Preditores biopsicossociais de dor, incapacidade e depressão em pacientes brasileiros com dor crônica

JUSTIFICATIVA E OBJETIVOS: Esta pesquisa foi baseada na perspectiva biopsicossocial de dor crônica, que sugere a existência de interrelação dinâmica entre alterações biológicas, estado psicológico e contexto social, onde cada uma destas dimensões apresenta um papel diferenciado na dor crônica, incapacidade e ajuste emocional. Este estudo examinou a aplicabilidade de preditores de dor, incapacidade e sofrimento propostos pelos modelos biopsicossociais de dor em amostra de pacientes brasileiros com dor crônica. MÉTODO: Estudo de corte transversal realizado com amostra de conveniência de 311 participantes atendidos em diversos centros de dor localizados no Sul e Sudeste do Brasil. As análises estatísticas para examinar as propriedades dos testes e relações entre as variáveis incluíram teste t, Análise de Variância, correlações, regressão hierárquica múltipla e logística. Todas as análises estatísticas foram realizadas com o programa SPSS-14. RESULTADOS: Os fatores orgânicos, sócio-demográficos e cognitivos contribuíram para incapacidade, depressão, intensidade da dor e empregabilidade de forma diferenciada. Nessa amostra, grau de escolaridade, local da dor e autoeficácia contribuíram para incapacidade; pensamentos catastróficos foram o único preditor de depressão; gênero e autoeficácia contribuíram para a intensidade da dor; e idade, grau de escolaridade, incapacidade e autoeficácia foram fatores de risco para desemprego. CONCLUSÃO: As evidências descritas na literatura baseadas na perspectiva biopsicossocial, que enfatizam o papel distinto de fatores biopsicossociais na dor, incapacidade e sofrimento mental foram confirmadas nesse estudo.

Women's subjective and objective health over time : the role of psychosocial conditions and physiological stress responses

Today, health problems are likely to have a complex and multifactorial etiology, whereby psychosocial factors interact with behaviour and bodily responses. Women generally report more health problems than men. The present thesis concerns the development of women’s health from a subjective and objective perspective, as related to psychosocial living conditions and physiological stress responses. Both cross-sectional and longitudinal studies were carried out on a representative sample of women. Data analysis was based on a holistic person-oriented approach as well as a variable approach. In Study I, the women’s self-reported symptoms and diseases as well as self-rated general health status were compared to physician-rated health problems and ratings of the general health of the women, based on medical examinations. The findings showed that physicians rated twice as many women as having poor health compared to the ratings of the women themselves. Moreover, the symptom ”a sense of powerlessness” had the highest predictive power for self-rated general health. Study II investigated individual and structural stability in symptom profiles between adolescence and middle-age as related to pubertal timing. There was individual stability in symptom reporting for nearly thirty years, although the effect of pubertal timing on symptom reporting did not extend into middle-age. Study III explored the longitudinal and current influence of socioeconomic and psychosocial factors on women’s self-reported health. Contemporary factors such as job strain, low income, financial worries, and double exposure in terms of high job strain and heavy domestic responsibilities increased the risk for poor self-reported health in middle-aged women. In Study IV, the association between self-reported symptoms and physiological stress responses was investigated. Results revealed that higher levels of medically unexplained symptoms were related to higher levels of cortisol, cholesterol, and heart rate. The empirical findings are discussed in relation to existing models of stress and health, such as the demand-control model, the allostatic load model, the biopsychosocial model, and the multiple role hypothesis. It was concluded that women’s health problems could be reduced if their overall life circumstances were improved. The practical implications of this might include a redesign of the labour market giving women more influence and control over their lives, both at and away from work.

Nondermatomal somatosensory deficits in chronic pain patients: are they really hysterical?

