Stefania Fabbri

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.

New Strategies in the Assessment of Psychological Factors Affecting Medical Conditions

In this article, we examine research that may lead to a better assessment of psychological factors affecting medical conditions. We performed a review of the psychosomatic literature using both Medline and manual searches. We selected papers that were judged to be relevant to new strategies of assessment, with particular reference to the use of the Diagnostic Criteria for Psychosomatic Research. We assessed 8 areas concerned with the assessment of psychological factors in the setting of medical disease: hypochondriasis, disease phobia, persistent somatization, conversion symptoms, illness denial, demoralization, irritable mood, and Type A behavior. A new subclassification of the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-V]; not yet published) category of psychological factors affecting physical conditions appears to be feasible and may provide the clinician with better tools for identifying psychological distress.

Self-Exposure Treatment of Recurrent Nightmares: Waiting-List-Controlled Trial and 4-Year Follow-Up

Background: In open and randomized controlled trials self-exposure therapy reduced the frequency of nightmares but follow-up ceased at 7 months post-entry. Method: Ten adults who attended an outpatient clinic and had DSM-IV nightmare disorder were put on a 3-month waiting-list. After 3 months they were given a self-exposure manual and were asked to follow its instructions for 4 weeks and were then followed up for 4 years. They were rated at 0, 3, 4, 5, 7, 10, 16, 28 and 52 months. At month 0 only, a matched control group of 10 subjects from the same clinic who had no axis I or II disorder was also rated. Results: At month 0, the nightmare sufferers had more nightmares, anxiety, depression, hostility and somatic symptoms than the matched control group. All 10 nightmare sufferers completed the 3-month waiting-list, 4-week self-exposure therapy and 4-year follow-up without any dropouts. The recurrent nightmares and most associated symptoms did not improve while on the waiting-list but improved markedly after self-exposure therapy and remained improved over the 4-year follow-up. Conclusions: Adults’ recurrent nightmares and associated symptoms failed to improve over a 3-month waiting-list period but reduced greatly after subsequent self-exposure therapy with minimal therapist contact over 1 month, and these gains continued over the next 4 years.

Development of a New Assessment Strategy in Psychosomatic Medicine: The Diagnostic Criteria for Psychosomatic Research

The Diagnostic Criteria for Psychosomatic Research (DCPR) are a diagnostic and conceptual framework that was proposed a decade ago by an international group of investigators. The DCPRs rationale was to translate psychosocial variables that derived from psychosomatic research into operational tools whereby individual patients could be identified. A set of 12 syndromes was developed: health anxiety, thanatophobia, disease phobia, illness denial, persistent somatization, conversion symptoms, functional somatic symptoms secondary to a psychiatric disorder, anniversary reaction, demoralization, irritable mood, type A behavior, and alexithymia. These criteria were meant to be used in a multiaxial approach. The aim of this work is to survey the research evidence which has accumulated on the DCPR, to provide specification for their development and validation and to examine the specific DCPR clusters. Their implications for classification purposes (DSM-V) are also discussed.

Technicalities: Getting and staying connected to people living with HIV/AIDS in the southern United States ☆

Dear Sirs, We read with interest the article by Konkle-Parker, Erlen, and Dubbert in which the authors describe feasibility of conducting a remote telephone-delivered HIV medication adherence intervention study in the southern United States [1]. We are most interested in Konkle-Parker et al.’s discussion of the feasibility of using telephones as a format for intervention delivery. In this study, the two intervention sessions conducted in-clinic were more often completed than the six intervention sessions by telephone. Participants were often unreachable for their telephone intervention sessions despite researchers’ request that participants provide three telephone numbers and the fact that researchers made up to nine call attempts and sent letters in attempt to complete the scheduled telephone intervention sessions. Konkle-Parker et al. posited reasons for difficulty making telephone contact with participants included participants’ inconsistent telephone access and providing incentives for in-clinic interventions but not telephone interventions. It is certainly likely that incentivizing participants would have led to a greater number of telephone intervention contacts and Konkle-Parker et al. suggest future researchers do this. Konkle-Parker et al. also suggest future researchers take into consideration participants’ inconsistent access to telephones, a poignant fact of life for many rural, poor patients living with HIV. It is this point that we address in this letter—the issue of access to telephones among southern people living with HIV/AIDS. As Konkle-Parker et al. noted, the HIV/AIDS epidemic disproportionately affects people living in the southern United States [2,3]. In our research studies, it has also been our experience that inconsistent access to telephones, as well as inadequate transportation associated with pervasive poverty and geographic dispersal, has been a barrier to scheduling, confirming, and conducting in-clinic intervention sessions. So, like Konkle-Parker et al., we are currently developing ways to reach this mostly rural and impoverished southern sub-group with efficacious adherence interventions that could be provided remotely. Studies have found technology-based HIV medication adherence interventions are promising including those using: telephones [4], the Internet [4], and videos delivered on personal digital assistants [5] and traditional television/video players [6,7]. Further, the National Institutes of Health is advocating for more studies testing the use and integration of technology into HIV medication adherence promotion interventions [8]. However, most technology-based intervention studies have provided the technological devices (such as mobile telephones) to the research participants, thus eliminating the problem of access. There is no doubt that these approaches are highly innovative but may not be sustainable or taken to scale in clinical programs after research projects end. We propose that using technological formats that the target population already has and uses may be more practical. To this end, we conducted a formative, pragmatic, mailed survey assessment of: demographic characteristics, access to, and use of specific technologies we are considering using (e.g., mobile telephones, landline telephones, televisions with video players). Not surprisingly, as Konkle-Parker et al. describe, our respondents reported inconsistent access to and use of mobile and landline telephones. In contrast, most had consistent access to and used televisions with DVD players, or less commonly, VCRs. Consistent with the only published study about technology access and use among people living with HIV/AIDS in the United States [9], we found the employed respondents, with at least some college, and income over

Psychological factors affecting medical condition: a new proposal for DSM-V.

10,000 per year were significantly more likely than all others to have access to and use both landline and mobile telephones; however, almost all respondents reported having access to a television with a video player. It is understandable that respondents with the resources to pay monthly bills would be able to maintain access to and use technologies, such as telephones, requiring payment of monthly fees. In comparison, access to and use of televisions with video players requires purchase costs rather than ongoing bills. Our findings suggest we could feasibly reach this group with a flexible combination of mailed DVDs and contact via mobile and or landline telephones. But, clearly, flexible procedures for telephone contact are needed to account for inconsistent telephone access associated with the ability to pay monthly bills. Additionally, interventions should be prepared on several video formats (e.g. VHS tapes or DVDs) to fit the type of video player each participant has. We believe using technologies that most people in the target population already have and use, as Konkle-Parker et al. did appears to be a good use of research dollars and importantly, is more likely to be sustainable than providing devices for each participant in a research study or patient in a clinic. Though, to achieve an efficacious ‘‘dose’’ of remote-delivered interventions, such as the one described in Konkle-Parker et al., research participants must have ongoing access to the format. Inadequate access to telephones while in a telephone-delivered intervention study is like inadequate access to transportation while in a clinic-based intervention. We recommend that other researchers investigate access to high and low technology devices as a preliminary formative research step. By doing so, we will be able to anticipate and employ the most appropriate technologies that southern people living with HIV/AIDS in rural catchment areas already have and use, leading to more rapid testing of sustainable interventions that could be taken to scale if found efficacious.