Laura Sirri

The unifying concept of illness behavior.

The concept of illness behavior was introduced to indicate the ways in which given symptoms may be perceived, evaluated and acted upon at an individual level. Illness behavior may vary greatly according to illness-related, patient-related and doctor-related variables and their complex interactions. In the past decades, important lines of research have been concerned with illness perception, frequent attendance at medical facilities, health care-seeking behavior, treatment-seeking behavior, delay in seeking treatment, and treatment adherence. They have, however, mostly investigated single aspects separately. In this concise review, we suggest that the concept of illness behavior may provide a unifying framework and useful insights to observations and findings that would otherwise remain scattered and unrelated in the medical literature. The wide range of expressions of illness behavior is likely to affect the presentation of any disease and its identification, course and treatment. Assessing illness behavior and devising appropriate responses by health care providers may contribute to the improvement of final outcomes.

Diagnostic criteria for psychosomatic research and somatic symptom disorders

Abstract The Diagnostic Criteria for Psychosomatic Research (DCPR) were introduced in 1995 by an international group of investigators to expand the traditional domains of the disease model. The DCPR are a set of 12 ‘psychosomatic syndromes’ which provide operational tools for psychosocial variables with prognostic and therapeutic implications in clinical settings. Eight syndromes concern the main manifestations of abnormal illness behaviour: somatization, hypochondriacal fears and beliefs, and illness denial. The other four syndromes (alexithymia, type A behaviour, demoralization and irritable mood) refer to the domain of psychological factors affecting medical conditions. This review describes the conceptual bases of the DCPR and the main findings concerning their application, with particular reference to the incremental information they added to the customary psychiatric classification. The DCPR were also compared with the provisional DSM-5 somatic symptom disorders. The DCPR were found to be more sensitive than DSM-IV in identifying subthreshold psychological distress and characterizing patients’ psychological response to medical illness. DSM-5 somatic symptom disorders seem to neglect important clinical phenomena, such as illness denial, resulting in a narrow view of patients’ functioning. The additional information provided by the DCPR may enhance the decision-making process.

Psychological predictors of mortality in heart transplanted patients: a prospective, 6-year follow-up study.

Background. Some reports suggest a link between poor psychological adjustment to heart transplantation and an increased risk of subsequent adverse clinical outcome. Despite its prognostic and therapeutic implications, this issue is still lacking adequate empirical studies. We prospectively tested the predictive value of a complete set of psychiatric and psychological variables, collected with both self-rating and observer-based instruments at midterm after heart transplantation, on the subsequent 6-year survival status. Methods. Ninety-five heart transplanted patients underwent the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-4th Edition and the structured interview for Diagnostic Criteria for Psychosomatic Research and filled three questionnaires assessing the dimensions of psychological distress, quality of life, and psychological well-being. Demographic characteristics and several clinical parameters were also collected. A 6-year follow-up survival was performed. Results. Analyses of survival showed that hostility, depression, purpose in life, the occurrence of at least one cardiac event, chronic renal insufficiency, diabetes, number of drug prescriptions, a New York Heart Association (NYHA) class more than or equal to II, and ischemic origin of the cardiopathy significantly predicted subsequent survival duration. When multivariate analyses were performed, high levels of hostility and the presence of diabetes resulted the independent predictors of survival status. Conclusions. These findings point out the predictive role of specific components of psychological adjustment to heart transplantation and pose the basis for the evaluation of whether the provision of pharmacologic and psychotherapeutic interventions, aimed at reducing the empirically identified psychological risk factors, may result in a better long-term outcome.

Type A behaviour: a reappraisal of its characteristics in cardiovascular disease

Aims:  The role of type A behaviour in cardiovascular disease is controversial and most of the research is based on self‐rating scales. The aim of this study was to assess the prevalence of type A behaviour in cardiology and in other medical settings using reliable interview methods that reflect its original description.

Psychological characterization of demoralization in the setting of heart transplantation.

