General Clinical Settings Research Articles

A comparison of the clinical features of fibromyalgia syndrome in different settings

Background The “funnel hypothesis” of fibromyalgia syndrome (FMS) assumes that the high levels of somatic and psychological symptoms reported by FMS-patients are due to a selection bias of patients seeking for medical specialist care. We tested the hypothesis by comparing FMS-patients from a general population sample and different clinical settings. Methods From a cross-sectional survey of a representative sample of the German general population, persons meeting FMS-criteria were selected. Consecutive in- and outpatients from German rheumatology, pain medicine, psychosomatic medicine and integrative medicine settings with established or initial diagnosis of FMS were recruited. FMS was diagnosed in all samples by the survey criteria of the regional pain scale. Somatic symptom intensity was measured by 13 items of the Patient Health Questionnaire PHQ 15, depressed mood by the 9-items PHQ 9. Results 96 persons of the general population, 86 of the rheumatology, 80 of the pain medicine, 69 of the psychosomatic medicine and 58 of the integrative medicine setting were included into the comparison. Patients of the clinical settings reported more pain sites and more somatic and depressive symptoms than FMS-persons of the general population. Patients of the different clinical settings did not differ in the number of pain sites and the intensity of depressive and somatic symptoms. Conclusions We found a “funnel” between FMS-persons of the general population and FMS-patients of clinical settings, but not between patients of different levels of care. Patients contacting the health care system did not differ in clinical features.

Panorama nacional do ensino da psiquiatria nas escolas médicas brasileiras

OBJETIVO: Determinar o perfil de ensino da psiquiatria nos cursos médicos brasileiros, verificando o número de professores envolvidos e suas titulações, o número de disciplinas e o enfoque predominante, material didático e local de ensino/aprendizagem. MÉTODO: O estudo foi baseado no levantamento de dados obtidos pela aplicação de questionários nas escolas médicas brasileiras que constam no site da Associação Brasileira de Educação Médica. RESULTADOS: Das 119 escolas médicas brasileiras, 85 (71%) responderam à pesquisa. O número de professores psiquiatras envolvidos no ensino variou de 1 a 5 (75,3%); desses, 1 a 2 (43,4%) eram doutores/livres-docentes, 1 a 2 (45,8%) eram mestres, e 1 a 2 (57,3%) eram especialistas. Observou-se que 41,2% das escolas oferecem duas disciplinas de psiquiatria, com enfoque predominantemente psicodinâmico e clínico (61,2%). Em 52,9% dos casos, o conteúdo programático não é desenvolvido apenas em cadeiras específicas de psiquiatria. As disciplinas oferecem, em 64,7% dos casos, aulas práticas em contextos clínicos gerais. A carga horária durante o curso é de 61-90 horas-aula (26,2%), e 88,9% têm livros-textos básicos. Em 83,3% das escolas médicas, essas disciplinas são avaliadas pelos alunos ao final das mesmas. CONCLUSÃO: Foi observada uma grande heterogeneidade nas regiões avaliadas, em pelo menos 71% das escolas. Novos estudos devem aprofundar este primeiro levantamento.

The n-of-1 clinical trial: the ultimate strategy for individualizing medicine?

N-of-1 or single subject clinical trials consider an individual patient as the sole unit of observation in a study investigating the efficacy or side-effect profiles of different interventions. The ultimate goal of an n-of-1 trial is to determine the optimal or best intervention for an individual patient using objective data-driven criteria. Such trials can leverage study design and statistical techniques associated with standard population-based clinical trials, including randomization, washout and crossover periods, as well as placebo controls. Despite their obvious appeal and wide use in educational settings, n-of-1 trials have been used sparingly in medical and general clinical settings. We briefly review the history, motivation and design of n-of-1 trials and emphasize the great utility of modern wireless medical monitoring devices in their execution. We ultimately argue that n-of-1 trials demand serious attention among the health research and clinical care communities given the contemporary focus on individualized medicine.

Commentary on Van Rooij et al. (2011): ‘Gaming addiction’- a psychiatric disorder or not?