Patients with chronic pain disorders frequently show nondermatomal somatosensory deficits (NDSDs) that are considered to be functional. Typically, NDSDs show quadratomal or hemibody distribution ipsilateral to the areas of chronic pain. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition and the International Classification of Diseases, 10th revision, such functional somatosensory deficits are classified in the chapter "conversion disorder." Many publications also used the term "hysterical sensory loss." However, doubts are increasing about this one-sided psychiatric view. We aimed to better characterize the biopsychosocial factors associated with NDSDs. Therefore, we compared 2 groups of inpatients with chronic pain disorder, of whom 90 suffered from NDSDs and 90 did not. The patients with NDSDs all showed widespread somatosensory deficits with hemibody distribution. On logistic regression analysis, history of a prior physical trauma was positively predictive for patients with NDSDs. Personality disorder and adverse childhood experiences were positively predictive for the control group with chronic pain disorders without NDSDs. The frequencies of comorbid depression and anxiety disorder did not differ statistically between groups. In conclusion, pain patients with NDSDs are, psychopathologically, by no means more noticeable personalities than patients with chronic pain disorder without NDSDs. Similar to complex regional pain syndromes, we assume a multifactorial etiology of NDSDs, including stress. Based on our observations, terms like "hysteric" should not be applied any longer to patients with NDSDs who suffer from chronic pain.

[Psychosomatic medicine in primary care]

Patients commonly visit their primary care physician (PCP) because of body symptoms. However, neither the PCP nor his patient can tell immediately whether or not psychosocial factors play a role in the disease manifestation. If this is the case, only a patient-centred approach and basic knowledge in biopsychosocial skills will help the PCP to diagnose and treat his patient appropriately. This article gives a comprehensive overview on how the PCP can approach patients with psychosomatic diseases (i.e. somatic symptoms exacerbated by psychosocial factors, medically unexplained symptoms, functional somatic syndromes, somatic manifestation of psychiatric diseases). Adopting this approach will allow the PCP to be challenged but not overburdened by, on an average, 30-50% of his patients presenting with psychosomatic symptoms.

Identifying mechanisms of treatment effects and recovery in rehabilitation of schizophrenia: longitudinal analytic methods

The longitudinal dimension of schizophrenia and related severe mental illness is a key component of theoretical models of recovery. However, empirical longitudinal investigations have been underrepresented in the psychopathology of schizophrenia. Similarly, traditional approaches to longitudinal analysis of psychopathological data have had serious limitations. The utilization of modern longitudinal methods is necessary to capture the complexity of biopsychosocial models of treatment and recovery in schizophrenia. The present paper summarizes empirical data from traditional longitudinal research investigating recovery in symptoms, neurocognition, and social functioning. Studies conducted under treatment as usual conditions are compared to psychosocial intervention studies and potential treatment mechanisms of psychosocial interventions are discussed. Investigations of rehabilitation for schizophrenia using the longitudinal analytic strategies of growth curve and time series analysis are demonstrated. The respective advantages and disadvantages of these modern methods are highlighted. Their potential use for future research of treatment effects and recovery in schizophrenia is also discussed.

The ventro-medial prefrontal cortex: a major link between the autonomic nervous system, regulation of emotion, and stress reactivity?

ABSTRACT: Recent progress in neuroscience revealed diverse regions of the CNS which moderate autonomic and affective responses. The ventro-medial prefrontal cortex (vmPFC) plays a key role in these regulations. There is evidence that vmPFC activity is associated with cardiovascular changes during a motor task that are mediated by parasympathetic activity. Moreover, vmPFC activity makes important contributions to regulations of affective and stressful situations.This review selectively summarizes literature in which vmPFC activation was studied in healthy subjects as well as in patients with affective disorders. The reviewed literature suggests that vmPFC activity plays a pivotal role in biopsychosocial processes of disease. Activity in the vmPFC might link affective disorders, stressful environmental conditions, and immune function.

[Implementation of a routine gradual psycho-diagnostic programme in somatic rehabilitation centres - results of a pilot study]

STUDY AIM: A pilot study was conducted to implement and evaluate a routine gradual psycho-diagnostic programme to improve diagnostics and treatment of mental disorders in somatic rehabilitation centres. First of all, implementation strategies were acquired in trainings together with psychologists and physicians. The psycho-diagnostic programme consists of a screening instrument (PHQ-9) designed to permit time-effective detection of comorbid mental disorders. Besides evaluation of the training, the aim of the study was to analyze the extent to which it is possible to implement the routine gradual psycho-diagnostic programme in practice. Additionally, it was intended to identify beneficial and obstructive conditions for implementation. METHODOLOGY: The pilot study was conducted in two orthopaedic and one cardiological rehabilitation centre. The training was evaluated directly after its completion using a questionnaire. Three months after its implementation, the introduction of the psycho-diagnostic programme was evaluated using interviews with n=11 physicians and psychologists. RESULTS: The training was rated positively by the participants . Implementation of the entire gradual psycho-diagnostic programme was possible in one centre and to some degree in the other two. Beneficial for implementation were a frank organisational climate, sufficient time resources, and physicians' biopsychosocial understanding of disease. A dismissive attitude towards psycho-diagnostics, little communication between staff members, little perceived advantage for one's own work and fear to stigmatise patients by psychiatric diagnoses were obstructive. CONCLUSION: Essential for a successful implementation are sufficient time and personal resources, a motivation for change in staff and centre management, and a positive attitude regarding psycho-diagnostics in clinic staff. Furthermore, flexibility in implementation strategies and the opportunity to participate in the implementation process are important.

