Fatigue and Co-occurring Symptoms in Women with Irritable Bowel Syndrome

Thesis (Ph.D.)--University of Washington, 2016-06

The development of psychological changes following whiplash injury

Psychological distress is a feature of chronic whiplash-associated disorders, but little is known of psychological changes from soon after injury to either recovery or symptom persistence. This study prospectively measured psychological distress (General Health Questionnaire 28 GHQ-28). fear of movement/re-injury (TAMPA Scale of Kinesphobia, TSK), acute post-traumatic stress (Impact of Events Scale, IES) and general health and well being (Short Form 36, SF-36) in 76 whiplash subjects within I month of injury and then 2, 3 and 6 months post-injury. Subjects were classified at 6 months post-injury using scores on the Neck Disability Index: recovered (< 8), mild pain and disability (10-28) or moderate/severe pain and disability (> 30). All whiplash groups demonstrated psychological distress (GHQ-28, SF-36) to some extent at 1 month post-injury. Scores of the recovered group and those with persistent mild symptoms returned to levels regarded as normal by 2 months post-injury, parallelling a decrease in reported pain and disability. Scores on both these tests remained above threshold levels in those with ongoing moderate/severe symptoms. The moderate/severe and mild groups showed elevated TSK scores at 1 month post-injury. TSK scores decreased by 2 months in the group with residual mild symptoms and by 6 months in those with persistent moderate/severe symptoms. Elevated IES scores, indicative of a moderate post-traumatic stress reaction, were unique to the group with moderate/severe symptoms. The results of this study demonstrated that all those experiencing whiplash injury display initial psychological distress that decreased in those whose symptoms subside. Whiplash participants who reported persistent moderate/severe symptoms at 6 months continue to be psychologically distressed and are also characterised by a moderate post-traumatic stress reaction. (C) 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Investigation of psychological and neuropsychological factors associated with clinical outcome following a group rehabilitation programme

The present study investigated neuropsychological and psychological factors associated with successful treatment outcome following a group intervention for individuals with acquired brain injury (ABI). Participants were classified into two groups (Clinically Improved and Not Improved) based upon the findings of a previous study (Ownsworth, McFarland, & Young, 2000a). A discriminant analysis was used to predict group membership on three outcome measures (Awareness and Strategy Behaviour indices of the Self-Regulation Skills Interview and the Psychosocial Dimension of the Sickness Impact Profile) between pre-assessment and post-assessment, and between pre-assessment and 6 months follow-up. Neuropsychological factors involved measures of executive functioning and psychological factors were assessed using measures of personality-related denial and coping-related denial. Overall, the results indicated that individuals with impaired executive functioning were most likely to be classified as Clinically Improved on measures of awareness, strategy behaviour and psychosocial functioning. Individuals who deny or minimise their ABI symptoms were less likely to improve their psychosocial functioning following the group intervention. Future research needs to evaluate interventions for enhancing self-regulation skills and improving psychosocial functioning for individuals who employ denial as a main strategy for coping following ABI.

Association between apolipoprotein E epsilon 4 and neuropsychiatric symptoms during interferon alpha treatment for chronic hepatitis C

Neuropsychiatric complications are common in patients with chronic hepatitis C undergoing treatment with interferon alpha. These side effects include alterations of mood, cognition, and neuroendocrine function and are unpredictable. In a number of neurological disorders characterized by neuropsychiatric symptoms and cognitive dysfunction, inheritance of an apolipoprotein E (APOE) epsilon4 allele is associated with adverse neuropsychiatric outcomes. The authors present evidence that the APOE genotype may influence a patient's neuropsychiatric response to interferon alpha treatment. The inheritance of APOE genotypes was examined in 110 patients with chronic hepatitis C treated with interferon alpha. A retrospective investigation was conducted by assessing the rates of psychiatric referral and neuropsychiatric symptoms experienced during treatment along with other complaints indicating psychological distress. A highly statistically significant association was seen between APOE genotypes and interferon-induced neuropsychiatric symptoms. Patients with an epsilon4 allele were more likely to be referred to a psychiatrist and had more neuropsychiatric symptoms during antiviral treatment than those without an epsilon4 allele. Additionally, patients with an epsilon4 allele were more likely to experience irritability or anger and anxiety or other mood symptoms. These data demonstrate that an individual's APOE genotype may influence the neuropsychiatric response to antiviral therapy with interferon alpha. Prospective studies evaluating the importance of APOE in susceptibility to interferon alpha-induced neuropsychiatric complications are needed. Moreover, pathways involving APOE should be considered in understanding the pathophysiology of interferon alpha-induced neuropsychiatric complications.