Van Rooij et al. [1] describe a longitudinal study evaluating the presence and persistence of compulsive or problematic internet gaming in a large sample of Dutch school children. In many ways, this study goes beyond earlier research in attempting to identify and evaluate longitudinally ‘gaming addiction’. It examined a large sample, had a high response rate, employed a longitudinal design and included assessments of other presumably related constructs, such as psychosocial health. ‘Gaming addiction’ and the more broadly construed ‘internet addiction’ are currently not classified as psychiatric disorders in the Diagnostic and Statistical Manual for Mental Disorders (DSM), 4th revision, although discussions are under way regarding the existence of such a putative disorder [2]. Many anecdotal reports exist regarding the excessive amounts of time spent in play, and adverse consequences of intensive play on individuals' personal, social and school or work functioning [e.g. 3]. Centers dedicated to the treatment of these conditions are also in operation [4]. However, there are not yet any clearly defined or well-established clustering of symptoms that characterizes gaming ‘addiction’. Expert consensus is not achieved in terms of what constitutes this putative disorder [5,6]. A variety of surveys exist to assess it, but none have well-established psychometric properties [6] and the research itself is inconsistent in its definition of problematic gaming. Some studies utilize diagnostic criteria for pathological gambling and reword them to assess gaming, other surveys integrate substance use disorder criteria, another set utilizes a combination of these two types of criteria, and still others propose new and unique ‘criteria’[e.g. 7–12]. Further complicating matters, many researchers and clinicians modify the existing instruments and employ different cut-points to identify problems [13,14]. Given the inconsistent methodology used to classify ‘gaming addiction’, it is not surprising that prevalence rates vary vastly depending upon the instruments and methods employed. Some reports suggest very low prevalence rates of ‘gaming addiction’[<1%; 15] and others very high rates [>35% 16]; rates may vary by culture, but even within countries high variability in prevalence rates of ‘gaming addiction’ are noted [c.f., 17,18]. Moreover, almost all the samples are derived from school- or university-based surveys, and representation of older and even young adult to middle-aged respondents in surveys assessing ‘gaming addiction’ are sorely lacking. When non-school-based surveys are conducted, most often it is a convenience sample of people recruited from gaming or internet websites [e.g. 19], thereby failing to be representative of the general population. The van Rooij et al. [1] study was a school-based survey, and it had a high response rate. The longitudinal nature of the study design is critical to interpretation of the findings. Interestingly, only half the respondents classified initially as ‘addicted’ to gaming remained so 1 year later. Although the sample size of ‘addicted’ gamers was small, the lack of persistence of ‘addiction’ over this relatively short time-frame suggests that the behavior may be transitory. Further, classification as ‘gaming addicted’ was not associated with poor psychosocial functioning in this study, even when a variety of instruments was used to examine mental health along a number of dimensions. The modest level of impairment noted in these presumably ‘addicted’ gamers indicates that perhaps this may not be a true psychiatric disorder, at least not as defined in that study. Much more scientific research is needed regarding gaming and internet ‘addictions’ more generally. Recommendations include establishment of a provisional expert consensus of the behavioral patterns underlying the condition(s). These criteria should be subjected to extensive psychometric testing to establish multiple forms of validity and reliability using samples drawn from the general population and clinical settings. Long-term prospective evaluations should be conducted using standardized criteria to determine temporal stability of the putative disorder(s). Familial and genetic patterns of the condition(s) should be evaluated, along with biomarkers. Finally, associations with other psychiatric disorders should be assessed to ascertain if they are unique disorders or manifestation of another (or other) psychiatric condition(s). Until such data are collected, caution should be extended when attempting to classify excessive behavior patterns as psychiatric disorders. As we move forward in understanding more clearly how, why and who engages in problematic internet gaming, we should also consider the past. The internet gaming ‘addiction’ of the early 21st century may be reminiscent of video arcade and television ‘addiction’ from the previous generation. If we draw the threshold too low, all excessive behavior patterns, including eating too much chocolate and working too much, may become psychiatric disorders, minimizing the experiences of, and ultimately limiting treatment availability and coverage for, individuals with true psychiatric disorders. None

Clustering of psychiatric and somatic illnesses in the general population: multimorbidity and socioeconomic correlates

