Archives 1992-2013

2009, volume 18, issue 2

World Psychiatry Forum

Effectiveness as an outcome measure for treatment trials in psychiatry

W. Wolfgang Fleischhacker, Guy M. Goodwin
Postępy Psychiatrii i Neurologii 2009; 18 (2): 111-116

There is at present some confusion about the relative value of clinical trials performed to investigate efficacy vs. those designed to investigate effectiveness. This is particularly challenging when studies performed as experiments for regulators by companies are used to shape and inform clinical practice, especially if studies conducted under more real life conditions fail to support predicted benefits. We review the field in relation to the new antipsychotics, inparticular. Other indications, including mood disorders, which are also briefly touched upon, have so far received less definitive attention, but are likely to encounter the same difficulties. We conclude that, where the results of efficacy trials arepositive and an effectiveness trial is negative, one should not necessarily prefer the effectiveness trial - it may simply have failed. Where efficacy trials and effectiveness trials point to similar conclusions, then the findings are mutually supportive.

Original paper

Personality traits related to the diagnosis of essential hypertension

Krzysztof Małyszczak, Angelika Pyszel, Andrzej Szuba
Postępy Psychiatrii i Neurologii 2009; 18 (2): 127-132

Objectives. To assess the relationship between selected personality traits and essential hypertension.
Method A total of 175 subjects participated in the study: 84 inpatients diagnosed with essential hypertension (52 men and 32 women) and 91 controls with no such diagnosis (56 men and 35 women). The following instruments were used: the Cook-Medley Hostility Scale (CMHS), the Toronto Alexithymia Scale (TAS-20), the Bermond-Vorst Alexithymia Questionnaire (BVAQ), the Marlowe-Crowne Social Desirability Scale (MCSDS), the Eysenck Personality Questionnaire (EPQ-R), the General Health Questionnaire (GHQ-30) by Goldberg, and the Symptom Checklist SCL-90-R.
Results. Four factors related to hypertension were found in factor analysis. The first reflects psychopathological symptomatology severity measured using the GHQ andSCL-90-R, and also included twopersonality traits: neuroticism and alexithymia (TAS-TIU). The second factor comprisedsocial desirability scores on MCSDS, and the Lie scale of the EPQ-R. The third included the scale of psychoticism and an artificial Alex3-2 scale, while the fourth - BMI values only.
Conclusions. Personality traits turned out to have a weak but statistically significant relation to the diagnosis of hypertension. Neuroticism and alexithymia were associated with anxiety-depressive symptoms severity and their relationship with hypertension resultsprobably from the somatic condition. Neither social desirability nor the Lie scale scores were related to symptom severity and they may be assumed to be predictors of essential hypertension.

Original paper

Relationship of nitroglycerin consumption and suffocating symptoms severity to depressive and anxiety disorders in IHD women - a one-year study

Grzegorz Nawarski, Tomasz Pawełczyk, Jolanta Rabe-Jabłońska
Postępy Psychiatrii i Neurologii 2009; 18 (2): 133-142

Objectives. The aim of the one-year study was to assess changes in nitroglycerin consumption and suffocating symptoms severity in relation to thepresence and severity of depressive and anxiety disorders in women with ischemic heart disease (IHD).
Method Participants in the study were female patients diagnosed with angina pectoris in the past year, successively admitted to one of several cardiologic outpatient clinics in Lodz. Three groups of 30patients each were enrolled: 1. IDH with no depressive disorders, 2. IHD with co-morbid depressive disorders treated with citalopram in therapeutic dosage, and 3. IHD with untreated depression. The suffocating symptoms severity was assessed using the Canadian Cardiologic Society (CCS) Angina Scale, nitroglycerin consumption - using a ąuestionnaire developed for thepurposes of the study, while depressive and anxiety disorders - using the Beck Depression Inventory (BDI), STAI-X1 and STAI-X2.
Results. Decrements in the number andseverity of depressive symptoms due to the one-year antidepressant treatment in IHD women were related to a significant positive outcome: diminished nitroglycerin consumption and suffocating symptoms severity. This was correlated with a significant decrement in trait and state anxiety levels.

