General practitioner psychological management of common emotional problems (I): Definitions and literature review.

General practitioners' (GPs') treatment of patients with common emotional problems often includes some form of psychological management within the consultation. Such psychological management may be limited to listening and discussion or may also include more specific psychological approaches, such as use of counselling, problem-solving, or cognitive-behavioural techniques. This paper defines GP psychological management and reviews what is known about its frequency and effectiveness. MEDLINE and PsychLIT searches were undertaken of empirical studies of the psychological management of emotional problems by GPs in routine consultations published up to 1998. Thirty-six studies were identified. Most lacked details of the nature of the psychological management reported, making it difficult to compare studies. The frequency of use of psychological management by GPs was found to be generally less when rated by external observers than when assessed by GP self-report. There is preliminary evidence from a few studies of the clinical effectiveness of GP psychological management in routine consultations.     

Patients' reasons for not presenting emotional problems in general practice consultations.

BACKGROUND: Patients commonly do not mention emotional problems in consultations, and this is a factor in general practitioners' (GPs') difficulty in identifying psychological morbidity. AIM: To investigate patients' self-reported reasons for not disclosing psychological problems in consultations with GPs. METHOD: From nine general practices, a sample of patients with high General Health Questionnaire scores, who planned to present only somatic symptoms to the GP, were interviewed after their consultation with the GP. The interview covered their reasons for not mentioning emotional problems. A patient satisfaction questionnaire was administered. RESULTS: A total of 83 patients were interviewed. Sixty-four patients confirmed that they had not mentioned emotional problems in the consultation; 23 (36%) of these gave primarily realistic reasons for not presenting emotional problems (e.g. able to cope with distress), 29 (45%) gave reasons related to psychological embarrassment or hesitation to trouble the GP, and 12 (19%) were mainly deterred by the doctors' interview behaviours. The latter group had significantly lower satisfaction scores than patients in the other two groups. In addition, patients in all groups commonly reported perceptions of lack of time (48%) and that there is nothing doctors can do to help (39%) as barriers to mentioning emotional problems. CONCLUSION: An understanding of patients' reasons for not disclosing emotional problems can assist in identifying subgroups of patients with different management needs.     

Decisional strategies for the attribution of emotional distress in primary care

BACKGROUND: In primary care the General Health Questionnaire (GHQ) is used to provide an independent assessment of probable caseness of psychological disorder against which to test the ability of the general practitioner (GP) to recognize patients with current emotional problems. METHOD: The aim of the present study was to identify those clinical and psychosocial data on patients that increase the likelihood of GPs' attribution of emotional distress (GP model) and those that predict patients' emotional distress as defined by the GHQ-12 (GHQ model). The associations were explored using a classification tree technique (CHAID) and compared using bivariate logistic regression. Six GPs and 444 primary care patients took part. RESULTS: The accuracy indices of the hierarchical GP and GHQ models were 72% and 69% respectively. The availability of information on patients' psychopharmacological and psychiatric/psychological treatment in the last year was the most important predictor of attribution. Occupational, financial and housing problems and life events of loss were the most important predictors of the GHQ-12 case definition. The overall accuracy of the bivariate model was 73%. Compared with the GHQ-12, GPs gave significantly more importance to psychiatric treatment, psychopharmacological drug use and chronic illness. CONCLUSIONS: The findings suggest that to improve the detection of current emotional distress in primary care patients GPs should pay foremost and systematic attention to social problems and recent life events of loss. These problems are important clues for the possible presence of emotional distress, whereas critical patient data, in particular psychiatric history and psychopharmacological treatment, increase the probability of attribution errors.     