The distribution of psychiatric disorders and of chronic medical illnesses was studied in a population-based sample to determine whether these conditions co-occur in the same individual. A representative sample (N = 1464) of adults living in households was assessed by the Composite International Diagnostic Interview, version 1.1, as part of the São Paulo Epidemiological Catchment Area Study. The association of sociodemographic variables and psychological symptoms regarding medical illness multimorbidity (8 lifetime somatic conditions) and psychiatric multimorbidity (15 lifetime psychiatric disorders) was determined by negative binomial regression. A total of 1785 chronic medical conditions and 1163 psychiatric conditions were detected in the population concentrated in 34.1 and 20% of respondents, respectively. Subjects reporting more psychiatric disorders had more medical illnesses. Characteristics such as age range (35-59 years, risk ratio (RR) = 1.3, and more than 60 years, RR = 1.7), being separated (RR = 1.2), being a student (protective effect, RR = 0.7), being of low educational level (RR = 1.2) and being psychologically distressed (RR = 1.1) were determinants of medical conditions. Age (35-59 years, RR = 1.2, and more than 60 years, RR = 0.5), being retired (RR = 2.5), and being psychologically distressed (females, RR = 1.5, and males, RR = 1.4) were determinants of psychiatric disorders. In conclusion, psychological distress and some sociodemographic features such as age, marital status, occupational status, educational level, and gender are associated with psychiatric and medical multimorbidity. The distribution of both types of morbidity suggests the need of integrating mental health into general clinical settings.

Wartezeiten und Länge des Arztgesprächs bestimmen aus Patientensicht die Qualität der Arzt-Patienten-Beziehung bei chronischer Hepatitis B und C: Ergebnisse einer prospektiven Studie bei 478 Patienten mit chronischer Virushepatitis

Little is known about the physician-patient interaction in hepatitis B and C. This study by the federal competence network hepatitis analysed the physician-patient interaction using the validated FAPI questionnaire. The questionnaire also contained questions concerning demography and disease characteristics. Of the total 1500 questionnaires sent out, 478 were returned (32 %) (20 % HBV vs. 80 % HCV). The FAPI index of patients with HBV/HCV infection (3.10 +/- 0,99) was lower than that in patients with other internal medicine diseases (3.61 +/- 0.92; n = 148). Women had lower values than men (2.98 vs. 3.25; p = 0.005). Patients with active HBV infection showed higher values than those with HCV infection (3.27 vs. 2.97; p < 0.05). Patients with successfully treated hepatitis B/C had higher values than those with active disease (3.36 vs. 3.02; p = 0.004). The index was lower in patients who waited > 2 weeks for the consultation when compared to those with a shorter wait (2.92 vs. 3.31; p < 0.001) and was also lower in patients who waited > 30 min at the consultation day when compared to those with a shorter wait (2.81 vs. 3.39; p < 0.001). The index gradually increased with the consultation length (2.47 < 10 min vs. 2.79 10 - 15 min vs. 3.21 15 - 30 min vs. 3.82 > 30 min; p < 0.001). The index was higher in patients seen by gastroenterologists (3.43) when compared with general practioners (3.10), internists (3.02) and clinical settings (3.13) (p < 0.05). A good information status was associated with higher FAPI values when compared with a bad information status (3.43 vs. 2.76; p < 0.001). Fibrosis, health insurance and age were not associated with FAPI index (p > 0.2). By multivariate analysis a long consultation, a good information status, patients' patience, short waiting times, and providing contact to a patient support group were independently associated with a high index. The physician-patient interaction in chronic viral hepatitis is worse than in other internal medicine diseases with problems being more pronounced in HCV infection and women when compared to men and HBV infection. Short waiting times and patients' patience ameliorated the interaction as well as the consultation length, the information status of the patient and providing contact to a patient support group. Type of health insurance did not affect either waiting times or physician-patient interaction; thus there is no hint for a two-class medicine in this part of hepatology.

An overview of radar based ultra wideband breast cancer detection algorithms

Breast cancer is the most common cancer in women in almost all countries around the world, and is one of the most common non-infective causes of death. Mammography, which uses ionising radiation, is the only early breast cancer screening technique proven to reduce breast cancer mortality in randomised controlled clinical trials. However, screening mammography is expensive, technically demanding and requires a high level of clinical expertise. It cannot be performed in general medical clinical settings readily. Ultra wideband (UWB) or microwave breast screening has the potential to be a safe, accurate and easy-to-use technique for breast disease detection that is more effective than routine clinical palpation or breast self-examination. Ultra wideband breast cancer detection algorithms have been researched by several groups for over a decade, with numerous algorithms reported. This paper serves to give an overview of existing algorithms for UWB breast cancer detection.