Prospective study of physical activity and depressive symptoms in middle-aged women

Background: Although many studies support an inverse association between physical activity (PA) and depressive symptoms, prospective relationships between these variables have been confounded by pre-existing psychological and physical health problems. Methods: This study examined the dose-response relationships between self-reported PA and depressive symptoms, using cross-sectional and prospective data from a population-based cohort of middle-aged women who participated in the Australian Longitudinal Study on Women's Health (ALSWH) between 1996 and 2001. Participants completed three mailed surveys (SI, 1996; S2, 1998; S3, 2001), which included questions about time spent in walking, moderate- and vigorous-intensity PA, and measures of psychological health (Center for Epidemiologic Studies Depression scale [CESD-10], and Mental health [MH] subscale of the Short Form 36 survey). Relationships between previous (SI, S2), current (S3), and habitual (S1, S2, S3) PA and depressive symptoms were examined, adjusting for sociodemographic and health-related variables (n = 9207). Results: Mean CESD-10 scores decreased, and MH scores increased with increasing levels of previous, current, and habitual activity. Odds ratios for CESD-10 scores >= 10 or MH scores = 60 minutes of moderate-intensity PA per week, compared with those who reported less PA than this. Women who were in the lowest PA category at SI, but who subsequently reported >= 240 metabolic equivalent minutes (MET.mins) per week had lower odds of CESD-10 scores of >= 10 or MH scores

Physical and psychological factors predict outcome following whiplash injury

Predictors of outcome following whiplash injury are limited to socio-demographic and symptomatic factors, which are not readily amenable to secondary and tertiary intervention. This prospective study investigated the predictive capacity of early measures of physical and psychological impairment on pain and disability 6 months following whiplash injury. Motor function (ROM; kinaesthetic sense; activity of the superficial neck flexors (EMG) during cranio-cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds, brachial plexus provocation test), sympathetic vasoconstrictor responses and psychological distress (GHQ-28, TSK, IES) were measured in 76 acute whiplash participants. The outcome measure was Neck Disability Index scores at 6 months. Stepwise regression analysis was used to predict the final NDI score. Logistic regression analyses predicted membership to one of the three groups based on final NDI scores (< 8 recovered, 10-28 mild pain and disability, > 30 moderate/severe pain and disability). Higher initial NDI score (1.007-1.12), older age (1.03-1.23), cold hyperalgesia (1.05-1.58), and acute post-traumatic stress (1.03-1.2) predicted membership to the moderate/severe group. Additional variables associated with higher NDI scores at 6 months on stepwise regression analysis were: ROM loss and diminished sympathetic reactivity. Higher initial NDI score (1.03-1.28), greater psychological distress (GHQ-28) (1.04-1.28) and decreased ROM (1.03-1.25) predicted subjects with persistent milder symptoms from those who fully recovered. These results demonstrate that both physical and psychological factors play a role in recovery or non-recovery from whiplash injury. This may assist in the development of more relevant treatment methods for acute whiplash. (c) 2004 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