Patients'' experiences of GP consultations for psychological problems: a qualitative study

BACKGROUND: The vast majority of patients with psychological problems are seen solely by their GP, but little is known about patients' perspectives regarding the variety of consultation skills that may be used in routine GP consultations with these patients. AIM: To identify which aspects of GP consultations patients presenting with psychological problems experience as helpful or unhelpful. DESIGN: Qualitative study. SETTING: Nine general practices in north central London. METHOD: Twenty patients, who had discussed psychological problems as a significant part of their index GP consultation, were asked in detail using the tape-assisted recall (TAR) method, about aspects of the consultation they had experienced as helpful or unhelpful. RESULTS: All patients described how the relationship with the GP helped or hindered them in discussing their problems; this was central to their experience of the consultation. An underlying attitude of genuine interest and empathy, within a continuing relationship, was highly valued. Patients also described how the GP helped them make sense of, or resolve their problems, and supported their efforts to change. CONCLUSION: These patient accounts suggest that routine GP consultations for psychological problems can have a powerful impact, at least short-term. The GP role in providing a safe place where patients feel they are listened to and understood should not be underestimated, particularly in the mental health context. Further research is required to investigate the longer-term impact of different GP behaviours on patient health outcomes. The TAR method has potential applications in primary care research and in the training of GPs and other health professionals.     

How general practice patients with emotional problems presenting with somatic or psychological symptoms explain their improvement.

BACKGROUND: The emotional problems of patients presenting only somatic symptoms are frequently not detected by general practitioners (GPs), yet clinical outcomes have often been found to be no different from emotional problems directly presented. AIM: To compare clinical outcomes and attributions for improvement of patients with emotional problems presenting only somatic symptoms to GPs, with patients directly presenting emotional problems. DESIGN OF STUDY: Survey of patients with General Health Questionnaire (GHQ) scores in the symptomatic range, with follow-up after three months of a repeat GHQ and a questionnaire of patients' attributions for improvement. SETTING: A sample of 152 adult patients from nine general practices in North and East London. METHOD: Consecutive patients were invited to complete an adapted GHQ prior to their consultation. The consultations were audiotaped and coded to indicate the extent to which psychological discussion took place, as against discussion of other issues. The GPs recorded whether they considered each patient to be emotionally disturbed or psychiatrically ill at the time of the consultation, to assess GP detection of emotional disturbance. To form the initial sample, interviews were conducted one to five days after the consultation with patients who intended to present with either psychological or somatic problems, with a follow-up questionnaire after three months. RESULTS: A total of 106 patients provided follow-up information, of whom 57 presented psychological problems directly at initial consultation and 49 presented only somatic symptoms. There were no differences in clinical outcome at three months between the two groups. Somatic presenters who improved were more likely than psychological presenters to attribute improvement to change in their physical health (68% versus 31%) while psychological presenters were more likely to attribute improvement to the GP's listening and counselling in the consultation (44% versus 18%). Other attributions for improvement, such as passage of time, change in life circumstances, support of family and friends, medication, and 'working through problems myself', were equally common in both groups. CONCLUSIONS: Patients with emotional problems presenting only somatic symptoms have equivalent clinical outcomes to patients presenting psychological problems directly, but are more likely to attribute emotional improvements to change in their physical health. For some such emotionally disturbed patients it may be sufficient for GPs to treat the physical health problems and to reassure the patient, without attempting to treat the underlying emotional disturbance.     

The workload of general practitioners does not affect their awareness of patients' psychological problems

OBJECTIVE: To investigate if general practitioners (GPs) with a higher workload are less inclined to encourage their patients to disclose psychological problems, and are less aware of their patients' psychological problems. METHODS: Data from 2095 videotaped consultations from a representative selection of 142 Dutch GPs were used. Multilevel regression analyses were performed with the GPs' awareness of the patient's psychological problems and their communication as outcome measures, the GPs' workload as a predictor, and GP and patient characteristics as confounders. RESULTS: GPs' workload is not related to their awareness of psychological problems and hardly related to their communication, except for the finding that a GP with a subjective experience of a lack of time is less patient-centred. Showing eye contact or empathy and asking questions about psychological or social topics are associated with more awareness of patients' psychological problems. CONCLUSION: Patients' feelings of distress are more important for GPs' communication and their awareness of patients' psychological problems than a long patient list or busy moment of the day. GPs who encourage the patient to disclose their psychological problems are more aware of psychological problems. PRACTICE IMPLICATIONS: We recommend that attention is given to all the communication skills required to discuss psychological problems, both in the consulting room and in GPs' training. Additionally, attention for gender differences and stress management is recommended in GPs' training.     