OBJECTIVE The aims of this study were to examine the psychological features of demoralization and its overlap with major depressive disorder in a sample of cardiac transplant recipients, with special reference to psychological well-being, quality of life, and psychological distress. We also tested whether demoralization was significantly associated with demographic characteristics and clinical parameters, including survival status at a 6-year follow-up. METHOD From May to December 2002, 95 heart transplanted patients were administered the Structured Clinical Interview for DSM-IV and the Diagnostic Criteria for Psychosomatic Research, leading to the identification of major depressive disorder and demoralization, respectively. Patients also completed Ryffs Scales of Psychological Well-Being, Kellners Symptom Questionnaire, and the World Health Organization Quality of Life-Brief Version scale. RESULTS Demoralization was related to impairments in physical, psychological, social, and environmental quality of life and in psychological well-being, especially self-acceptance and environmental mastery (all P ≤ .05). It was also associated with higher levels of psychological distress, and it was more frequent in women (P = .027) and in single patients (P = .038). The co-occurrence of a major depressive episode did not alter this pattern of associations. The addition of demoralization to major depressive disorder resulted in decreased Scales of Psychological Well-Being autonomy, positive relations, and self-acceptance (all P ≤ .05). Demoralization and major depressive disorder were identified in 31 (32.6%) and 14 (14.7%) patients, respectively. Among depressed subjects, 5 (35.7%) were not demoralized, and 22 (71%) of those with demoralization did not satisfy the criteria for major depressive disorder. Nine patients were both depressed and demoralized. CONCLUSION Diagnostic Criteria for Psychosomatic Research-defined demoralization has some distinctive features that confirm previous phenomenological observations.

Alexithymia in the medically ill. Analysis of 1190 patients in gastroenterology, cardiology, oncology and dermatology

OBJECTIVE To use the Diagnostic Criteria for Psychosomatic Research (DCPR) for characterizing alexithymia in a large and heterogeneous medical population, in conjunction with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and other DCPR criteria. METHOD Of 1305 patients recruited from 4 medical centers in the Italian Health System, 1190 agreed to participate. They all underwent an assessment with DSM-IV and DCPR structured interviews. A total of 188 patients (15.8%) were defined as alexithymic by using the DCPR criteria. Data were submitted to cluster analysis. RESULTS Five clusters of patients with alexithymia were identified: (1) alexithymia with no psychiatric comorbidity (29.3% of cases); (2) depressed somatization with alexithymic features (23.4%); (3) alexithymic illness behavior (17.6%); (4) alexithymic somatization (17%) and (5) alexithymic anxiety (12.8%). CONCLUSIONS The results indicate that DCPR alexithymia is associated with a comorbid mood or anxiety disorder in about one third of cases; it is related to various forms of somatization and abnormal illness behavior in another third and may occur without psychiatric comorbidity in another subgroup. Identification of alexithymic features may entail major prognostic and therapeutic differences among medical patients who otherwise seem to be deceptively similar since they share the same psychiatric and/or medical diagnosis.

Kellner's emotional inhibition scale: a clinimetric approach to alexithymia research.

Background: Emotional inhibition has been an enduring concept in the psychosomatic literature explaining the onset and course of medical disorders. Currently the personality style of alexithymia is a focus of this dimension in psychosomatic theory, while actual conscious emotional inhibition, which may overlap with alexithymia, has received less attention. In the early 80s Robert Kellner developed the Emotional Inhibition Scale (EIS), a self-rating scale for emotional inhibition based on clinimetric principles. In this study we explored whether the EIS differentiated a sample of cardiac recipients from normal controls, as well as the associations between the EIS and 2 measures of alexithymia, i.e. the Toronto Alexithymia Scale-20 (TAS-20) and the Diagnostic Criteria for Psychosomatic Research (DCPR). We also examined whether the EIS and the TAS-20 were differently related to depressive symptoms measured by the Symptom Questionnaire (SQ). Methods: Ninety-five heart-transplanted patients and a sample of normal controls, matched for sociodemographic variables, were administered the EIS (total score and 4 subscales concerning ‘verbal inhibition’, ‘timidity’, ‘disguise of feelings’, and ‘self-control’), the TAS-20, the SQ, and the Structured Interview according to the DCPR for alexithymia. Results: Cardiac recipients did not display significant differences compared to normal controls in observer (DCPR) and self-rated (TAS-20) measures of alexithymia. There were, however, significant differences in EIS with regard to ‘disguise of feelings’. In both groups the EIS ‘verbal inhibition’ and ‘timidity’ subscales were positively associated with the TAS-20, while the EIS ‘disguise of feelings’ and ‘self-control’ subscales were independent of alexithymia. Depressive symptoms were more related to TAS-20 than EIS total scores. Conclusions: Our results suggest that emotional inhibition and alexithymia are distinct phenomena even though they may share certain features. The EIS appears to be relatively independent of depressed mood and will be useful in assessing the individual’s conscious management of affect in future psychosomatic research.