Metabolic control in children and adolescents with diabetes mellitus type I in Berne: a cross-sectional study.

AIMS/HYPOTHESIS In diabetes mellitus type I, good glycaemic control is crucial in preventing long-term diabetic complications. The aim of this study was to determine the current level of metabolic control in children and adolescents in our diabetes outpatient clinic at the University Children's Hospital, Berne. Furthermore, the impact of different factors such as age, pubertal stage, sex, duration of diabetes and insulin regimen on glycaemic control was studied. METHODS In a cross-sectional, prospective study 168 children and adolescents with type I diabetes mellitus (f:m = 87:81; prepubertal 48 [mean age 4.4 years, mean duration of diabetes 2.8 years]; pubertal 120 [mean age 9.4 years; mean duration of diabetes 5.2 years]) were studied for three months. Clinical data and HbA1c levels (latex immunoagglutination test) were recorded, statistically analysed and compared with the international literature. RESULTS In our type I diabetic children and adolescents the overall HbA1c was 8.07 +/- 1.15% (mean +/- SD; test-specific norm for healthy subjects: 4.1-6.1%). Glycaemic control was significantly worse in the pubertal group compared to the prepubertal (HbA1c 8.22 +/- 1.25% vs. 7.81 +/- 0.87%; p < 0.01). In addition, we found better metabolic control in patients with duration of diabetes below 2 years in children and adolescents (HbA1c prepubertal < 2 years: 7.45 +/- 0.67% vs. > 2 years: 8.05 +/- 0.93%, p < 0.05; pubertal < 2 years: 7.62 +/- 0.75% vs. > 2 years: 8.31 +/- 1.29%, p < 0.005). Importantly, sex and insulin regimen did not significantly influence glycaemic control. CONCLUSION/INTERPRETATION The current level of metabolic control in our children and adolescents with diabetes mellitus type I is comparable to the glycaemic control of the intensively treated adolescent group of the DCCT-study, in whom decreased risk of long-term diabetic complications was found. In contrast, our patients were intensively treated in terms of frequent contacts with the diabetes team, but were not necessarily on an intensified insulin regimen. The impact of biopsychosocial support from multidisciplinary diabetes team on good metabolic control in children and adolescents with type I diabetes mellitus and their families seems to be very important.

Time pressure, social work stressors and blood pressure in a team of seven IT-workers during one week of intense work

Background. In the field of information technology (IT) time pressure is common. Working with tight deadlines together on the same task increases the risk of social stressors referring to tensions and conflicts at work. Purpose. This field study tested both the association of time pressure and social stressors with blood pressure during work. Method. Seven employees – staff of a small IT enterprise – participated in repeated ambulatory blood pressure measurements over the course of one week. Time pressure and social stressors at work were assessed by questionnaire at the beginning of the study. Results. Multilevel regression analyses of 138 samples revealed higher levels of time pressure to be related to marginally significant increases in mean arterial blood pressure at noon and in the afternoon. In addition, higher levels of social stressors at work were significantly associated to elevated mean arterial pressure in the afternoon. Conclusion. Findings support the view that threats to the social self play an important role in occupational health.