The impact of training in problem-based interviewing on the detection and management of psychological problems presenting in primary care.

BACKGROUND: The vast majority of mental health problems present to primary care teams. However, rates of under-diagnosis remain worryingly high. This study explores a GP-centred approach to these issues. AIM: To examine the impact of training in problem-based interviewing (BPI) on the detection and management of psychological problems in primary care. METHOD: The detection and management of psychological problems by 10 general practitioners (GPs) who had received PBI training 12 months earlier was compared with that of 10 control GPs matched for age, sex, clinical experience, and practice setting; and had originally applied for, but had not been able to attend, BPI training. Consecutive attendees at one randomly selected surgery undertaken by each GP were invited to participate in the study. Two hundred and eighty patients living in Newcastle upon Tyne met inclusion criteria and gave informed consent. The presence or absence of psychological problems was assessed using patient self-ratings on the 28-item version of the General Health Questionnaire (GHQ) and blind independent observer ratings of the brief Present State Examination (PSE). Patient satisfaction with interviews was rated using the Medical Interview Satisfaction Scale (MISS). After each consultation, the GPs (blind to subjective and observer ratings) recorded their assessment and management of the patients' problems on a Practice Activity Card (PAC). RESULTS: In comparison with control GPs, index GPs demonstrated significantly greater sensitivity in the detection of psychological problems in the GHQ-PAC ratings. The absolute decrease in misdiagnosis of GHQ cases was 9% and of PSE cases was 15%. Patients meeting GHQ criteria for caseness were more likely to be prescribed psychotropic medication by an index GP than compared with a control GP. Length of interview did not differ between the groups and mean scores on the MISS suggested that patients attending PBI-trained GPs, compared with control GPs, were as satisfied or slightly more satisfied with their consultation. CONCLUSION: In comparison with control GPs, PBI-trained GPs were better at recognizing and managing psychological disorders. The potential benefits of BPI training are discussed in light of other attempts to improve mental health skills in primary care.     

Frequency of consultations and general practitioner recognition of psychological symptoms.

BACKGROUND: General practitioners (GPs) are widely reported to 'miss' half of the psychological problems present in their patients. AIMS: To describe the relationship between frequency of consultations and GP recognition of psychological symptoms. DESIGN OF STUDY: Survey of GPs and their patients. Setting: General practices in the southern part of New Zealand's North Island. METHOD: Participants were randomly selected GPs (n = 70), and their patients (n = 3414, of whom a sub-set of 386 form the basis of this study). The main measure was the comparison between GP and composite international diagnostic interview (CIDI) recognition of psychological problems. RESULTS: Of the GPs selected, 90% participated. The CIDI was completed by 70% of selected patients. In patients (n = 386) with a CIDI-diagnosed disorder, 63.7% (95% confidence interval [CI] = 53.3 to 74.1) were considered by the GP to have had psychological symptoms in the last year; 40.1% (CI = 31.0 to 49.2) to have had clinically significant psychological problems, and 33.8% (CI = 24.9 to 42.6) were given an explicit diagnosis. However, in those CIDI-diagnosed patients who had been seen five or more times during the previous year, these recognition figures increased to 80.2% (CI = 68.9 to 91.4), 59.4% (CI = 45.9 to 72.9) and 53.6% (CI = 40.1 to 67.1) respectively, and dropped to 28.8% (CI = 13.0 to 44.7), 13.6% (CI = 3.4 to 23.7), and 10.7% (CI = 1.4 to 19.9) among patients not consulting during the previous year. GPs often differed from the CIDI in their assessment of clinical significance and diagnosis. CONCLUSION: GP non-recognition of psychological problems was at a problematic level only among patients with little recent contact with the GP. Efforts to improve GP recognition of mental disorder may be more effective if they target new or infrequent attenders, and encourage patient disclosure of psychological issues.     