Original paper

Coping with the stressful stigma of sexually transferred disease

Teresa Rzepa, Ryszard Żaba
Postępy Psychiatrii i Neurologii 2009; 18 (2): 143-148

Objectives. (1) To compare syphilis patients with healthy controls for the level of experienced stress and coping strategies; (2) to investi-gate their ways of coping with the stigma of sexually transferred disease (STD).
Method. Participants in the study were 21 patients with syphilis (14 male and 7 female) and 21 healthy controls pair-matched for sex and age. All subjects were examined using the Social Readjustment Rating Scale (SRRS, with additional items), and the patients additionally with the Mental Adjustment to Cancer (Mini-MAC) scale in the Polish adaptation.
Results. The syphilis patients as compared to healthy controls had experienced more severe stressful events, mostly associated with the stigma of syphilis. Almost all the healthy controls utilized active, task-oriented coping strategies, while the patients (particularly female) used avoidant coping and a wait-and-see strategy. Male patients with syphilis tended to utilize predominantly active ways of coping with the stigma, while females represented anxious coping.
Conclusions. The stigma of syphilis results in a high level of stress in STD patients, irrespective of gender. Their awareness of being stigmatized and exposed to noxious social conseąuences to a significant degreeprevents them from disclosing the truth about their condition, which may lead to their spreading the disease.

Original paper

Sense of alienation and perceived social support among patients with Multiple Sclerosis: there are reasons for optimism

Ewa Małgorzata Szepietowska, Magdalena Przybyło
Postępy Psychiatrii i Neurologii 2009; 18 (2): 149-155

Objectives. In their study the authors comparedpatients with multiple sclerosis (MS) and those suffering from discopathy for the sense of alienation (SA) level. Individual characteristics (age, education, gender, perceived social support) and clinical variables (duration of disease in both groups and the course of illness in MS) possibly associated with the sense of alienation were taken into account.
Method. Participants were 23 MS patients and 20 persons with discopathy. The Sense of Alienation Scale and Social Support Scale were used (both developed by K. Kmiecik-Baran), as well as a modified version of the MMSE.
Results. No intergroup differences were found regarding the sense of alienation and perceived social support, and the scores suggest satisfaction with social contacts in both groups. Some individual and clinical factors were differentially related to SA levels in the compared groups. In older MS patients the sense of alienation and isolation was diminishing, while in persons with discopathy a global SA increased with age. In both groups neither the duration of disease nor gender were related to SA levels. MMSE scores correlated with SA indicators only in the group with discopathy Patients with the relapsing-remitting form of MS as compared to those with progressive MS had higher levels of SA and its dimensions.
Conclusions. The findings justify a discussion about the role of social support in comprehensive rehabilitation ofpatients with multiple sclerosis. They suggest also a high level of various interventions supporting this group of patients.


Aggressive behaviors in male residents of a juvenile correctional center

Sławomir Szubert, Marta Strombek-Milczarek, Piotr Wierzbiński, Małgorzata Szpilewska, Antoni Florkowski
Postępy Psychiatrii i Neurologii 2009; 18 (2): 157-162

Objectives. The aim of the study was to investigate socio-demographic andpsychopathological determinants of aggressive behaviors in male residents of a juvenile correctional center, and to assess their aggression level.
Method The subjects were compared with junior high school students enrolled as the controls. The Buss-Durkee Scale was used to assess various forms of aggression, and a sociodemographic ąuestionnaire developed by the authors - to collect personal data. Moreover, mental condition was evaluated in both groups.
Results. A majority of the correctional center residents had a working-class background. The main source of their family income included various forms of social benefits (unemployment compensation, alimony old age or disability pensions), and they mostly rated their material situation as bad or very bad. Approximately 50% of the controls had a white-collar background, 95% of theirparents were employed, and the material situation of the family was perceived as very good by over a half of the group. All the boys from the juvenile correctional center manifested behavior disorders. In some cases also otherpsychopathological conditions were diagnosed. On the other hand, no conduct abnor-malities were found in the control group of junior high school students.
Conclusions. In the study group of correctional facility residents the aggression level was higher than that among the controls. The difficult background socio-economic conditions of the former could have intensified their family problems, affecting in turn their psychophysical development. Their scholastic difficulties, environmental neglect, a sense of rejection by the family and relatives might intensify their aggres-sion and make them seek groups that would accept such behaviors.


