Hoyle Leigh

Repressive/defensive coping, endogenous opioids and health: how a life so perfect can make you sick

Hyperactivity of endogenous opioid systems has been postulated to mediate the associations between defensive/repressive coping styles, enhanced stress responsivity, and reduced immunocompetence. Study 1 examined whether repressive/defensive coping would be associated with greater sensitivity to opioid antagonism. Judgments of the painfulness of ascending series of electrocutaneous stimulation applied to the forearm were determined before and after the administration of naloxone and placebo in 38 men and 42 women. All subjects were healthy with a mean age of 32.9 years. Naloxone (10 mg i.v.) and placebo were administered in double-blind fashion and counterbalanced. Subjects were classified as High- and Low-defensive and repressive copers on the basis of scores on the Marlowe-Crowne Social Desirability Scale and the Balanced Inventory of Desirable Responding, respectively. High Self-Deception was associated with naloxone-induced hyperalgesia, whereas no effects of naloxone on pain ratings were observed in low-Self-Deceptive subjects. In Study 2, resting plasma beta-endorphin levels were found to be positively correlated with defensiveness in men (n = 26), but not women (n = 44). Study 3 examined 82 healthy subjects (mean age = 28.7 years). Beta-endorphin/defensiveness correlations were found to be greater following, compared to prior to, electrical nociceptive stimulation in men (n = 49), but unrelated in women (n = 33). These findings are consistent with the hypothesized endorphinergic dysregulation associated with repressive/defensive coping styles and are discussed in terms of the immuno-regulatory implications of such a dysregulation.

Denial and helplessness in cancer patients undergoing radiation therapy: Sex differences and implications for prognosis

One hundred consecutive outpatients undergoing radiation therapy were prospectively studied using the Locus of Control Inventory designed by Rotter and a questionnaire covering various aspects of diagnosis, implications of disease, and details of therapy. The Locus of Control Inventory, which measures a persons belief that lifes important events are controlled by personal effort (internality) as opposed to factors outside of ones control (externality), revealed a significant difference between men and women in this study. Although women were similar to the general healthy population, men expressed a greater sense of control as their radiation therapy progressed. Men were also more likely to characterize their illness as not very serious and to deny knowledge of their correct diagnoses or details of their treatment. With survival determined at two years following the study, it was found that living and deceased women had initially rated the seriousness of their illnesses appropriately, while deceased men had rated their illnesses as significantly less serious than women or surviving men. It is concluded that sexual differences in coping mechanisms may be accentuated by malignancy and men may actively deny their diagnosis and its implications. This amount of denial and sense of personal control in the face of a potentially fatal illness may indicate a need for more supportive clinical intervention for the radiation therapy patient.

Behavioral and physiologic effects of littermate removal on the remaining single pup and mother during the pre-weaning period in rats.

&NA; Wistar rat litters were reduced to a single pup shortly after birth. Prior to 10 days of age, this procedure generally resulted in inanition and death of the remaining pup, but by the 12th postnatal day 100% survived. Mothers increased the proportion of time spent with ‘singletons’ to 70‐100% and showed more licking of the singleton and maintenance of a nursing posture than controls. Single pups showed increased stimulation of the mother, self‐grooming and locomotion; they maintained weight gains indistinguishable from controls and developed cardiac acceleratory responses significantly greater than controls. We hypothesize that, with only a single pup present, the rat mother may not be stimulated to develop the normal changes in maternal behavior compatible with the growing age of her pup, resulting in altered development of her infant.

The patient evaluation grid ☆: A systematic approach to comprehensive care

A comprehensive approach to patients requires a systemic method that complements the clinical approach to disease. The method described here utilizes a patient evaluation grid that takes into account the biological, personal, and environmental dimensions of the patient and the current, recent, and background contexts of illness. It allows the clinician to anticipate problems relating to patient care and to assign priorities to management plans formulated in the three dimensions. It may also facilitate further research into the interrelationships among the multiple determinants of illness. This approach may help to bridge the gap between psychiatry and medicine by providing an integrated conceptual framework of organizing information.

DSM III and consultation-liaison psychiatry: Toward a comprehensive medical model of the patient

The descriptive and multiaxial approaches in DSM III encourage comprehensive conceptualization of the patient. The use of explicit criteria for diagnosing syndromes facilitates communication between psychiatry and general medicine. The DSM III category Psychological Factors Affecting Physical Condition should be further elaborated into (a) Psychiatric Factors Affecting Physical Condition, and (b) Physical Condition Affecting Psychiatric Disorder. In addition, the phase of the illness these factors affect should be specified, i.e., the precipitation, course, and recovery. Somatoform Disorder should not be a diagnosis of exclusion, and the diagnostic criteria should clearly specify that conversion symptoms may be superimposed on a pre-existing physical disorder. The DSM III axes are not coherent: they include diagnostic categories, statements concerning possible relationships, and factors that might affect outcome. We propose an alternative to the DSM III Axes based on the Patient Evaluation Grid (PEG), a system comprised of four axes, including Biological Dimension, Personal Dimension, Environmental Dimension, and Assessment of Interaction Among Dimensions. Developing a comprehensive diagnostic model for both medical and psychiatric patients that can be shared by all physicians may be an important function of the liaison psychiatrist.

