Michiel W. Hengeveld

Unexplained physical symptoms: outcome, utilization of medical care and associated factors

The aim of the study was to investigate the recovery and frequency of physician contact in patients with unexplained physical symptoms and to identify factors associated with persistent disorder. Of 100 consecutive patients who presented with medically unexplained symptoms to a general medical out-patient clinic, 81 participated in a follow-up study. The mean follow-up time was 15.2 months (S.D. 4.0). At follow-up, many of the patients with unexplained physical symptoms reported that they had recovered (30%) or improved (46%) with regard to their presenting symptoms. Female sex and a high number of symptoms predicted a bad outcome in terms of recovery. Persistence of symptoms was not related to the duration of the symptoms, type of presenting complaint or the presence of psychiatric disorder. Forty per cent of patients with unexplained symptoms did not visit their general practitioner on their own initiative in the year following the initial visit to the clinic. Medical care utilization appeared to be associated with female sex, age, number and duration of symptoms, fatigue and psychiatric disorder, especially somatoform disorders. However, the association of a high frequency of physician contact with female sex and psychiatric disorder was not sustained after controlling for possible confounding factors.

Physician-Assisted Death in Psychiatric Practice in the Netherlands

BACKGROUND In 1994 the Dutch Supreme Court ruled that in exceptional instances, physician-assisted suicide might be justifiable for patients with unbearable mental suffering but no physical illness. We studied physician-assisted suicide and euthanasia in psychiatric practice in the Netherlands. METHODS In 1996, we sent questionnaires to 673 Dutch psychiatrists - about half of all such specialists in the country - and received 552 responses from the 667 who met the study criteria (response rate, 83 percent). We estimated the annual frequencies of requests for physician-assisted suicide by psychiatrists and actual instances of assistance. RESULTS Of the respondents, 205 (37 percent) had at least once received an explicit, persistent request for physician-assisted suicide and 12 had complied. We estimate there are 320 requests a year in psychiatric practice and 2 to 5 assisted suicides. Excluding those who had ever assisted, 345 of the respondents (64 percent) thought physician-assisted suicide because of a mental disorder could be acceptable, including 241 who said they could conceive of instances in which they themselves would be willing to assist. The most frequent reasons for refusing were the belief that the patient had a treatable mental disorder, opposition to assisted suicide in principle, and doubt that the suffering was unbearable or hopeless. Most, but not all, patients who had been assisted by their psychiatrists in suicide had both a mental disorder and a serious physical illness, often in a terminal phase. Thirty percent of the respondents had been consulted at least once by a physician in another specialty about a patients request for assisted death. The annual number of such consultations was estimated at 310, about 3 percent of the estimated 9700 requests for euthanasia or physician-assisted suicide in medical practice. CONCLUSIONS Explicit requests for physician-assisted suicide are not uncommon in psychiatric practice in the Netherlands, but these requests are rarely granted. Psychiatric consultation for medical patients who request physician-assisted death is relatively rare.

The effect of antipsychotic medication on facial affect recognition in schizophrenia: A review

Patients with schizophrenia suffer from impairments in facial affect recognition and social functioning. Since antipsychotic medication affects different areas in the brain, they may also affect target areas involved in emotional processing mechanisms. In this article, we review the findings of the effect of antipsychotic medication on facial affect recognition in schizophrenia. We searched PubMed for articles in English with the keywords schizophrenia, facial, affect, emotion, antipsychotic and medication, published till January 2008. Eight relevant articles were found describing original studies. No substantial improvements in facial affect recognition were found after treatment with either typical or atypical antipsychotic drugs. Facial affect recognition was not related to neuropsychological functioning, and it was unclear whether improvement of symptom severity was related to performance on the facial affect recognition tasks. It is recommended that future research should focus on measuring social skills and social functioning more directly, and by investigating the effects of additional behavioural treatments on facial affect recognition and social functioning relative to treatment with antipsychotic medication alone.

Somatoform disorders in consultation-liaison psychiatry: a comparison with other mental disorders

Consultation-liaison (C-L) psychiatry has an important role in the management of somatoform disorders (SD). Characteristics of SD patients in C-L psychiatry are largely unknown and are presented in this paper. We analyzed 13,314 Dutch psychiatric consultations from 1984 to 1991 and compared patients diagnosed with SD to patients with other mental disorders and to those without a mental disorder. The comparison included socio-demographic variables, consult characteristics, medical history, current somatic morbidity, information about additional diagnostic tests, hospital admission time and aftercare management. Of the 544 SD patients 39.5% (n = 215) were diagnosed with a conversion disorder that illustrates the highly selected nature of SD patients in C-L psychiatry. Employment among SD patients decreased significantly from 58% in the group aged 20-29 years to 6% in the group aged 50-59 years. This decrease was significantly larger as compared to other mental disorders and no mental disorders and was virtually unaffected by correction for potential confounding by gender. Contrary to our expectation no difference between the three groups was observed in claims for disability benefits. Of the SD patients 74.5% were referred for aftercare management, significantly more than the other two groups which is considered a promising development in C-L psychiatry.

Randomised clinical trial: escitalopram for the prevention of psychiatric adverse events during treatment with peginterferon-alfa-2a and ribavirin for chronic hepatitis C

Aliment Pharmacol Ther 2011; 34: 1306–1317

Drug-free patients with major depression show an increased electrophysiological response to valid and invalid feedback.

