Behavioral treatment of sleep dysfunction in patients with the Rett syndrome

Aberrant sleep patterns are commonly experienced by girls with the Rett syndrome. In this investigation, the problematic sleep of three girls with the Rett syndrome was regulated using a bedtime fading procedure with response cost. The treatment involved systematically delaying the bedtime and utilized a response cost component, removing the child from bed for one hour, when the child did not experience short latency to sleep onset. Daytime sleep was interrupted, except during regularly scheduled naps. A fading procedure was then successfully utilized to advance the bedtimes. This treatment resulted in more regular sleep patterns for the girls by increasing appropriate nighttime sleep, reducing inappropriate daytime sleep and reducing problematic nighttime behaviors (e.g., night wakings). These preliminary findings are important because they suggest that the dysfunctional sleep patterns of girls with the Rett syndrome may be amenable to behavioral treatments.     

Mental disorders in patients with noncardiac chest pain

About 70% of noncardiac chest pain (NCCP) patients have mental disorders as reported from Western countries. The phenomenon of somatization is considered to be aetiologically important in the genesis of NCCP. Though somatization is generally considered as more prevalent among non-Western cultures, systematic studies of mental disorder among NCCP patients are rare from developing countries. Based on treadmill test, 54 male inpatients in a cardiology general ward in India were divided into a group having ischaemic heart disease (IHD) and another group of NCCP. A psychiatric interview was conducted blindly on these subjects with the help of a structured interview schedule, and DSM-III-R diagnosis was made. Sixty-eight percent in the NCCP group and 27% in the IHD group had a mental disorder. The total number of subjects with a mental disorder, including panic disorder and major depression, were significantly more in the NCCP group. Mental disorders appears to be equally common among NCCP patients in developing countries also and detailed psychiatric assessment is warranted in patients with chest pain of non-IHD origin.     

Axis I disorders in ER patients with atypical chest pain

To examine the contribution of psychopathology to emergency room (ER) visits for atypical chest pain, we administered two screening measures and the Structured Clinical Interview for DSM III-R (SCID) to thirty-five subjects within seventy-two hours of their ER visit. Follow-up SCID interviews were completed in thirty subjects at five to twelve months. Sixty percent of the sample had an initial Axis I diagnosis, predominately affective (34%) and anxiety (46%) disorders. Forty percent had multiple diagnoses initially. The most common diagnoses were panic disorder (31%) and major depression (23%). At follow-up 47 percent had Axis I diagnoses, 30 percent had multiple diagnoses, with only slightly decreases rates for panic disorder (27%) and major depression (17%). Many subjects had lost, gained, or switched diagnoses by follow-up, in spite of one consistent rater and a few subjects seeking treatment. ER physicians often do not recognize these psychiatric disorders in chest pain patients. The high risk of suicide in panic disorder and depression, and the high cost of disability in recurrent chest pain make it essential that ER physicians include these disorders in the differential of atypical chest pain.     

Alexithymia and anxiety sensitivity in patients with non-cardiac chest pain

The aim of this study was to examine independent and combined influences of alexithymia and anxiety sensitivity on chest pain and life interference in patients with non-cardiac chest pain (NCCP). Theories of NCCP posit a central role for emotion in the experience of chest pain, however, studies have not examined how alexithymia characterized by a difficulty identifying or verbalizing emotions, may influence this relationship. This study examined 231 patients (56% females, M age = 50 years) with chest pain seeking cardiac evaluation, who showed no abnormalities during exercise tolerance testing. Forty percent (40%) scored at or above the moderate range of alexithymia. Whereas health care utilization was associated with elevated alexithymia among men, health care utilization was associated with elevated anxiety sensitivity among women. Hierarchical regression analyses revealed that alexithymia and anxiety sensitivity were both uniquely and independently associated with pain severity and life interference due to pain. Alexithymia-pain links were stronger for men compared to women. Secondary analyses conducted with a subsample suggest that alexithymia may be increasingly stable over time (i.e., 18-month follow-up). Findings are largely congruent with theoretical models of NCCP showing that personality and emotional factors are important in this medically unexplained syndrome.     

Behavioral covariation in the treatment of chronic pain

The successful use of operant procedures to alter behaviors associated with various medical conditions suggests that such behaviors may be learned and that the principles of learning may be applied not only to treatment but also to the study of the pathogenesis of illness behavior. The present study, conducted within an ongoing neuromuscular research project, assessed the covariation of behaviors associated with chronic pain within and across behavioral and drug approaches to treatment. Problems of screaming and five other behaviors (including self-reports of pain) were measured across conditions of varying behavioral contingencies (noncontingent reinforcement vs the removal of reinforcement contingent upon screaming) and varying administration (time since medication and dosage) of Parsidol during attempts to treat the muscle pain of a 24-year-old male with a severe, chronic neuromuscular disorder diagnosed as dystonia musculorum deformans (DMD). Results indicated that: (a) pain behaviors covaried during behavioral and drug conditions even though the behavioral intervention only targeted screaming; (b) effects were greater on nontargeted behaviors during periods that followed rather than preceded drug administration; (c) in contrast to behavioral observation data, physiological measures of neuromuscular activity (EMG) did not differ across conditions. These results suggest that functional response-response relationships exist in patients as the result of their illness experience.     