Constructing the Vulvar Pain Assessment Questionnaire Inventory

The goals of this program of research were to examine the link between self-reported vulvar pain and clinical diagnoses, and to create a user-friendly assessment tool to aid in that process. These goals were undertaken through a series of four empirical studies (Chapters 2-6): one archival study, two online studies, and one study conducted in a Women’s Health clinic. In Chapter 2, the link between self-report and clinical diagnosis was confirmed by extracting data from multiple studies conducted in the Sexual Health Research Laboratory over the course of several years. We demonstrated the accuracy of diagnosis based on multiple factors, and explored the varied gynecological presentation of different diagnostic groups. Chapter 3 was based on an online study designed to create the Vulvar Pain Assessment Questionnaire (VPAQ) inventory. Following the construct validation approach, a large pool of potential items was created to capture a broad selection of vulvar pain symptoms. Nearly 300 participants completed the entire item pool, and a series of factor analyses were utilized to narrow down the items and create scales/subscales. Relationships were computed among subscales and validated scales to establish convergent and discriminant validity. Chapters 4 and 5 were conducted in the Department of Obstetrics & Gynecology at Oregon Health & Science University. The brief screening version of the VPAQ was employed with patients of the Program in Vulvar Health at the Center for Women’s Health. The accuracy and usefulness of the VPAQscreen was determined from the perspective of patients as well as their health care providers, and the treatment-seeking experiences of patients was explored. Finally, a second online study was conducted to confirm the factor structure, internal consistency, and test-retest reliability of the VPAQ inventory. The results presented in these chapters confirm the link between targeted questions and accurate diagnoses, and provide a guideline that is useful and accessible for providers and patients.

Fatores de risco em saúde mental : contributos para o bem-estar biopsicossocial dos profissionais da saúde

CONTEXTO: A nossa investigação estuda o stress no trabalho e a sua relação com a saúde mental. Descrevemos fatores específicos e de risco psicossocial no trabalho, particularmente no trabalho dos enfermeiros, e as suas implicações para a saúde mental e para o bem-estar biopsicossocial, tais como: Tipo de trabalho; Conteúdo do trabalho; Desempenho de papel; Relações interpessoais e grupais; Desenvolvimento da carreira; Novas tecnologias e Aspetos organizacionais. OBJETIVO(S): O objetivo fundamental foi estudar a influência de algumas variáveis pessoais e situacionais de risco biopsicossocial na saúde mental e no bem-estar dos profissionais de saúde, em contexto hospitalar METODOLOGIA: Trata-se de um estudo quantitativo, transversal e descritivo, do tipo correlacional. A recolha de informação obedeceu a um protocolo constituído por dados pessoais e as escalas: Satisfação geral do trabalho, Questionário geral de saúde, Questionário de saúde, Escala de fadiga crónica, Escala de ansiedade cognitiva-somática, Inventário de personalidade de Eysenck, Inventário clínico de autoconceito, Inventário de resolução de problemas, Questionário de vulnerabilidade ao stress e Questionário de stress ao trabalho. A amostra foi não probabilística intencional, constituída por 570 enfermeiros, a laborarem por turnos e em regime normal, no contexto hospitalar, perfazendo, no final, 360 enfermeiros. RESULTADOS: Os principais resultados apontam o seguinte: Os enfermeiros manifestam algum descontentamento com o ambiente de trabalho; A globalidade da amostra demonstra índices de saúde baixos; Regra geral, todos os enfermeiros estão vulneráveis ao stress; Em relação ao stress produzido pelas circunstâncias organizacionais, a totalidade da amostra revela elevados índices de stress e o seu bem-estar biopsicossocial, manifestamente afetado. CONCLUSÕES: Destes resultados fomos levados a concluir que quanto maior for a fadiga crónica, o neuroticíssimo e a ansiedade cognitiva, maior será a tendência dos enfermeiros para diminuírem a autorresponsabilização e o medo. Esta relação pode tornar-se circular e levar a comportamentos desajustados como, por exemplo, indiferença, desinteresse, relações interpessoais conflituosas, entre outros aspetos. As consequências de tais comportamentos poderão traduzir-se em absentismo, erros de desempenho ou vontade de abandonar a instituição.

A comparison of body-image dissatisfaction and eating disturbance among Australian and Hong Kong women

The current cross-cultural study was designed to test the validity of a biopsychosocial mediation model which hypothesized that a variety of biological, psychological and social variables would have their mode of action upon eating disturbance through the mediation of body-image dissatisfaction. The biopsychosocial variables examined were body mass, self-esteem, weight-related teasing, previous dieting and sociocultural influences. Forty-eight Hong Kong and 100 Australian females aged 17-28 years were assessed. Results revealed no significant difference between the groups of women in levels of body dissatisfaction and eating disturbance; however, different variables in the biopsychosocial model appeared to have contributed to their predisposition to these conditions. The findings suggest that there appear to exist important cultural differences in various aspects of dieting and body image in young women. Implications for prevention, treatment and future research are discussed. Copyright (c) 2005 John Wiley & Sons, Ltd and Eating Disorders Association.