Psychological Predictors of Survival in Cancer Patients Undergoing Radiation Therapy

In a prospective study to identify psychological factors affecting survival in cancer patients receiving radiation therapy, 101 consecutive patients were evaluated for anxiety, depression, and perception of the seriousness of the condition. In 3 years, the survivors were compared to the nonsurvivors. The survivors had significantly higher mean trait anxiety (p less than 0.05) than the nonsurvivors. State anxiety and depression scores also tended to be higher in the survivors (p less than 0.01). Self-assessment of the seriousness of their disease did not differentiate the two groups. The nonsurvivors had significantly more pain (p less than 0.05). Within the nonsurvivor group, survival time was negatively correlated with state anxiety (p less than 0.01), trait anxiety (p less than 0.02), and depression (p less than 0.01). In the nonsurvivors, women rated their condition to be significantly more serious than men (p less than 0.01). Female nonsurvivors tended to rate their condition to be more serious than female survivors (p less than 0.1), while male nonsurvivors rated their condition to be significantly less serious than male survivors (p less than 0.01). Only among female nonsurvivors did the seriousness rating correlate significantly with anxiety (p less than 0.01). The sex differences confirm our previous finding that men may tend to cope with cancer with more massive denial than women. We hypothesize that patients with higher anxiety and depression in the nonsurvivor group had a massive defensive failure, while those who had high anxiety levels in the survivor group had been more realistic about their disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Telepsychiatry appointments in a continuing care setting: kept, cancelled and no-shows

We reviewed the appointment data for a psychiatry service in California that provided consultations and also therapy through telepsychiatry. Over an 18-month period, there were 7523 telepsychiatry appointments and 115,148 conventional (face-to-face) appointments. A higher proportion of the telepsychiatry appointments was kept (92% telepsychiatry vs. 87% non-telepsychiatry). Also, telepsychiatry appointments were significantly less likely to be cancelled by patients (3.5% vs. 4.8%) and significantly less likely to be no-shows (4.2% vs. 7.8%). These findings were similar in three of the four counties where the service was delivered. However, one county was different, and further examination suggested that the morale of the staff and patients may have contributed to the unenthusiastic acceptance of telepsychiatry. We conclude that telepsychiatry can be used effectively in continuing care settings as well as in evaluation settings, and that staff and patient morale are important factors in successful telepsychiatry.

Handbook of consultation-liaison psychiatry

Preface.- Part I: Nature and Evolution of CL Psychiatry.- Consultation-Liaison Psychiatry and Psychosomatic Medicine.- The Functions of CL Psychiatry.- The Why and How of Psychiatric Consultation.- Evidence Based Literature Evaluation in Consultation-Liaison Psychiatry.- Common Reasons for Consultation and their Management.- Part II: Psychiatric Syndromes in Consultation-Liaison Psychiatry.- Basic Foundations of Diagnosis, Psychiatric Diagnosis, and Final Common Pathway Syndromes.- Delirium, Dementia, Alcohol Intoxication and Withdrawal Syndromes.- Anxiety and Anxiety Syndromes, Acute Stress & PTSD.- Depression, Mania, and Mood Syndromes.- Psychosis.- Chronic Pain.- Substance Use Problems.- Psychological Factors Affecting Medical Conditions, Somatoform Disorders, Conversion, Dissociation, and Factitious Syndromes.- Somatization, Hypochondriasis, and Somatization Disorder.- Patients Personality, Personality Types and Traits, and Disorders.- Part III: Special Patients and Settings in Consultation-Liaison Psychiatry.- The Acutely Ill Patient and ICU Setting.- The Chronic Patient/Palliative Care Settings/The Dying Patient.- Consultation-liaison Psychiatry in the Outpatient Setting.- The Kidney Impaired Patient.- The Immune-Compromised Patients- HIV and Organ Transplantation.- The Liver Impaired Patient.- The Cross-Cultural Patient: Cultural Aspects of Consultation-Liaison Psychiatry.- Obstetrics and Gynecology Patients: Menstrual Cycle, Pregnancy and Postpartum Related Psychiatric Disorders.- Children and Adolescents.- The Geriatric Patient.- The Emergency Department Setting.- Part IV: Special Techniques in Consultation-Liaison Psychiatry.- Interviewing in Consultation-Liaison Psychiatry.- Systems Understanding and Intervention, Ethical Issues.- Special Procedures: Intravenous Sedative Interviews, Hoover Test, Hypnosis.

The Clinical Applications of the Biopsychosocial Model

In attempting to teach the biopsychosocial model (1–3) to medical students and house staff, I found that few would disagree with the basic concepts, but, for most, the model remained at the level of a homily psychiatrists were wont to give to nonpsychiatric colleagues about the importance of the psyche. While most students recognized that psychological factors were, indeed, important in the management of their patients, such as their personality styles and patterns of psychological defense, few were convinced of the role of the psychological factors in the etiology and pathogenesis of most medical disorders. Another problem with the traditional biopsychosocial model was that the open-ended interacting bio-psychosocial model did not render itself easily to a crisp medical case presentation format -- i.e., chief complaint, present illness, past history, etc.

The current status of placebo in hospital practice

Despite a voluminous literature on the topic of placebo, there has been little documentation of either actual clinical practice of prescribing placebo or the attitudes that surround it. Through a questionnaire survey of all head nurses of clinical units in one health services area of Connecticut, data were obtained on current practices regarding placebo use in the natural hospital setting. Multiple reasons for placebo use in the natural hospital setting. Multiple reasons for placebo use were given, and it was noted that patients receiving placebo tended to be viewed in certain ways. The effectiveness of placebo in symptom relief was reported as nearly double that reported in the experimental literature. Methodologic issues of the study and of placebo investigation, in general, are discussed. Because common clinical problems appear to generate most instances of placebo use, several issues pertinent to medical education are raised. Some future directions for placebo research are proposed.