A self-reported instrument for prodromal symptoms of psychosis: Testing the clinical validity of the PRIME Screen—Revised (PS-R) in a Japanese population

Objective: Early intervention for psychosis requires an easy, useful assessment instrument to identify subjects with prodromal symptoms at an early stage. The aim of this study was to test the clinical validity of the PRIME Screen—Revised (PS-R), a 12-item self-reported instrument for prodromal symptoms of psychosis, by comparing the results for a non-clinical population with those for a clinical population. Method: The PS-R was administered to 1024 subjects (496 students and 528 outpatients). Of the 528 patients, 115 were randomly recruited and tested using the Structured Interview for Prodromal Syndromes (SIPS) to determine the concordant validity of the PS-R. The predictive validity of the PS-R was measured by determining the transition rate to psychosis during a 6-month follow-up period. Results: The specificity and sensitivity of the PS-R, using the SIPS as a gold standard, were 0.74 and 1.00. The concordant validity of the PS-R against the SIPS was 0.43. The predictive validity of the PS-R and the SIPS, defined as the transition rate to psychosis, were 0.11 and 0.25, respectively. None of the patients with negative PS-R results developed psychosis. Conclusions: Our findings showed that the PS-R was highly valid and that its usage is feasible in both general practice and clinical settings. This self-reported instrument represents a useful screening tool for alerting clinicians to subjects with psychotic prodromal symptoms.

Comparison of Prostate Volume Measured by Transrectal Ultrasonography and MRI with the Actual Prostate Volume Measured after Radical Prostatectomy

Aim: To compare the prostate volume, as measured by transrectal ultrasonography (TRUS) and by MRI, with that of the actual prostate volume measured after a radical prostatectomy (RRP). Materials and Methods: This prospective study included 21 patients who had undergone RRP. TRUS prostate volumes were calculated using the prolate ellipsoid volume formula, with the anteroposterior diameter measured from axial (TRUS-V1) and mid-sagittal images (TRUS-V2). Two prolate ellipsoid volumes (MRI-EV1 and MRI-EV2) were calculated from the MRI using the same method, and planimetric volume (MRI-PV). The actual prostate volume (Actual-V) was measured in a measuring jug within 1 h after RRP. Results: Mean of Actual-V was 40.3ml (21.0–82.0). In paired sample tests, the correlation coefficients (R) for all methods were over 0.8. In a Student’s t test (paired), MRI-PV (p = 0.620), MRI-EV2 (p = 0.703) and TRUS-V1 (p = 0.099) showed no significant differences compared to the Actual-V. The linear regression models of these three methods were y = 1.025x – 0.268, y = 0.946x + 2.979 and y = 1.046x + 0.381, respectively. Conclusions: Between two TRUS volumes, TRUS-V1 was shown to be superior to TRUS-V2. In MRI, MRI-EV2 was more accurate than MRI-EV1. However, MRI-PV was the most accurate method. TRUS-V1 and MRI-EV2 could be used instead of MRI-PV in general clinical settings.

The relevance of trauma to general clinical practice.

Research findings on the prevalence in general clinical settings of trauma histories, trauma-related disorders and various other psychological disorders associated with trauma exposure, and physical health problems related to trauma are surveyed. It is argued, on the basis of diverse comorbid conditions associated with trauma exposure, that generalists with varied experience who obtain specialized trauma training are especially well equipped to develop competency in trauma practice. There are many subjects that have the potential to be useful and relevant facets of the psychology practitioner’s repertoire of knowledge and skills. Why should clinicians, who already have such a wide-ranging compendium of material to master in order to maintain competency in general practice, expend the time and effort to master yet another content area? It is this question that the remainder of this article aims to address. Appreciation of the relevance of trauma to understanding psychological difficulties played a central role in the very first pioneering stages of the development of psychotherapeutic practice (Herman, 1992b). The sustained, systematic empirical study of trauma, however, is much more recent. The legitimization of psychological trauma as an issue worthy of study can be traced back roughly a quarter century to the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–III; American Psychiatric Association, 1980). This event marked the official recognition of posttraumatic stress disorder (PTSD) as a diagnostic syndrome. In the intervening period between 1980 and the present, the study of trauma has evolved rapidly, generating a vast body of empirical, clinical, and theoretical literature (Gold & Faust, 2002). The systematic study of the impact of trauma on psychological functioning is so recent that even the most elementary aspects of the identification, assessment, and treatment of psychological trauma have not been incorporated into the standard curriculum for training professional psychologists (Courtois, 2002). The vast majority of psychologists currently practicing, therefore, are not familiar with this knowledge base. The overwhelming majority of contemporary psychological trauma specialists were of necessity self-taught, since their graduate training occurred in an era predating the existence of their field of specialization. They developed their expertise in trauma studies on their own initiative by reading and attending workshops