The workload of GPs: consultations of patients with psychological and somatic problems compared

BACKGROUND: GPs report that patients' psychosocial problems play a part in 20% of all consultations. GPs state that these consultations are more time-consuming and the perceived burden on the GP is higher. AIM: To investigate whether GPs' workload in consultations is related to psychological or social problems of patients. DESIGN OF STUDY: A cross-sectional national survey in general practice, conducted in the Netherlands from 2000-2002. SETTING: One hundred and four general practices in the Netherlands. METHOD: Videotaped consultations (n = 1392) of a representative sample of 142 GPs were used. Consultations were categorised in three groups: consultations with a diagnosis in the International Classification of Primary Care chapter P 'psychological' or Z 'social' (n = 138), a somatic diagnosis but with a psychological background according to the GP (n = 309), or a somatic diagnosis and background (n = 945). Workload measures were consultation length, number of diagnoses and GPs' assessment of sufficiency of patient time. RESULTS: Consultations in which patients' mental health problems play a part (as a diagnosis or in the background) take more time and involve more diagnoses, and the GP is more heavily burdened with feelings of insufficiency of patient time. In consultations with a somatic diagnosis but psychological background, GPs more often experienced a lack of time compared to consultations with a psychological or social diagnosis. CONCLUSION: Consultations in which the GP notices psychosocial problems make heavier demands on the GP's workload than other consultations. Patients' somatic problems that have a psychological background induce the highest perceived burden on the GP.     

The place of general practitioner in the management of patients with rare disease and intellectual disability: A qualitative study

The management of patients with rare diseases (RD) presents many challenges including diagnosis, coordination of care, and orientation in the health system. For these patients, the general practitioner (GP) is not always the referring physician. The aim of this study was to determine the place of the GP in management of patients with RD. We used a qualitative study by case-study. From March to October 2020, semi-structured interviews were conducted by telephone with the families of adult patients with RD and intellectual disability, and with the health professionals involved in their management. Patients were recruited through RD reference centres, patient associations or GPs. The interviews were transcribed and analysed by two independent investigators. A grounded theory-based analysis was performed. Eight case studies were conducted with 20 participants. Our results highlighted the trajectory of the patients through the development of the career of the primary informal caregiver. The caregivers developed skills required for the management of the care recipient. Within this trajectory, the GP found his place depended on the skills he could provide, their interest in the disease, the skills developed by the caregiver, and the caregiver/care recipient needs. The GP was mostly consulted for routine care and administrative procedures, but when a trusting relationship was established, they also accompanied the patient and their family by providing appropriate medical, social or psychological support. The GP will be all the more a privileged actor in the care process that he will be involved in the coordination of all other actors, professional as non-professionals.     

Psychological and genetic counseling implications for adolescent daughters of mothers with breast cancer

Adolescent daughters of women with breast cancer (BC) are themselves at risk for heritable BC. Although some preliminary evidence suggests this group is at an increased risk for emotional problems, evidence is limited to studies with small samples and no comparison groups. This study examined psychological and family functioning, health attitudes and beliefs about genetic risks in adolescent females. A case-comparison design was used to compare 55 mother-daughter pairs in which the mother had been treated for BC (BC group) to 55 families from the general population (GP). Participants completed an assessment battery measuring perceptions of personal risk for BC and attitudes about gene testing for BC susceptibility, family functioning, and adolescent psychological adjustment. Based on manova, no significant differences were found between the two groups on measures of the psychological functioning. However, BC group adolescents reported significant (p < 0.01) worries about their future health and genetic risk for BC. About 68% of BC adolescents compared with 12% of GP adolescents reported being moderately to greatly concerned about their susceptibility to genetic mutations. Further, 85% of BC group adolescents believed they were susceptible to BC compared with 10% of GP adolescents. The results indicated no evidence of emotional, behavioral, or familial distress in these families. However, BC adolescents have significant worries about their future health. The results of this study demonstrate the need to develop a comprehensive model of care where accurate information about genetics and health risks can be provided. The adolescents also need support to help them cope and communicate with their mothers their worries about BC.     