Platelet glycoprotein VI (GPVI) for early identification of acute coronary syndrome in patients with chest pain

Background

Platelet glycoprotein VI (GPVI) is elevated in patients with acute coronary syndrome (ACS), stroke and associated with acute coronary events. GPVI may be helpful to distinguish an imminent ACS from non-coronary (NC) causes in patients with chest pain who were transferred to chest pain unit, before the myocardial necrosis is evident with classical biomarkers.

Methods

Based on the findings of our previous studies, we consecutively examined 1004 patients with chest pain in a prospective study design. ACS was found in 416 (41.4%), stable angina pectoris (SAP) in 233 (23.2%), and NC causes of chest pain (hypertension, musculoskeletal disease, pulmonary embolism, myocarditis, cardiophobia) in 355 patients (35.4%). Platelet surface expression of GPVI was measured by flow cytometry.

Results

Patients with ACS showed significantly enhanced GPVI expression levels compared to patients with SAP or NC causes of chest pain (ACSvs.SAP(mean fluorescence intensity (MFI) ± SD):18.9 ± 7.4vs.17.9 ± 9.5;P = 0.028;ACSvs.NC:15.4 ± 6.9;P = 0.002). Elevated GPVI expression was associated with ACS independent of markers of myocardial necrosis like troponin and creatine kinase-MB. Patients with an elevated GPVI expression (MFI ≥ 18.6) had a poorer clinical outcome than patients with baseline GPVI expression in regard to composite cumulative survival that included myocardial infarction, stroke, and cardiovascular death at three months (Log rank;P = 0.025).

Discussion

Platelet GPVI surface expression is enhanced in patients at risk for an ACS and is an early marker for imminent acute coronary events in patients with chest pain.     

Cerebral oxygenation and hemodynamics during hyperventilation and sleep in patients with Rett syndrome

We continuously monitored changes in cerebral oxygenation and hemodynamics in the frontal lobes of six patients with Rett syndrome during the awake state, which is associated with hyperventilation (HV) and breath-holding (BH), and during sleep by near-infrared spectroscopy. We also monitored three adult volunteers during simulated episodes of HV and BH. In patients with Rett syndrome, the oxygenated hemoglobin (HbO₂) and total hemoglobin (HbT) decreased significantly during HV and BH in the awake state compared with the sleep state. The HbO₂ and HbT decreased gradually in adult volunteers in response to prolonged episodes of HV and BH. Further studies are required to investigate the relationship, if any, between the discovered continuous decreases in HbO₂ and HbT during the awake state and the brain damage seen in patients with Rett syndrome.     

Implicit affective evaluation of somatosensory sensations in patients with noncardiac chest pain

Background and objectives

Etiological models of noncardiac chest pain (NCCP) stress the importance of abnormal implicit affective evaluations of somatosensory sensations, but this has never been studied empirically. The aim was therefore to assess implicit affective evaluations of somatosensory stimuli in NCCP using an experimental design.

Methods

A total of 34 patients with NCCP, 24 patients with cardiac chest pain, and 46 healthy controls, took part in the study. Participants completed a tactile modification of the Affect Misattribution Procedure (tAMP) and answered self-report measures on anxiety sensitivity, somatosensory amplification, and somatic symptom distress.

Results

A 3 × 3-ANOVA revealed that most negative judgments were found in the aversive condition, but this effect was not specific to patients with NCCP. Anxiety sensitivity was positively associated with negative implicit evaluations of aversive tactile stimuli in the tAMP.

Limitations

The task seemed to be too difficult for older participants. Also, future studies should apply clinically more relevant, e.g., heart related, stimuli that are more ecologically valid than the electrical stimulation of the finger used as a proxy for aversive somatosensory sensations here.

Conclusions

Against theoretical assumptions, patients with NCCP do not seem to show a stronger implicit negative interpretation bias concerning somatosensory sensations in comparison to patients either with cardiac chest pain, or without chest pain. Nevertheless, anxiety sensitivity seems to contribute significantly to implicit affective interpretations of somatic sensations. Further studies are required investigating the relevance of implicit interpretative processes for the course of NCCP and distressing somatic symptoms in general.     

The detection of panic disorder in chest pain patients

The aims of this study were to 1) develop a detection model for recognizing panic disorder (PD), 2) develop a simple questionnaire as a screening instrument for PD detection, and 3) test in an outpatient cardiological chest pain population a detection model for panic disorder previously described by Fleet et al. [20]. Logistic regression analysis was performed to explore factors predictive of panic disorder and to test the cross-cardiological setting constancy of the Fleet model in 199 chest pain patients without previously known heart disease referred to cardiological outpatient investigation of chest pain. The SCL-90 somatization subscale, Agoraphobia Cognitions Questionnaire, chest pain quality, pain localization, and age were the best predictors of the presence of panic disorder. This model correctly classified 78% of the subjects. The sum-score of a three-item questionnaire correctly classified 74% of the subjects, while the previously described model by Fleet et al. correctly classified 73% of the subjects. A detection model and a screening questionnaire are proposed to improve the recognition of PD in this chest pain population. This study partly supports the cross-setting validity of a previously described detection model.     