P4-394: Lack of evidence for the efficacy of memantine in mild Alzheimer's disease and modest effects in moderate Alzheimer's disease

is over 6,600 men in the U.S., Canada, and Puerto Rico in collaboration with the NCI-sponsored prostate prevention study. The accuracy of the primary, brief memory screening tool is critical for identifying possible incident cases of dementia, and triggers a second-level mental status exam that can trigger a medical evaluation for AD. Objectives: (1) Provide validation results for screening tools from a prevention trial. (2) Compare results of the Memory Impairment Screen (MIS) to expanded measures of memory. Methods: PREADVISE participants are screened annually with the Memory Impairment Screen (MIS). A Normal Aging (NAG) validation sub-sample is given an expanded battery annually that includes CERAD measures supplemented with tests (e.g., NYU paragraph recall, phonemic fluency, clock drawing). The current analysis evaluates the correspondence between MIS performance and memory scores from 410 men (mean: age 70.6 5.6; education 15.6 2.3; 10% African-American). Results: MIS performance for 84.4% of the sample was 7 or 8 (8 max), while 5.4% scored in the low normal range (5 or 6) and 10.2% scored at or below the cutoff of 4. Age, but not education differed between the 3 MIS groups. ANCOVA’s (age covariate) revealed group differences for multiple expanded memory measures. A follow-up multiple linear regression model shows a statistically significant prediction of MIS scores by measures of recognition errors (false positives) plus category fluency (R 0.59) and delayed recall (10-item word list; NYU paragraph; R 0.10). Conclusions: These data suggest that the 3-minute MIS has utility as a screening tool for prevention trials based on its association with other episodic memory tests. Sensitivity and specificity will be ascertained as more incident AD cases are identified. Further, as PREADVISE progresses, these validation methods can also indicate if the MIS could be improved through the addition of other cognitive components, providing an effective tool for AD detection in general clinical settings.

Does Systematic Graded Exposure In Vivo Enhance Outcomes in Multidisciplinary Chronic Pain Management Groups?

Graded exposure in vivo (GEXP) treatment has been successfully used to reduce levels of pain-related fear and disability in some chronic pain patients, but its effectiveness has not been evaluated in general clinical settings using group-design studies. The purpose of this study was to determine if the systematic incorporation of GEXP into a multidisciplinary chronic pain management group (PMG) treatment program would result in better treatment outcomes than usual PMG treatment. One hundred forty-three chronic pain patients who were assessed as suitable for an outpatient multidisciplinary chronic PMG program were randomly allocated to 3 experimental conditions; usual PMG, PMG incorporating systematic graded exposure, and wait-list control. The clinical outcomes of the 2 treatment conditions were not significantly different, suggesting that the systematic incorporation of GEXP into a multidisciplinary PMG program did not result in better treatment outcomes than usual PMG treatment. Both group treatment programs were associated with significant treatment effects when compared with the wait-list control on measures of pain intensity, fear of movement/(re)injury, pain self-efficacy, activity level, and depression. No treatment effects were found on self-report measures of pain disability or anxiety. The addition of systematic graded exposure into a multidisciplinary chronic pain management program did not result in better clinical outcomes than the usual group treatment program. The validity of GEXP to the broader population of chronic pain patients warrants further investigation.

Impulse Control Disorders and Co-Occurring Disorders: Dual Diagnosis Considerations

ABSTRACT Impulse control disorders (ICDs) such as pathological gambling frequently co-occur with a broad range of other psychiatric disorders. Relatively little research has investigated the nature of the relationships between ICDs and other psychiatric disorders. Important theoretical and clinical considerations exist regarding how best to conceptualize and treat ICDs within a dual diagnosis framework. Common genetic and environmental contributions have been reported for ICDs and other psychiatric disorders. Clinically, individuals with an ICD and another co-occurring disorder typically fare more poorly than those with either. Data suggest that ICDs frequently go undiagnosed in psychiatric patients. In order to optimize treatment, improved methods for screening individuals for ICDs should be developed and implemented in clinical settings. With increase in the emeregence of empirically validated treatments for ICDs, it is important to investigate their efficacies and tolerabilites in dually diagnosed groups and their effectiveness in general clinical settings.