An exploration of the value of the personal doctor-patient relationship in general practice.

BACKGROUND: Within the context of general practice, continuity of care creates an opportunity for a personal doctor-patient relationship to develop which has been associated with significant benefits for patients and general practitioners (GPs). Continuity of care is, however, threatened by trends in the organisational development of primary health care in the United Kingdom and its intrinsic role within general practice is currently the subject of debate. AIMS: To determine how many patients report having a personal doctor and when this is most valued, to compare the value of a personal doctor-patient relationship with that of convenience, and to relate these findings to a range of patient, GP, and practice variables. DESIGN OF STUDY: Cross sectional postal questionnaire study. SETTING: Nine hundred and ninety-six randomly selected adult patients from a stratified random sample of 18 practices and 284 GP principals in Oxfordshire. METHOD: Qualitative interviews with patients and GPs were conducted and used to derive a parallel patient and GP questionnaire. Each patient (100 from each practice) was invited to complete a questionnaire to evaluate their experience and views concerning personal care. All GP principals currently practising in Oxfordshire were sent a similar questionnaire, which also included demographic variables. RESULTS: Overall, 75% of patients reported having at least one personal GP. The number of patients reporting a personal GP in each practice varied from 53% to 92%. Having a personal doctor-patient relationship was highly valued by patients and GPs, in particular for more serious, psychological and family issues when 77-88% of patients and 80-98% of GPs valued a personal relationship more than a convenient appointment. For minor illness it had much less value. CONCLUSIONS: Patients and GPs particularly value a personal doctor-patient relationship for more serious or for psychological problems. Whether a patient has a personal GP is associated with their perception of its importance and with factors which create an opportunity for a relationship to evolve.     

How does the general practitioner understand the patient? A qualitative study about psychological interventions in general practice

Objectives General practitioners (GPs) treat more than 90% of common mental disorders. However, the content of their interventions remains undefined. The present study aimed to explore GPs' processes of understanding the patients with emotional problems. Design The study was qualitative using semi‐structured interviews with 14 general practitioners sampled purposively. Observation was done in the surgeries of four of the GPs. Methods Analysis of the interviews was made by Interpretative Phenomenological Analysis (IPA). Observation notes were analysed from a hermeneutic‐phenomenological perspective, inspired by IPA. Results GPs had very different approaches to patients with emotional problems. Physical symptoms were the usual reason for consulting the GP. Understanding patients' perception of the meaning of their bodily symptoms in their complex life‐situation was considered important by some of the participants. Arriving at this understanding often occurred through the narrative delivered in different narrative styles mirroring the patients' mental state. Awareness of relational factors and self‐awareness and self‐reflexivity on the part of the GP influenced this process. Other participants did not enter this process of understanding patients' emotional problems. Conclusions The concept of mentalization could be used to describe GPs' processes of understanding their patients when making psychosocial interventions and could form an important ingredient in a general practice theory in this field. Only some participants had a mentalizing approach. The study calls attention to the advantage of training this capacity for promoting professional treatment of patients and a professional dialogue across sector borders.     