Research problems and methodological errors in psychiatry - selected issues

Andrzej Jasiewicz, Anna Grzywacz, Marcin Jabłoński, Jerzy Samochowiec
Postępy Psychiatrii i Neurologii 2009; 18 (2): 163-168

Objective. To present difficulties encountered by those engaged in broadly defined scientific research in psychiatry.
Review. The paper presents an overview of major research issues and potential errors that may be involved at every stage of scientific research and reąuire a multidimensional analysis. Beginning from legal regulations, through formulation of research hypotheses, clinical drug trials, genetic research, up to the laboratory stage and mental state assessment - the authors analyze difficulties and potential errors than can be encountered at each of these stages.
Conclusions. Due to its specificity, psychiatry reąuires a special approach both to individual patients and to the ways of performing research and interpreting the findings. The knowledge about sources of errors in the research process may enable us to eliminate them and thus to improve the value of obtained results.


Available methods of compliance assessment in pharmacological treatment of psychoses

Karolina Friemann, Jacek Wciórka
Postępy Psychiatrii i Neurologii 2009; 18 (2): 169-181

Objectives. To discuss methods of assessment of adherence to medical recommendations, their respective accuracy and comparability.
Review. Available methods of measurement of compliance with medical recommendations are presented. Their advantages and limita-tions are discussed. Methodological flaws of compliance studies are outlined. The review includes objective, subjective, indirect and direct assessment methods.
Conclusions. There are many methods of compliance assessment, some very modern (using electronics and virtual reality), but none seems to deserve the name of a golden standard, being: reliable, not too intruding into the patient 's life, and free from biases typical of self-report techniąues. Certain compliance assessment methods may bepreferable to other ones in a specific clinical situation, but a combination of many methods increases the reliability and validity of obtained results.


Semantic dementia - the role of interview and neuropsychological assessment in differential diagnosis

Emilia J. Sitek, Dariusz Wieczorek, Ewa Narożańska, Emilia J. Sitek
Postępy Psychiatrii i Neurologii 2009; 18 (2): 183-187

Objectives. The aim of the article is to describe cognitive dysfunction specificity in semantic dementia (SD ) in the context of other dementia types and to point to the importance of interview and neuropsychological assessment in differential diagnosis.
Views. Semantic dementia (SD) is a subtype of frontotemporal dementia (FTD). Progressive loss of semantic knowledge constitutes the core deficit. Episodic memory dysfunction is of late onset and milder character than semantic memory impairment, differentiating SD from Alzheimer 's disease. Language dysfunction at onset is limited mostly to naming and single-word comprehension, which allows differen-tiation between SD and various primary progressive aphasia types. Absence or mild intensity of behavioral disturbance in SD differentiate the condition from the behavioral variant FTD. Neuropsychological assessment allows to establish whether semantic memory deficit predominates in the clinical picture and to what extent the profile of other cognitive functions is characteristic of SD. Neuropsychological data combined with structural and functional neuroimaging findings that show atrophy and dysfunction of temporal poles provide grounds for a reliable diagnosis of SD.
Conclusions. Semantic dementia is a separate clinical entity, so far rarely diagnosed in Poland. Differential diagnosis of SD, enabled by the state-of-the-art knowledge about the condition characteristics, reąuires both neuropsychological assessment and neuroradiological examination.