Behavioral influences and physiological indices of ventilatory control in subjects with idiopathic hyperventilation

Idiopathic hyperventilation has been defined as a respiratory-related psychophysiological complaint. This study attempted to clarify relationships between psychological and physiological variables in this condition. Participants demonstrated increased anxiety, depression, and symptoms consistent with hyperventilation. This was associated with a reduced peripheral chemosensitivity (isocapnic hypoxic rebreathe; -0.84 +/- 0.5 min-1.%O2(-1)), which was normalized with experimentally increased pCO2. Resting CO2 sensitivity was close to normal (2.1 +/- 1.0 min-1.mmHg-1). Breath hold time was significantly reduced versus controls (20.4 s +/- 12 s vs. 63 s +/- 31 s), and resting PETCO2 was correlated with the anxiety score. Also, the ventilatory response to moderate intensity exercise was augmented (vs. controls). The normalcy of pulmonary and chemoreceptor responses suggests that psychological factors may initiate this hyperventilation, which may become a conditioned response with an increased drive to breathe.     

A long-term follow-up study of patients with ischaemic heart disease versus patients with nonspecific chest pain

Ninety consecutive patients who were admitted to hospital with acute chest pain were followed-up five years later. At the time of the original admission, all of the patients received a detailed physical and psychiatric evaluation. Seventy-one patients were diagnosed as having ischaemic heart disease, and 19 were diagnosed as having nonspecific chest pain. Patients with nonspecific pain were younger, consumed greater amounts of alcohol, smoked more than their organic counterparts, and were more likely to suffer from psychiatric disorder. The five-year assessment was carried out using a self-report questionnaire. Of the original 71 patients with ischaemic heart disease, 14 had died; 43 questionnaires were returned, 80.2% of the original sample. Sixteen (84.9%) of the patients with nonspecific pain were followed up; none had died. Both groups were predominantly male. The patients with nonspecific pain still smoked more than the patients with ischaemic heart disease, and they had significantly more symptoms of anxiety. The overall prevalence of psychiatric morbidity remained high, however, in both groups. Patients who had psychiatric illness at the time of the original assessment were more anxious at follow-up and more likely to complain of chest pain than those who had been well. Patients with nonspecific chest pain continued to seek treatment on a regular basis from their general practitioners either for chest pain or for other symptoms, but few were in frequent contact with hospital services. The possible preventive effects of psychiatric intervention at an earlier stage in both groups of patients needs to be investigated.     

A controlled study of a breathing therapy for treatment of hyperventilation syndrome

A therapy directed toward slowing and regularizing the ventilatory pattern was compared with a partial-treatment, comparison procedure for individuals with somatic and psychological symptoms attributable to hyperventilation episodes (i.e. hyperventilation syndrome). Comparing repeated measures between a pretreatment baseline session and a post-treatment followup, we found that the experimental therapy, in contrast to the comparison procedure, produced a greater number of, and more extensive, improvements in psychological, symptom complaint and ventilatory dimensions. Results also suggest changes in central respiratory control mechanisms as a consequence of treatment.     

Hyperventilation provocation in patients with chest pain and a negative treadmill exercise test

Seventeen (39%) of 44 patients with chest pain but without significant ST depression on treadmill exercise had their usual chest pain reproduced during or after 3 min of voluntary hyperventilation (VHV) at rest. These patients with hyperventilation positive tests had not only significantly more hyperventilation-related symptoms and respiratory complaints but also shorter breath-holding times, lower mean resting end-tidal pCO2 and higher mean respiratory rates than those with negative tests and normal controls. Of the psychological variables, only phobic avoidance scores for agoraphobia were higher in patients with positive tests. These findings suggest that in two fifths of patients with exercise tests negative for ischaemia, chest pain is associated with HV, but abnormalities of breath control and relative hypocapnia are present even in the absence of chest pain. It is possible that a chronic abnormality of respiratory control may interact with attitudinal factors in the experience of non-cardiac chest pain.     

Treatment needs of patients admitted for acute chest pain

Objective: To examine the characteristics, subsequent resource use and outcome of a consecutive cohort of admissions with acute chest pain not due to myocardial infarction. Methods: Subjects (n=356) identified in the course of a epidemiological study of myocardial infarction were interviewed and completed HAD, SF-36 and other self-report information in hospital and at 3 months and 1 year. Hospital casenotes were reviewed at 1 year. Results: A total of 218 subjects were given cardiac diagnoses and 138 noncardiac diagnoses. Cardiac subjects were more distressed and disabled and used more resources. Those in the noncardiac group reported distress and disability and resource use comparable to infarct admissions. Conclusion: Awareness of psychosocial variables would aid in the assessment and management of those with and without ischaemic heart disease.