Differences in verbal behaviours of patients with and without emotional distress during primary care consultations

BACKGROUND: In primary care consultations patients with emotional distress tend to give verbal cues or symptom reports with psychological or psychiatric contents. This study examined the cue behaviour defined not only by psychological, but also by medical, social and life episodes related contents in patients with and without emotional distress, recognized and not by their GP. The GP's verbal behaviour in relation to patients' cue emission was also investigated. METHOD: For the six participating GPs two groups of matched pairs of patients (N = 238) were created. The two groups comprised either patients considered by GPs as being without emotional distress or patients considered as emotionally distressed. Within each pair, one patient was a case (GHQ-12 score > 2) and the other was the matched control (GHQ-12 score < 3). The medical interviews with these patients were transcribed and classified according to the Verona Medical Interview Classification System (VR-MICS). RESULTS: GHQ positive patients of both groups gave more cues in terms of total proportion than their matched controls (GHQ negative patients). The proportion of cues given by patients was related also to GP's verbal behaviour, increasing with closed psychosocial questions and decreasing with the use of active interview techniques. Attribution of emotional distress was more frequent when patients were high attenders and had a past psychiatric history. The content of cues changed in relation to GP's attribution: recognized patients gave more cues and more often with psychological content, patients not recognized as distressed gave mainly cues related to their lifestyle and life episodes. CONCLUSIONS: To improve the recognition of those emotionally distressed patients most likely to be missed GPs should increase their attention to cues related to life style and life episodes.     

Anxiety in allergy and atopic dermatitis

PURPOSE OF REVIEW: Individuals suffering from allergies often exhibit a specific psychological profile characterized by anxiety, depression and emotional excitability. Emotional stress precipitates allergic symptoms not only by heightening anxiety levels but also by dysregulating immune-cell functions. The primary objective of this report is to review recent findings of the relationship between anxiety and hypersensitivity responses in the context of psychoneuroimmunology in allergic individuals, notably patients with atopic dermatitis. RECENT FINDINGS: Atopic subjects with emotional problems develop a vicious cycle between anxiety and clinical symptoms. Acute stresses, which repeatedly and chronically affect patients with atopic dermatitis, raise anxiety in general more preferentially than anxiety at present. This psychological failure enhances Th2-type responses due to dysregulation of the neuroimmune system, leading to worsening of allergic symptoms. Tandospirone, a 5-hydroxytryptamine 1A receptor agonist with anxiolytic and antidepressant effects, attenuates itching through successful control of emotional difficulties. These data suggest the efficacy of administrating drugs with anxiolytic effects as part of the management strategy of stress-associated itching in patients with atopic dermatitis. SUMMARY: Psychological interventions such as periodic monitoring of anxiety levels in the context of immune functions and skin conditions are fundamental in therapy of allergic patients with emotional problems.     

Factors that influence the detection of psychological problems in adolescents attending general practices

BACKGROUND: Epidemiological studies indicate that the prevalence of psychological problems in patients attending primary care services may be as high as 25%. AIM: To identify factors that influence the detection of psychological difficulties in adolescent patients receiving primary care in the UK. DESIGN OF STUDY: A prospective study of 13-16 year olds consecutively attending general practices. SETTING: General practices, Norfolk, UK. METHOD: Information was obtained from adolescents and parents using the validated Strengths and Difficulties Questionnaire (SDQ) and from GPs using the consultation assessment form. RESULTS: Ninety-eight adolescents were recruited by 13 GPs in Norfolk (mean age = 14.4 years, SD = 1.08; 38 males, 60 females). The study identified psychological difficulties in almost one-third of adolescents (31/98, 31.6%). Three factors significant to the detection of psychological disorders in adolescents were identified: adolescents' perceptions of difficulties according to the self-report SDQ, the severity of their problems as indicated by the self-report SDQ, and whether psychological issues were discussed in the consultation. GPs did not always explore psychological problems with adolescents, even if GPs perceived these to be present. Nineteen of 31 adolescents with psychological difficulties were identified by GPs (sensitivity = 61.2%, specificity = 85.1%). A management plan or follow-up was made for only seven of 19 adolescents identified, suggesting that ongoing psychological difficulties in many patients are not being addressed. CONCLUSIONS: GPs are in a good position to identify psychological issues in adolescents, but GPs and adolescents seem reluctant to explore these openly. Open discussion of psychological issues in GP consultations was found to be the most important factor in determining whether psychological difficulties in adolescents are detected by GPs.     

