Joan de Pablo

Psychosocial adjustment to orthotopic liver transplantation in 266 recipients.

Although the survival rate of patients undergoing orthotopic liver transplantation (OLT) is highly satisfactory, one of the most important objectives for liver transplantation teams at the present time is to achieve the best possible quality of life and psychosocial functioning for these patients after transplantation. We present the preliminary results of a study designed to determine which domains of psychosocial functioning are most affected in liver transplant recipients, and to examine the factors associated with poorer adjustment after OLT, using a utility‐based standardized measure. Patients who had undergone liver transplant more than 12 months previously were eligible. They were administered the Psychosocial Adjustment to Illness Scale (PAIS), and they provided the answers themselves. Multivariate regression models showed that attitudes toward health care were poorer in women (β = 0.916, P < .001), in patients who were employed at the moment of transplantation (β = 0.530, P = .032), and in patients of lower social class (β = 0.722, P = .026) than in men, unemployed patients, and patients of higher social class. Sexual functioning was worse in women (β = 0.907, P = .001) and older patients (β = 0.999, P < .001) than in men or younger patients. Psychological distress was higher in women (β = 0.981, P = .001) than in men, and lower in currently employed patients (β = −0.937, P = .001) than in the unemployed. Only gender remained significantly associated with the total PAIS score (β = 0.969, P < .001), with women showing a poorer overall psychosocial adjustment to OLT. In conclusion, there seems to be no doubt that liver transplantation improves quality of life, but special attention should be paid to female recipients, who seem to have more difficulty than their male counterparts in adjusting to the psychosocial consequences of the procedure. (Liver Transpl 2004;10:228–234.)

Changes in dreaming induced by CPAP in severe obstructive sleep apnea syndrome patients

To study dream content in patients with severe obstructive sleep apnea syndrome (OSAS) and its modification with Continuous Positive Airway Pressure (CPAP) therapy. We assessed twenty consecutive patients with severe OSAS and 17 healthy controls. Polysomnograms were recorded at baseline in patients and controls and during the CPAP titration night, 3 months after effective treatment and 2 years later in patients. Subjects were awakened 5–10 min after the beginning of the first and last rapid eye movement (REM) sleep periods and we measured percentage of dream recall, emotional content of the dream, word count, thematic units, sleep architecture and REM density. Dream recall in REM sleep was similar in patients at baseline and controls (51.5% versus 44.4% respectively; P = .421), decreased to 20% and 24.3% the first and third month CPAP nights, and increased to 39% 2 years later (P = 0.004). Violent/highly anxious dreams were only seen in patients at baseline. Word count was higher in patients than in controls. REM density was highest the first CPAP night. Severe OSAS patients recall dreams in REM sleep as often as controls, but their dreams have an increased emotional tone and are longer. Despite an increase in REM density, dream recall decreased the first months of CPAP and recovered 2 years later. Violent/highly anxious dreams disappeared with treatment. A dream recall decrease with CPAP is associated with normalization of sleep in OSAS patients.

Alexithymia, type A behaviour and bulimia nervosa

This paper studies the prevalence of alexithymia and type A behaviour among women with bulimia nervosa and the psychometric relations between these two psychological constructs. A group of 35 patients selected according to DSM-III-R diagnostic criteria was evaluated using the Toronto Alexithymia Scale (TAS) and the Jenkins Activity Survey (JAS) and compared with a matched control group of healthy women. Bulimic patients scored significantly higher than controls in alexithymia and in I and II TAS factors, and in speed/impatience and hard-driving style. Type A prevalence was similar in both groups and overall results suggest that alexithymia and type A behaviour are heterogeneous psychological constructs. Copyright

Psychogenic pain and depressive disorders: an empirical study

A sample of 31 patients of both sexes suffering from psychogenic pain disorder (DSM-III) were studied in order to test if their clinical and biological features as well as their response to antidepressant treatment support the hypothesis that relates this syndrome to depressive disorders. Biological variables were basal cortisol and dexamethasone suppression test, and treatment consisted of daily administration of 100-175 mg of imipramine for a period of 5 months. Mood state was evaluated by the Hamilton scale and pain was assessed through visual analogue scales immediately before starting treatment and 3 months later. There was a low prevalence of non-suppressors (9.6%) and all patients significantly improved in mood and pain after antidepressant treatment. However, general results support both the hypothesis linking psychogenic pain to depressive disorders and its possible understanding in terms of failed adjustment processes.

El proyecto multinacional europeo y multicéntrico español de mejora de calidad asistencial en psiquiatría de enlace en el hospital general: el perfil clínico en España

BACKGROUND In the frame of the European study on quality assurance in consultation liaison psychiatry and psychosomatics (supported by the BIOMED 1 program), the clinical <<process>> of consultation-liaison psychiatry units pertaining to six Spanish general hospitals is analyzed. PATIENTS AND METHOD A sample of 3. 608 consecutive patients referred to the consultation-liaison psychiatry units of five public general hospitals (Clínico of Zaragoza, Clínico of Barcelona, General of Alicante, Ramón y Cajal of Madrid, Princesa of Madrid) and one private gynecological hospital (Dexeus of Barcelona) was studied. The data were recorded with a standardized instrument (CL-BDoK-P), validated in a previous study. RESULTS Consult request took place 10.6 days (on average) after the patients admission (<<lagtime 1>>), half the requests were urgent, and psychiatric consultants examined the patients 1.9 days (on average) after the request (<<lagtime 2>>). The most frequent reasons for referral were current psychiatric symptoms (50.3%), unexplained physical symptoms (15.2%), substance abuse (9.2%), psychiatric history (8.5%), suicide risk (6%) and coping with illness (5.8%). The main referral services were internal medicine (17.5%), traumatology (7.5%) and general surgery (7.3%). An important clinical activity is documented in patients frequently considered to be <<complex>>, with broad spectrum diagnostic and interventions processes and both in-hospital and out-patient follow-up. However, some problems were also detected in the clinical <<process>>. CONCLUSIONS The results outline the clinical importance of Spanish consultation-liaison psychiatry in the general hospital, but the possibility of improving its efficiency through the implementation of integrative models, organizational changes and modern models of <<quality assurance>> is also emphasized.