How to recognize and manage psychological distress in cancer patients

Psychological distress is common in cancer patients, however, it is often unrecognized and untreated. We aimed to identify barriers to cancer patients expressing their psychological concerns, and to recommend strategies to assist oncologists to elicit, recognize, and manage psychological distress in their patients. Medline, Psychlit, and the Cochrane databases were searched for articles relating to the detection of emotional distress in patients. Patients can provide verbal and non-verbal information about their emotional state. However, many patients may not reveal emotional issues as they believe it is not a doctor's role to help with their emotional concerns. Moreover, patients may normalize or somatize their feelings. Anxiety and depression can mimic physical symptoms of cancer or treatments, and consequently emotional distress may not be detected. Techniques such as active listening, using open questions and emotional words, responding appropriately to patients' emotional cues, and a patient-centred consulting style can assist in detection. Screening tools for psychological distress and patient question prompt sheets administered prior to the consultation can also be useful. In conclusion, the application of basic communication techniques enhances detection of patients' emotional concerns. Training oncologists in these techniques should improve the psychosocial care of cancer patients.

Effect of information provision on trauma symptoms following therapeutic writing

Recent studies in the area of psychological debriefing (PD) have reported adverse effects. This study examined one possible explanation for such effects, that of sensitisation to the possibility of pathology. Subjects were 161 psychology students (female, n = 121; male, n = 40) who had experienced trauma but received no previous treatment. Subjects either received an explanation (explanation group) or received no explanation at all (no explanation group) about trauma reactions prior to undertaking a therapeutic writing protocol. The hypothesis of increased morbidity where the possibility of pathology was made explicit was not supported. At 2 months, the explanation group had a greater reduction on Impact of Events Scale Revised JES-R) total scores, F(1, 151) = 3.98, p = .048, and on the General Health Questionnaire - 28 (GHQ-28) Anxiety and Insomnia subscale, F(1, 151) = 9.84, p = .002, and total score F(1, 150) 5.05, p = .026. High-avoidance copers in particular appeared to benefit from information provision, F(1, 148) = 4.2 6, p = .044. Results suggest that adverse findings associated with PD may not be due to information sensitising of participants to pathology and that the provision of information to trauma survivors appears to be a useful strategy. Recommendations were made regarding the management of those exposed to trauma and for future research.

Physical and psychological factors maintain long-term predictive capacity post-whiplash injury

Higher initial levels of pain and disability, older age, cold hyperalgesia, impaired sympathetic vasoconstriction and moderate post-traumatic stress symptoms have been shown to be associated with poor outcome 6 months following whiplash injury. This study prospectively investigated the predictive capacity of these variables at a long-term follow-up. Sixty-five of an initial cohort of 76 acutely injured whiplash participants were followed to 2-3 years post-accident. Motor function (ROM; kinaesthetic sense; activity of the superficial neck flexors (EMG) during cranio-cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds and brachial plexus provocation test), sympathetic vasoconstrictor responses and psychological distress (GHQ-28, TSK and IES) were measured. The outcome measure was Neck Disability Index (NDI) scores. Participants with ongoing moderate/severe symptoms at 2-3 years continued to manifest decreased ROM, increased EMG during cranio-cervical flexion, sensory hypersensitivity and elevated levels of psychological distress when compared to recovered participants and those with milder symptoms. The latter two groups showed only persistent deficits in cervical muscle recruitment patterns. Higher initial NDI scores (OR 1.00-1.1), older age (OR 1.00-1.13), cold hyperalgesia (OR 1.1-1.13) and post-traumatic stress symptoms (OR 1.03-1.2) remained significant predictors of poor outcome at long-term follow-up (r(2) = 0.56). The robustness of these physical and psychological factors suggests that their assessment in the acute stage following whiplash injury will be important. (c) 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Improvement in measures of psychological distress amongst amphetamine misusers treated with brief cognitive-behavioural therapy (CBT)