Is Depression the Wrong Treatment Target for Improving Outcome in Coronary Artery Disease

HART) [7] , on depressed patients after CAD, found that the effect of sertraline was greater in patients with severe and recurrent depression. It is also true that, in cardiac settings, mild depressive symptoms are sufficient to enhance cardiovascular risk even in the absence of major depressive disorder [8–11] . Antidepressant treatment could thus be successful in terms of cardiac prognosis only in the subgroup of cardiac patients with more severe depression, but not in those with milder depression at equally elevated cardiac risk. It has been suggested that selective serotonin reuptake inhibitors (SSRIs) might ameliorate the adverse effect of depression on cardiovascular disease through the inhibition of platelet aggregation, even independently of changes in depression [12] . This potential benefit, however, is counteracted by recognized adverse cardiovascular side effects [13–15] . In particular, the use of SSRIs such as citalopram and escitalopram is associated with cases of arrhythmias and prolonged QTc interval on electrocardiogram in patients lacking cardiovascular disorders [16] . Licht et al. [17] found that all antidepressants, including SSRIs, have a lowering effect on cardiac vagal control that has been found to be associated with increased blood pressure and other metabolic abnormalities, such as unfavorable lipid profiles and high glucose levels [18] . A significant relationship between depression and cardiac morbidity has been documented [1] . The identification of depression as an unfavorable marker of the clinical course in coronary artery disease (CAD) in the 1990s [2– 4] generated the hope of improving the prognosis of cardiovascular disease with treatment of depression. This hope, however, has not survived the test of time. In a Cochrane review on randomized controlled clinical trials (RCTs) of any length of treatment and any length of follow-up [5] , psychological and pharmacological interventions have shown a small yet clinically meaningful effect on depression outcomes in CAD patients. However, no beneficial effects on the reduction of mortality rates and cardiac events have been found. Indeed, in some cases, treatment of depression was found to entail negative physical consequences. There are several potential explanations, involving drugs and psychotherapy, which account for this phenomenon.

Assessing psychological factors affecting medical conditions: comparison between different proposals.

OBJECTIVE We compared the provisional Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for Somatic Symptom Disorders (SSD) and an alternative classification based on the Diagnostic Criteria for Psychosomatic Research (DCPR) as to prevalence and associations with dimensional measures of psychological distress and functioning in a population of medical patients. METHOD Seventy consecutive outpatients with congestive heart failure were administered an ad hoc structured clinical interview for the identification of DSM-5 SSD, the section concerning hypochondriasis of the Structured Clinical Interview for DSM-IV, the Structured Interview for DCPR and Paykels Clinical Interview for Depression. Subjects also completed the Symptom Questionnaire and the Psychosocial Index. Global assessment of functioning was performed with the DSM-IV Axis V. RESULTS A diagnosis within DSM-5 SSD was found in 13 patients (18.5%): 61.5% of them were diagnosed with the Psychological Factors Affecting Medical Condition category. Twenty-nine patients (41.4%) were classified according to the DCPR-based proposal: illness denial, demoralization and irritable mood were the most frequent specifiers. The DCPR-based classification showed a greater number of significant associations with dimensional measures of psychological distress, global functioning and stress. CONCLUSION Compared to DSM-5 SSD, the DCPR-based proposal was more sensitive in detecting psychological factors relevant to illness course and provided a better characterization of such factors. The DCPR-based proposal was also superior in identifying patients with increased psychological distress and poor psychosocial functioning.

Predictors of perceived social support in long-term survivors of cardiac transplant: The role of psychological distress, quality of life, demographic characteristics and clinical course

Aim: To examine associations between perceived social support, quality of life, psychopathological, demographic and clinical variables in long-term heart transplant survivors. Methods: Sixty six patients transplanted from 10.2 ± 3.3 years completed the Interpersonal Support Evaluation List, Symptom Questionnaire and World Health Organization Quality of Life-BREF. Parameters of post-transplant medical course were retrieved. Spearman rank order correlation, Mann–Whitney U test, Kruskal–Wallis test and multiple regression analyses were performed. Results: At multiple regression analyses SQ depression significantly predicted Interpersonal Support Evaluation List (ISEL) total and appraisal scores (p = 0.005 and p = 0.047), indicating better satisfaction for support in patients with less depressive symptoms. Low levels of depression and being married or living as married were significantly associated with better ISEL belonging (p = 0.03 and p = 0.008) and self-esteem (p < 0.001 and p = 0.038). Skin cancer significantly correlated with better tangible (p = 0.02) and total (p = 0.05) support. Social quality of life was positively associated with ISEL total (p < 0.01), appraisal (p < 0.05), belonging (p < 0.01) and tangible (p < 0.05) scores; yet, it significantly predicted none of the them. Conclusions: Depressive symptoms may worsen patients’ satisfaction for their interpersonal support. Marital status seems to foster sense of belonging and self-esteem. The paucity of significant associations between ISEL and clinical parameters may reflect the caregivers’ continuous provision of support regardless of clinical status.