Control of Ventilation, Breathlessness Perception and Alexithymia in Near-Fatal Asthma

Several studies have demonstrated impaired control of ventilation in some patients with near-fatal asthma (NFA). The objective of our study was to determine a possible relationship between alexithymia (a cognitive processing disorder), control of ventilation, and breathlessness perception in patients who had an NFA attack. We analyzed data from 100 subjects: 50 with NFA, 25 asthmatics without NFA, and 25 non-asthmatic controls. Ventilatory responses to hypoxia and hypercapnia were measured by the rebreathing technique in terms of slope of ventilation and mouth occlusion pressure (P0.1). Breathlessness perception was assessed with the Borg scale and alexithymia with the Toronto Alexithymia Scale (TAS). No statistical differences were observed between groups in breathlessness perception and ventilatory responses. The mean (SD) TAS score of 63.6 (14.9) in the NFA group was significantly higher than the score of 56.4 (12.1) in the non-asthmatic group (p = 0.007). More subjects with alexithymia were identified in the NFA group (24%) than in the non-NFA group (12%) or the non-asthmatic control group (12%). Although the presence of alexithymia did not correlate with poor ventilatory responses or breathlessness perception, it was associated with a larger number of previous hospitalisations: 6.2 (8.1) in the NFA group and 2.8 (4.8) in the non-NFA group (p = 0.036). In conclusion, the prevalence of alexithymia is higher among NFA patients than among asthmatics who have not experienced NFA attacks. Neither altered breathlessness perception nor ventilatory response to hypoxia seems to play a role in NFA, although alexithymia may favor poor clinical control.

Psychogenic Pain and Psychological Variables: a Psychometric Study

A sample of 41 women suffering from psychogenic pain according to DSM-III diagnostic criteria were psychometrically studied, in order to ascertain if they showed specific psychological traits or mechanisms. Type A behavior, extraversion, neuroticism, psychoticism and dissimulation and hostility-aggressivity traits were the psychological variables studied both in the pain sample and in a matched control group. Psychogenic pain patients were significantly more neurotic and suspicious and less physically aggressive than healthy subjects and also scored significantly higher in dissimulation, which suggests a tendency to use defense mechanisms of denial.

Depression in hospitalized patients with malignant melanoma treated with interferon-alpha-2b: primary to induced disorders

Our objective was to study the clinical and management differences between primary and interferon (IFN)-induced depressive disorders in malignant melanoma patients visited by the consultation-liaison team during a two year period. This was a prospective study of 31 patients with malignant melanoma treated with IFN-alpha in a general teaching hospital. Clinical, psychiatric variables and DSM-IV-TR diagnosis were analyzed. The Clinical Global Impression Severity (CGI-S) and Improvement (CGI-I) of illness scales were administered at the time of consultation and at the end of hospitalization. The main diagnoses were depressive adjustment disorders in 14 patients (45.16%) followed by interferon-induced depressive disorders in 6 (19.36%). In patients with adjustment disorders, melanoma stage was significantly more advanced than in those with interferon-induced depressive disorder (p = 0.019). The latter scored higher in the CGI-S scale (p = 0.044) and in the CGI-I scale (p = 0.029). The interferon-induced depressive disorders, except one who required a reduction of IFN-alpha-2b dose, were successfully treated with antidepressant drugs. Clinical management and antidepressant treatment allowed the continuation of interferon therapy in malignant melanoma patients. Interferon-induced depression occurred in a few patients, which in turn were the most severe. Adjustment depressive disorder was the most common psychiatric diagnosis.

Rapidly Cycling Bipolar II Disorder Following Liver Transplantation

During the last decade the psychiatric aspects of liver transplantation have been widely described. Although affective complications are some of the most prevalent, a complete and persistent bipolar II syndrome following transplantation has never been reported before. In this paper we describe a patient who developed a rapidly cycling bipolar II disorder after liver transplantation. He presented a major depressive episode within the first 48 hours following transplantation, and subsequently started cycling from depression to hypomania with only brief periods of euthymia. One year after transplantation, only lithium carbonate has proved to be useful to ameliorate his persistent disorder. There was no premorbid or family history of affective illness. Although the course of the disorder seemed to be independent from any pharmacologic or psychosocial factor, it is suggested that transplantation, corticosteroids, and cyclosporine may have played some role in the pathogenesis of the syndrome.

Lack of clinical relevance of routine chest radiography in acute psychiatric admissions

To make clinically relevant recommendations for chest X-ray testing in acute psychiatric admissions, this study examined the current practice of this screening test in patients admitted to a University Hospital. The records of the 332 first consecutive admissions to the psychiatric ward were assessed. In 200 patients (60%) a chest X-ray was requested. The X-ray film was normal in 81.5% of patients. The remaining subjects presented abnormalities: nonrelevant in twenty-seven (13.5% of the total), and relevant in eleven (5.5%). Since all these relevant abnormalities were already known, in no cases was the test followed by changes in therapy or by additional diagnostic procedures. In almost all cases this screening test was of no practical value. Our findings challenge the systematic indication of chest X-ray in acute psychiatric patients, and suggest that the number of tests performed and the cost of medical care could be reduced by a more efficient use of past medical history and physical examination criteria, without compromising the quality of patient care.