteristics and psychological symptoms that might be accurately assessed in clinical settings.