The Cambridge Behavioral Inventory: Validation and Application in a Memory Clinic

The authors examined the validity of the Cambridge Behavioral Inventory (CBI), a questionnaire investigating broad neuropsychiatric symptoms and everyday functional ability in dementia. Test-retest reliability of the CBI was acceptable. Cross-validation with the Neuropsychiatric Inventory showed good concurrent validity of the CBI. The CBI reliably demonstrated that disinhibition, stereotypic behavior, elation, anxiety, poor self-care, and changes in eating habits occurred more commonly in patients with frontotemporal lobar degeneration than those with Alzheimer's disease. The authors concluded that the CBI is a reliable informant-based assessment of neuropsychiatric symptoms and everyday functioning and may be a suitable tool for use in general clinical practice settings.

Development and validation of a questionnaire for anxiety and depression in Pakistan

Background Currently clinicians and researchers in Pakistan have to use translated western instruments to screen for anxiety and depressive disorders. This study investigated the local idioms of emotional distress in Pakistan to develop a culturally valid and easy-to-use instrument to screen for common mental disorders in general clinical settings. Methods A systematic survey was conducted of psychiatric case notes of patients attending clinics in Peshawar and Lahore, diagnosed with anxiety or depressive disorders, to identify the range of common idioms of psychological distress. A pilot version of the questionnaire was refined and validated among a composite sample of 330 patients in inpatient, outpatient and rural community settings. ICD-10 Diagnostic Criteria for Research were used to define cases and patients' relatives acted as normal controls. Results The pilot version of the questionnaire was reduced to 42 items based on odds ratios between cases and controls. Anxiety symptoms were generally reported by depressed patients, but not vice versa. Finally 30 items were selected, in two sub-scales. This final version achieved sensitivity, specificity, and positive and negative predicted values of over 90% when comparing cases and controls. Limitations This questionnaire was based on what patients tell doctors and may not capture the entire repertoire of local idioms of distress. The validation study was conducted only in an Urdu/Punjabi speaking population, in Lahore and surrounding areas. Conclusions The Pakistan Anxiety and Depression Questionnaire consists of an anxiety/depression scale and a depression scale, each of 15 items. It demonstrates excellent validity as screening instrument for anxiety and depressive disorders in clinical settings in Pakistan.

The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure

Empathy is a key aspect of the clinical encounter but there is a lack of patient-assessed measures suitable for general clinical settings. Our aim was to develop a consultation process measure based on a broad definition of empathy, which is meaningful to patients irrespective of their socio-economic background. Qualitative and quantitative approaches were used to develop and validate the new measure, which we have called the consultation and relational empathy (CARE) measure. Concurrent validity was assessed by correlational analysis against other validated measures in a series of three pilot studies in general practice (in areas of high or low socio-economic deprivation). Face and content validity was investigated by 43 interviews with patients from both types of areas, and by feedback from GPs and expert researchers in the field. The initial version of the new measure (pilot 1; high deprivation practice) correlated strongly (r = 0.85) with the Reynolds empathy measure (RES) and the Barrett-Lennard empathy subscale (BLESS) (r = 0.63), but had a highly skewed distribution (skew -1.879, kurtosis 3.563). Statistical analysis, and feedback from the 20 patients interviewed, the GPs and the expert researchers, led to a number of modifications. The revised, second version of the CARE measure, tested in an area of low deprivation (pilot 2) also correlated strongly with the established empathy measures (r = 0.84 versus RES and r = 0.77 versus BLESS) but had a less skewed distribution (skew -0.634, kurtosis -0.067). Internal reliability of the revised version was high (Cronbach's alpha 0.92). Patient feedback at interview (n = 13) led to only minor modification. The final version of the CARE measure, tested in pilot 3 (high deprivation practice) confirmed the validation with the other empathy measures (r = 0.85 versus RES and r = 0.84 versus BLESS) and the face validity (feedback from 10 patients). These preliminary results support the validity and reliability of the CARE measure as a tool for measuring patients' perceptions of relational empathy in the consultation.

The relevance of trauma to general clinical practice.