This trial of cognitive-behavioural therapy (CBT) based amphetamine abstinence program (n = 507) focused on refusal self-efficacy, improved coping, improved problem solving and planning for relapse prevention. Measures included the Severity of Dependence Scale (SDS), the General Health Questionnaire-28 (GHQ-28) and Amphetamine Refusal Self-Efficacy. Psychiatric case identification (caseness) across the four GHQ-28 sub-scales was compared with Australian normative data. Almost 90% were amphetamine-dependent (SDS 8.15 +/- 3.17). Pretreatment, all GHQ-28 sub-scale measures were below reported Australian population values. Caseness was substantially higher than Australian normative values {Somatic Symptoms (52.3%), Anxiety (68%), Social Dysfunction (46.5%) and Depression (33.7%). One hundred and sixty-eight subjects (33%) completed and reported program abstinence. Program completers reported improvement across all GHQ-28 sub-scales Somatic Symptoms (p < 0.001), Anxiety (p < 0.001), Social Dysfunction (p < 0.001) and Depression (p < 0.001)}. They also reported improvement in amphetamine refusal self-efficacy (p < 0.001). Improvement remained significant following intention-to-treat analyses, imputing baseline data for subjects that withdrew from the program. The GHQ-28 sub-scales, Amphetamine Refusal Self-Efficacy Questionnaire and the SDS successfully predicted treatment compliance through a discriminant analysis function (p

An overview of psychological and neurobiological mechanisms by which early negative experiences increase risk of mood disorders

Objective: Early life experiences are associated with severe and long-lasting effects on behavioural and emotional functioning, which in turn are thought to increase the risk for unipolar depression and other disorders of affect regulation. The neurobiological and psychological mechanisms through which adverse early life experiences confer risk are poorly understood. Method: Alterations in brain structure and function in limbic and prefrontal cortical regions have been linked to early negative experiences and to mood disorders. Results: There are a number of psychological domains that may be dysfunctional in people with mood disorders, and which, if the dysfunction occurs prior to onset of mood symptoms, may signify a risk factor for depression. Cognitive dysfunction has been examined in patients with mood disorders, with some suggestion that changes in cognitive function may antedate the onset of mood symptoms, and may be exacerbated in those who experienced early negative trauma. Social cognition, including emotion comprehension, theory of mind and empathy, represent under-studied domains of psychological function that may be negatively influenced by early adverse experience. Temperament and personality factors may also leave people vulnerable to mood instability. Conclusion: This review summarizes the evidence for dysfunction in each of these domains for people with mood disorders.

Maternal symptoms of depression are related to observations of controlling feeding practices in mothers of young children

Maternal depression can impair parenting practices and has been linked with less sensitive feeding interactions with children, but existing research is based on self-reports of feeding practices. This study examined relationships between maternal self-reported symptoms of depression with observations of mothers' child feeding practices during a mealtime. Fifty-eight mothers of 3-and 4-year-old children were video recorded eating a standardized lunch. The recording was then coded for instances of maternal controlling feeding practices and maternal vocalizations using the Family Mealtime Coding System. Mothers also provided information on current symptoms of depression and anxiety. Mothers who reported greater symptoms of depression were observed to use more verbal and physical pressure for their child to eat and to offer more incentives or conditions in exchange for their child eating. Mothers also used more vocalizations with their child about food during the observed mealtime when they had greater symptoms of depression. There was no link between symptoms of depression and observations of maternal use of restriction. Symptoms of depression are linked with observations of mothers implementing a more controlling, less sensitive feeding style with their child. Health professionals working with families in which mothers have symptoms of depression may benefit from receiving training about the possible impact of maternal depression on child-feeding practices, and mothers with symptoms of depression may benefit from guidance regarding its potential impact on their child-feeding interactions ©2013 American Psychological Association.

Screening for Sexual Trauma, Intimate Partner Violence and Mental Health Symptoms among HIV Positive South African Women

Background: The psychological sequelae of sexual trauma and physical intimate partner violence (IPV) exposure can lead to poor HIV care outcomes, including poor treatment adherence. This study aimed to estimate the prevalence of and factors associated with mental health symptoms and trauma among HIV positive women. Additionally, the study aimed to assess the feasibility and acceptability of screening for trauma and mental health symptoms among HIV positive South African women. Finally, the study aimed to elicit healthcare workers’ perceptions related to sexual trauma and the provision of care and services for HIV positive women with trauma histories.