Controversies on bloodpressure control and the use of drugs acting via the cerebral renin-angiotensin- aldosterone system in Alzheimer's disease

Maciej Banasiak, Tadeusz Pietras, Ilona Kurnatowska, Łukasz Wieteska, Michał Nowicki
Postępy Psychiatrii i Neurologii 2009; 18 (2): 189-194

Objectives. The aim of this study is to review a potential role of antihypertensive drugs acting via the renin-angiotensin-aldosterone system (RAA) in theprevention and treatment of Alzheimer 's disease (AD).
Views. AD and vascular dementia (VD) are the most common causes of dementia. Recent research suggests a possible relationship between vascular and neurodegenerative diseases. Therefore, long-term arterial hypertension may contribute not only to vascular dementia, but also to the development of AD. Numerous epidemiological studies have reported that high mid-life blood pressure may increase the risk of developing AD in later life. A ąuestion arises whether the use of antihypertensive drugs could reduce the incidence of dementia and improve cognitive functions in AD patients. A potential role of antihypertensive drugs acting via the renin-angiotensin-aldosterone (RAA) system in theprevention of neurodegenerative disorders has been widely studied in recentyears. Earlier research findings indicate that the brain has its own independent RAA system that mediates some cognitive functions, such as memory and learning. It is also well known that angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists (ARA) reduce cardiovascular morbidity and mortality rates, irrespective of their blood pressure-lowering effect.
Conclusions. Although hypertension and cerebrovascular damage are significant factors in cognitive impairment and AD progression, the RAA involvement the pathophysiology ofAD and the potential role of drugs acting via the RAA system in the prevention and treatment of AD remain unclear. More controlled randomized prospective trials with well-defined endpoints are needed to determine the role of the RAA system and RAA-modifying antihypertensive treatment in the pathogenesis of AD.


The anatomical basis and clinical implications of the trigemino-cardiac reflex

Wojciech Świątnicki, Cyprian Wolski, Bartłomiej Woźniakowski, Arkadiusz Rotkiewicz, Marek Zawirski, Krzysztof Tybor
Postępy Psychiatrii i Neurologii 2009; 18 (2): 195-199

Objectives. To present the anatomical basis and mechanism underlying the trigemino-cardiac reflex (TCR), and to indicate some potential clinical implications of the TCR.
Review. The TCR is a brain-stem reflex that has gained much attention in clinical medicine in recent years. The reflex is evoked by stimulation of any of the sensory branches of the trigeminal nerve, directly increasing parasympathetic impulsation transmitted via the vagal nerve. The picture predominating in the course of TCR is primary inhibiting of the automatism of the sinoatrial node, and a decrease in the ino-, chrono- and dromotropism of myocardiac cells caused by increasedparasympathetic vagal tone. As a result, a sudden development of hemodynamic instability such as cardiac dysrhythmia up to asystole, arterial hypotension and apnea are manifested.
Conclusions. Due to the long course of the trigeminal nerve at the skull base, the TCR may occur during surgery freąuently performed in this region. Therefore, the knowledge of the mechanism and clinical features of this reflex is essential to effectively prevent and reduce the risk of potential complications associated with the trigemino-cardiac reflex.

Case report

Diagnosis of schizophrenia as a case of medical malpractice

Jan Koziełł, Mieczysław Janiszewski, Wioletta Jarosz-Nowakowska, Maciej Masztalerz
Postępy Psychiatrii i Neurologii 2009; 18 (2): 201-209

Objective. An attempt was made in the paper to re-discuss principles that might protect psychiatrists from such conflicts as that des-cribed below.
Case. Medical history of MH, treated since 1991 in the Provincial Mental Hospital (PMH) in Toruń, is presented together with press articles of2007 concerning thispatient. Diagnosticprocedures used in the PMH, as well as subseąuent discrepant diagnoses made in other psychiatric facilities are outlined. Criteria for the assessment of these diagnoses in terms of possible medical malpractice are proposed. Moreover, the issues of the relationship amongpsychiatrists and the way of presenting mental health problems by mass media are discussed.
Commentary. The diagnostic procedures currently in force allow to increase compatibility of diagnoses made in different centers, but are not sufficient for their unification.