Interfaces between cardiovascular and kidney disease among Aboriginal Australians

Rates of kidney disease among several indigenous groups have been shown to be substantially higher than corresponding non-indigenous groups. This excess has been clearly shown among Aboriginal Australians with respect to both end-stage kidney disease and early kidney disease. Rates of cardiovascular disease among Aboriginal Australians are also very high, as are rates of diabetes, smoking, and possibly overweight and obesity. These factors have been traditionally linked with cardiovascular and renal disease as part of a broader metabolic syndrome. However, the links and interfaces between cardiovascular and kidney disease in this environment extend beyond these traditional factors. The factors associated with atherosclerosis have expanded in recent years to include markers of inflammation, some infection, antioxidants, and other non-traditional risk factors. Given the high rates of acute infection and poor living conditions endured by many indigenous people, one might expect these non-traditional risk factors to be highly prevalent. In this review, we explore the relationships between markers of inflammation, some serological markers of infection, and other selected markers and both cardiovascular and renal disease. In doing so, we demonstrate links between kidney and cardiovascular disease at a number of levels, beyond the traditional cardiovascular/renal risk factors. Many of these factors are beyond the control of the individual or even community; addressing these issues a broader focus and biopsychosocial model. (C) 2005 by the National Kidney Foundation, Inc.

A review of awareness interventions in brain injury rehabilitation

Unawareness related to brain injury has implications for participation in rehabilitation, functional outcomes, and the emotional well-being of clients. Addressing disorders of awareness is an integral component of many rehabilitation programmes, and a review of the literature identified a range of awareness interventions that include holistic milieu-oriented neuropsychological programmes, psychotherapy, compensatory and facilitatory approaches, structured experiences, direct feedback, videotaped feedback, confrontational techniques, cognitive therapy, group therapy, game formats and behavioural intervention. These approaches are examined in terms of their theoretical bases and research evidence. A distinction is made between intervention approaches for unawareness due to neurocognitive factors and approaches for unawareness due to psychological factors. The socio-cultural context of unawareness is a third factor presented in a biopsychosocial framework to guide clinical decisions about awareness interventions. The ethical and methodological concerns associated with research on awareness interventions are discussed. The main considerations relate to the embedded nature of awareness interventions within rehabilitation programmes, the need for individually tailored interventions, differing responses according to the nature of unawareness, and the risk of eliciting emotional distress in some clients.

Symptom reporting and associations with compensation status, self-awareness, causal attributions, and emotional wellbeing following traumatic brain injury

Individuals seeking compensation following traumatic brain injury (TBI) are often found to report a disproportionately high level of symptoms relative to objective indicators of impairment. Previous studies highlight that level of symptom reporting is also related to self-awareness, causal attribution, and emotional wellbeing. Therefore, the reasons for high symptom reporting in the context of compensation are generally unclear. This study aimed to identify whether self-awareness, causal attribution, and emotional wellbeing are significantly associated with level of symptom reporting after controlling for compensation status. A sample of 54 participants with TBI comprised two groups, namely, claimants (n = 27) and non-claimants (n = 27), who were similar in terms of demographic and neuro-cognitive variables. Participants completed the Symptom Expectancy Checklist, Hospital Anxiety Depression Scale, Awareness Questionnaire and a causal attribution scale. A series of independent t tests and Pearson's correlations identified that a higher level of symptom reporting was associated with the following: seeking compensation, less severe TBI, increased age, greater self-awareness, increased post-injury changes reported by relatives, a higher level of mood symptoms, and a tendency to blame other people. Multivariate analysis identified that after controlling for demographic, injury, and compensation status variables, level of mood symptoms and self-awareness were significantly associated with level of symptom reporting. The findings suggest that mood symptoms and heightened self-awareness are significantly related to high symptom reporting independent of compensation status, thus supporting the need for clinicians to interpret symptom reporting within a biopsychosocial context.