Methods: The study utilized a mixed-methods approach that included a cross-sectional survey of 70 HIV positive women recruited through referral sampling and key informant interviews with seven healthcare workers (HCWs). A study-screening instrument consisting of 24 items from standard measures was used to screen women for sexual trauma, physical intimate partner violence (IPV), depression and PTSD. Sexual trauma and IPV were assessed across the lifetime, while depression and PTSD were current assessments. Logistic regression models were used to explore the relationship between trauma exposure and mental health symptoms, while controlling for age and education. Interview transcripts were coded and analyzed for emergent themes on HCWs perceptions on sexual trauma and HIV care.

Results: Among participants, 51% had sexual trauma experience and 75% had intimate partner violence (IPV) experience. Among participants, 36% met screening criteria for major depression; among those with traumatic experiences (n=57), 70% met screening criteria for post-traumatic stress disorder (PTSD). Compared to having no sexual trauma or IPV exposure, having both sexual trauma and IPV was significantly associated with higher odds of depression (OR = 8.11; 95% CI 1.48-44.34), while having either IPV or sexual trauma individually was not significantly associated with increased odds of depression. Compared to having either IPV or sexual trauma, having both sexual trauma and IPV was not significantly associated with PTSD. Responses from participants’ feedback on screening process suggest that screening was feasible and acceptable to participants. Some of the health care workers (HCWs) did not perceive dealing with trauma to be part of their duties, but instead viewed social workers or psychologists as the appropriate health cadre to provide care related to trauma and mental health.

Conclusions: High levels of sexual trauma, IPV and mental health distress were reported among HIV positive women in this setting. Screening for trauma and mental health symptoms was acceptable to the participants, but several challenges were encountered in implementing screening. Given the potential impact of trauma and mental health on HIV care engagement, interventions to address trauma and its psychological sequelae are needed.

Psychosocial Functioning in Women with Symptoms of Persistent Genital Arousal

Persistent genital arousal disorder (PGAD) is characterized by physiological sexual arousal (vasocongestion, sensitivity of the genitals and nipples) that is described as distressing, and sometimes painful. Although awareness of PGAD is growing, there continues to be a lack of systematic research on this condition. The vast majority of published reports are case studies. Little is known about the symptom characteristics, biological factors, or psychosocial functioning associated with the experience of persistent genital arousal (PGA) symptoms. This study sought to characterize a sample of women with PGA (Study One); compare women with and without PGA symptoms on a series of biopsychosocial factors (Study Two); and undertake an exploratory comparison of women with PGA, painful PGA, and genital pain (Study Three)—all within a biopsychosocial framework. Symptom-free women, women with PGA symptoms, painful PGA, and genital pain, completed an online survey of biological factors (medical history, symptom profiles), psychological factors (depression, anxiety) and social factors (sexual function, relationship satisfaction). Study One found that women report diverse symptoms associated with PGA, with almost half reporting painful symptoms. In Study Two, women with symptoms of PGA reported significantly greater impairment in most domains of psychosocial functioning as compared to symptom-free women. In particular, catastrophizing of vulvar sensations was related to symptom ratings (i.e., greater severity, distress) and psychosocial outcomes (i.e., greater depression and anxiety). Finally, Study Three found that women with PGA symptoms reported some overlap in medical comorbidities and symptom expression as those with combined PGA and vulvodynia and those with vulvodynia symptoms alone; however, there were also a number of significant differences in their associated physical symptoms. These studies indicate that PGA symptoms have negative consequences for the psychosocial functioning of affected women. As such, future research and clinical care may benefit from a biopsychosocial approach to PGA symptoms. These studies highlight areas for more targeted research, including the role of catastrophizing in PGA symptom development and maintenance, and the potential conceptualization of both PGA and vulvodynia (and potentially other conditions) under a general umbrella of ‘genital paraesthesias’ (i.e., disorders characterized by abnormal sensations, such as tingling and burning).