BACKGROUND Depressed patients are biased in their response to negative information. They have been found to show a maladaptive behavioral and aberrant electrophysiological response to negative feedback. The aim of this study was to investigate the behavioral and electrophysiological response to feedback validity in drug-free depressed patients. METHOD Fifteen drug-free in-patients with unipolar major depression disorder (MDD) and 30 demographically matched controls performed a time-estimation task in which they received valid and invalid (i.e. related and unrelated to performance) positive and negative feedback. The number of behavioral adjustments to the feedback and the feedback-related negativity (FRN) were measured. RESULTS Patients made fewer correct adjustments after valid negative feedback than controls, and their FRNs were larger. Neither patients nor controls adjusted their time estimates following invalid negative feedback. CONCLUSIONS The FRN results suggest that depressed drug-free in-patients have an atypical rostral anterior cingulate response to feedback that is independent of feedback validity. Their behavioral response to invalid negative feedback, however, is not impaired. This study confirms the notion that the behavioral responses of depressed individuals to negative feedback are context dependent.

The anterior cingulate cortex responds differently to the validity and valence of feedback in a time-estimation task

This study examined the role of the medial frontal cortex in the processing of valence and validity of performance feedback using a time-estimation paradigm. Participants had to produce 1s intervals followed by positive and negative feedback that could be valid or invalid (i.e., related or unrelated to task performance). Performance results showed that participants used the validity information to adjust their time estimations to negative feedback. The rostral cingulate zone (RCZ) was more active after valid feedback than after invalid feedback, but was insensitive to the valence of the feedback. The rostral anterior cingulate cortex (rACC), posterior cingulate and right superior frontal gyrus, however, appeared to be primarily sensitive to the valence of the feedback; being more active after positive feedback. The results are discussed along the lines of the ACCs cognitive and affective subdivisions and their structural and functional connections.

Understanding and improving treatment adherence in patients with psychotic disorders: A review and a proposed intervention

Non-adherence to treatment of patients with psychotic disorders is related to higher rates of relapse, hospitalization, and suicide. Important predictors of non-adherence include poor social structure, cognitive deficits, negative medication attitude, side effects, depression, a sealing-over recovery style, feelings of stigmatization, denial of treatment need, and lack of insight. Attempts to improve adherence have shown that psychoeducation alone is not fully effective, and that motivational interviewing, behavioral strategies, and linking a patient s personal goals to treatment may increase adherence. Based on the empirical data reviewed, we formed four clusters of possible causes of non-adherence, each of which can be targeted by a specific module of our developed Treatment Adherence Therapy (TAT). These four modules are: self-enhancement, motivational interviewing, medication dosage trials, and behavioral training. An individual patient may benefit from one or more of these modules; and thus the contents of TAT vary in accordance with individual causes of non-adherence. Basically, TAT aims to help patients work out what they want regarding treatment and then support them in following this through. TAT will be investigated in a multicenter randomized clinical trial in the Netherlands, starting March 2006.

Cardiovascular variability during treatment with haloperidol, olanzapine or risperidone in recent-onset schizophrenia

Abstract This study aimed to investigate the effects of treatment with haloperidol, olanzapine and risperidone on cardiovascular variability in patients with recent-onset schizophrenia by means of spectral analysis. Unmedicated patients (n = 18) had a higher mean heart rate and a tendency for a lower high-frequency power of heart rate variability than healthy control subjects (n = 57), indicating a decreased cardiac vagal control in unmedicated patients with schizophrenia. Patients treated with haloperidol (n = 10) showed significantly lower low-frequency power of heart rate and systolic blood pressure variability compared with olanzapine-treated patients, suggesting that haloperidol attenuated sympathetic functioning. On the contrary, olanzapine-treated patients (n = 10) showed the highest power in the low-frequency range of heart rate and systolic blood pressure variability, suggesting an increased sympathetic cardiac functioning. No significant effects of risperidone (n = 13) were found. None of the antipsychotic agents differed in their parasympathetic cardiovascular effects. We conclude that young, unmedicated patients with schizophrenia differed from controls in their parasympathetic functioning, but the antipsychotic agents haloperidol, risperidone and olanzapine induced only minor cardiovascular side effects.

Lack of motivation for treatment in emergency psychiatry patients.

A lack of motivation for treatment on the part of patients is a major problem for emergency psychiatric services. Little is known about its determinants. The aim of this study was to investigate determinants of treatment motivation in emergency psychiatric patients. A cross-sectional study of 719 patients was made. Motivation for treatment and other clinical variables were assessed using the Severity of Psychiatric Illness scale and the Brief Psychiatric Rating Scale. In all, 47% of patients were not motivated for treatment and they also had severe clinical problems. Lack of motivation was associated with danger to others [odds ratio (OR) 2.03; confidence interval (CI) 1.21–3.40], substance abuse (OR 1.71; CI 1.09–2.67), suspiciousness (OR 1.4; CI 1.19–1.64), grandiosity (OR 1.19; CI 1.01–1.4), anxiety (OR 0.74; CI 0.64–0.86), and GAF score (OR 0.98; CI 0.96–0.99). Lack of motivation for treatment is a common phenomenon among severely mentally ill patients seen by emergency psychiatric services. Lack of motivation was associated with danger and paranoid symptoms. Motivational techniques as well as involuntary treatment may help to overcome problems due to lack of motivation in these patients.