Health status and management of chronic non-specific abdominal complaints in general practice.

BACKGROUND: While chronic non-specific abdominal complaints are common in general practice, data on patients' perspective and management of these complaints are lacking. Knowledge of these data is important for the development of guidelines for management and assessment of the burden of chronic non-specific abdominal complaints on society. AIM: To draw a comprehensive picture of chronic non-specific abdominal complaints in general practice, including volume, patients' perspective, and health care involvement. METHOD: In a retrospective study, 644 patients were selected in 16 general practices. Patients and general practitioners (GPs) received a questionnaire regarding the nature of complaints and health care management during the previous 12 months. RESULTS: Overall, 619 questionnaires were returned and 291 patients participated. Of the study population, 15% of patients were diagnosed as suffering from non-ulcer dyspepsia, 39% from irritable bowel syndrome, and 45% from other abdominal complaints. Over 50% of patients suffered from chronic non-specific abdominal complaints on a daily or weekly basis. In these patients, general health perception is impaired and above norm scores on SCL-anxiety and SCL-depression scales were recorded. Only 4% of patients showed complete resolution of complaints during the previous 12 months. Fifty-two per cent of patients consulted their GP for abdominal complaints. Diagnostic modalities were used frequently. Medication was prescribed in 83% of patients with abdominal complaints. Twenty per cent of patients were referred to secondary or tertiary care. There was a considerable inter-doctor variation in the management of chronic non-specific abdominal complaints. CONCLUSION: Once non-specific abdominal complaints have become chronic they are mainly managed by the GP. The impact on patients' physiological and psychological well being is large. Diagnostic and therapeutic modalities are frequently used. Given the considerable inter-doctor variation, research into the evidence base of management strategies is recommended.     

Validation of a computerized assessment (PROQSY) of minor psychological morbidity by Relative Operating Characteristic analysis using a single GP's assessments as criterion measures

This is a study of the criterion validity of a newly developed computerized assessment (PROQSY) of minor psychological morbidity based on the Clinical Interview Schedule, employing a single GP's assessments as criterion measures of such morbidity and Relative Operating Characteristic (ROC) analysis. Two-stage screening was carried out with a consecutive sample of 256 patients aged 15-69 consulting an experienced GP in a semi-rural setting over a six-week period. The GP made a standardized assessment of the reason for consultation and the degree of psychological disorder present. A 40% random sub-sample was then assessed using PROQSY. The area under the ROC curve using a GP criterion of minor psychological disorder ('degree of psychological problem - mild or greater') was 0.81 (S.D. = 0.06). However, the kappa coefficient obtained between this criterion assessment and the PROQSY assessment of minor psychological problem at the observed optimal cut-off score was only 0.28 (S.E. = 0.1; Z = 2.83). It is concluded that PROQSY may be recommended for further development as a research tool providing a valid measure of minor psychological morbidity as assessed by GPs in primary care settings.     

Clinical aspects and treatment of migraine]

The paper is concerned with clinical, therapeutical and classification problems of migraine. A "vegetative" form of migraine is distinguished characterized by a vegetovascular crisis in the disease episodes. Clinico-psychophysiological characteristics are provided for 30 patients with common and 40 with vegetative migraine. The latter run seems more severe with frequent episodes, permanent vegetative disorders in the episodes-free period, marked emotional symptoms (hypochondriac, demonstrative and anxious). In addition to clinico-neurological, questionnaire and thermographic methods, the study employed visual analog pain scale, tests of segmentary vegetative apparatuses (6 cardiovascular tests and time of pupil cycle), psychological tests (MIL, Spilberger's). Differential approaches to migraine forms are advocated, basic principles of optimal therapy of migraine cephalalgia are formulated.