Research findings on the prevalence in general clinical settings of trauma histories, trauma-related disorders and various other psychological disorders associated with trauma exposure, and physical health problems related to trauma are surveyed. It is argued, on the basis of diverse comorbid conditions associated with trauma exposure, that generalists with varied experience who obtain specialized trauma training are especially well equipped to develop competency in trauma practice. There are many subjects that have the potential to be useful and relevant facets of the psychology practitioner’s repertoire of knowledge and skills. Why should clinicians, who already have such a wide-ranging compendium of material to master in order to maintain competency in general practice, expend the time and effort to master yet another content area? It is this question that the remainder of this article aims to address. Appreciation of the relevance of trauma to understanding psychological difficulties played a central role in the very first pioneering stages of the development of psychotherapeutic practice (Herman, 1992b). The sustained, systematic empirical study of trauma, however, is much more recent. The legitimization of psychological trauma as an issue worthy of study can be traced back roughly a quarter century to the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–III; American Psychiatric Association, 1980). This event marked the official recognition of posttraumatic stress disorder (PTSD) as a diagnostic syndrome. In the intervening period between 1980 and the present, the study of trauma has evolved rapidly, generating a vast body of empirical, clinical, and theoretical literature (Gold & Faust, 2002). The systematic study of the impact of trauma on psychological functioning is so recent that even the most elementary aspects of the identification, assessment, and treatment of psychological trauma have not been incorporated into the standard curriculum for training professional psychologists (Courtois, 2002). The vast majority of psychologists currently practicing, therefore, are not familiar with this knowledge base. The overwhelming majority of contemporary psychological trauma specialists were of necessity self-taught, since their graduate training occurred in an era predating the existence of their field of specialization. They developed their expertise in trauma studies on their own initiative by reading and attending workshops

Arginine Vasopressin and Nocturnal Polyuria in Older Adults With Frequent Nighttime Voiding

We determined in older adults whether frequent nighttime voiding is associated with urine overproduction at night or nocturnal polyuria (NP) and whether NP is associated with abnormalities of arginine vasopressin (AVP) blood levels and/or renal responsiveness to AVP. We used a convenience sample of adults 65 years and older in home and general clinical research center settings. A total of 45 participants completed the 3-day general clinical research center stay. We used 7-day voiding diaries to determine which participants had 2 or greater nighttime voids and NP, defined as 35% or greater of 24-hour urine output at night. Abnormalities in AVP release and secretion were determined by water deprivation testing and by twice daily blood AVP measurement. There was a strong positive association between the number of nighttime voids and the proportion of urine produced at night (r = 0.6, p <0.001). There was no association between NP and AVP blood levels or action. Participants with and without NP had similar maximum urine osmolality following water deprivation and exogenous AVP administration (mean 549 mOsm, range 422 to 713 and 547 mOsm, range 353 to 692, respectively). We found no association between NP and AVP abnormalities in this sample of older adults. Study participants had low maximal urine osmolality in response to fluid deprivation and exogenous vasopressin administration irrespective of whether they were identified as having NP.

Teaching psychiatry in poor countries: priorities and needs. A description of how mental health is taught to medical students in Malawi, Central Africa.

In developing countries poor standards of clinical service may be an obstacle to medical education. The paper outlines the inadequate mental health service in Malawi, Central Africa, which as well as failing patients obstructs the training of health workers. A new mental health curriculum at Malawi's medical school is described. The notion of psychiatry as a medical specialty is abandoned and the focus moved to psychological and psychiatric factors as they present in general clinical settings and primary care. Students are encouraged to consider how they may address mental health issues through the many and varied roles which doctors in resource poor countries must fulfil (administrator, trainer, primary health care doctor, hospital physician). This training strategy accords with a shift of attention among health service planners world-wide from specialist services towards primary care, and may generalize to other settings in which specialist clinical services are poorly developed.

A Cantonese linguistic communication measure

Although there has been a longstanding interest in English aphasic speech, studies of Cantonese aphasic narratives have only emerged recently. This paper presents a Cantonese linguistic communication measure (henceforth, CLCM), which is a convenient measure for analysing Cantonese aphasic narratives. Taking into consideration the characteristics of the Cantonese grammar, the lexical diversity, communication efficiency, grammaticality and elaborateness of Cantonese aphasic speech are quantified. Sixteen Cantonese-speaking aphasic patients and 16 control subjects were recruited to carry out a picture description task. The findings indicated that most indices could distinguish between normal and aphasic speakers. Moreover, two indices indicating the length of the narrative and the rate of information conveyed could further discriminilte fluent from non-fluent aphasics. Given the simplicity of index computation, the CLCM may render speech therapists in general clinical settings an objective, quick and convenient means to quantify patients' expressive language abilities.