Showing papers by "David Spiegel published in 2006"

Art Therapy for Combat-Related PTSD: Recommendations for Research and Practice

Abstract: With a new generation of American combat veterans returning from Iraq, the nation has an obligation to do everything possible to improve care for posttraumatic stress disorder (PTSD) Although art therapy has been understudied in this context, it shows promise as a means of treating hard-to-treat symptoms of combat-related PTSD, such as avoidance and emotional numbing, while also addressing the underlying psychological situation that gives rise to these symptoms In this paper, we establish a conceptual foundation for research about art therapy as a treatment for combat-related PTSD by situating art therapy within the context of other PTSD treatments, outlining a theoretical rationale for using art therapy as a treatment for PTSD, and clarifying "best practices" for using art therapy as a treatment for combat-related PTSD We recommend group treatment in three stages and suggest that art therapists who treat combat-related PTSD receive specialized training in trauma intervention and PTSD theory

Design decisions to optimize reliability of daytime cortisol slopes in an older population

Abstract: Objective The daytime log-cortisol slope appears to be of growing importance in studying the relationship between stress and health How best to estimate that slope with minimal burden to the participants and the cost of the study is a decision often made without empiric foundation Methods In 50 older participants, the authors examined cortisol assay comparability across laboratories, assay reliability, test–retest reliability of slopes, and comparability of slope estimates for two, three, and four samples per day Results The authors demonstrate in an older sample that 1) assay reliability is a relatively minor issue, that one assay per saliva sample suffices; 2) the use of a sample obtained at wake time for each participant appears to be a preferred anchor for the slope estimate in comparison to a sample 30 minutes postwake time; 3) self-reported times appear preferable to automatic time recording; and 4) test–retest reliability of slopes, however, is not sufficiently high to base a slope estimate on one day; minimally two days and preferably three should be required Conclusions Whether these conclusions apply to other populations, or using other protocols, is not assured, but the study itself provides a model that can be used to check research decisions Unnecessarily imposing a burdensome protocol has both ethical and scientific ramifications and should be carefully avoided

The effect of peer counseling on quality of life following diagnosis of breast cancer: an observational study.

Abstract: Women with breast cancer express the greatest need for counseling at the time of diagnosis and report that the intervention they want is to be able to speak with someone who has the same cancer, but has lived through the crisis of treatment and is leading a ‘normal’ life. We conducted an observational study of a 6-month peer-counseling intervention testing outcomes for both newly diagnosed women (Sojourners) and peer counselors (Navigators) as a first step toward the goal of validating a peer navigator program. Significant improvement in the Sojourners was observed in trauma symptoms, emotional well-being, cancer self-efficacy, and desire for information on breast cancer resources. Navigators maintained baseline levels of the outcome variables, but increased in dissatisfaction with their interactions with their medical team and increased emotional suppression. Our findings indicate that peer navigation may halt a decline in quality of life that is commonly found in the first year following breast cancer diagnosis. In addition, Navigators were not adversely affected by their experience; however, careful training and supervision of Navigators is crucial to overall success. Randomized clinical trials are needed to demonstrate the efficacy of peer navigator programs. Copyright © 2006 John Wiley & Sons, Ltd.

Depression and stress reactivity in metastatic breast cancer.

Abstract: OBJECTIVE: Cancer-related distress due to the psychological and physical challenges of metastatic breast cancer (MBC) may result in symptoms of depression, which negatively affects quality and may influence quantity of life. This study investigated how depression affects MBC stress reactivity, including autonomic (ANS) and hypothalamic-pituitary-adrenal (HPA) axis function. METHOD: Forty-five nondepressed and 45 depressed patients with MBC underwent a modified Trier Social Stress Test (TSST) while affect, cardiovascular, respiratory, and cortisol responses were measured. RESULTS: At study entry, depressed compared with nondepressed patients had significantly lower log cortisol waking rise levels (p = .005) but no other HPA differences. Positive affect (p = .025) and high-frequency heart-rate variability (lnHF) (p = .002) were significantly lower at TSST baseline in depressed patients. In response to the TSST, depressed patients reported significantly lower positive (p = .050) and greater negative affect (p = .037) and had significantly reduced lnHF (p = .031). In secondary analyses, at TSST baseline both low-frequency (lnLF) (p = .002) and very-low-frequency (lnVLF) (p = .0001) heart rate variability were significantly lower in the depressed group. In secondary analyses during the TSST, those who were depressed had significantly lower lnVLF (p = .008) and did not increase aortic impedance reactivity as much as did the nondepressed during the stressor (p = .005). CONCLUSION: Depression in patients with MBC was associated with alterations in autonomic regulation, particularly reductions in respiratory sinus arrhythmia, a measure of cardiac vagal control, at baseline and during the TSST. In addition, depression was associated with blunted HPA response to awakening. Both MBC groups had relative cortisol hyporesponsiveness to acute stress.

Evidence for a dissociative subtype of post-traumatic stress disorder among help-seeking childhood sexual abuse survivors

Abstract: This study examined evidence for a dissociative subtype of post-traumatic stress disorder (PTSD) among women seeking psychotherapy for childhood sexual abuse (CSA). One hundred and twenty-two women seeking treatment for CSA completed a battery of questionnaires assessing PTSD, dissociative symptoms, and child maltreatment. Using signal detection analysis, we identified high and low dissociation PTSD subgroups. A constellation of three PTSD symptoms-hypervigilance, sense of foreshortened future, and sleep difficulties-discriminated between these two subgroups (OR = 8.15). Further evidence was provided by the finding of a nonlinear relationship between severity of childhood maltreatment and dissociation in the women with PTSD. These results provide support for a dissociative subtype of PTSD that may stem from more severe childhood experiences of neglect and abuse.

Psychophysiological and cortisol responses to psychological stress in depressed and nondepressed older men and women with elevated cardiovascular disease risk.

Abstract: OBJECTIVE: The objective of this study was to compare psychophysiological and cortisol reactions to psychological stress in older depressed and nondepressed patients at risk for cardiovascular disease (CVD). METHODS: Forty-eight depressed participants and 20 controls with elevated cardiovascular risk factors underwent a psychological stress test during which cardiovascular variables were measured. Salivary cortisol was collected after each test segment. Traditional (e.g., lipids) and atypical (e.g., C-reactive protein) CVD risk factors were also obtained. RESULTS: At baseline, the groups did not differ on lipid levels, flow-mediated vasodilation, body mass index, or asymmetric dimethylarginine. However, the depressed patients had significantly higher C-reactive protein levels. Contrary to our hypothesis, there were no differences in baseline cortisol levels or diurnal cortisol slopes, but depressed patients showed significantly lower cortisol levels during the stress test (p = .03) and less cortisol response to stress. Compared with nondepressed subjects, depressed subjects also showed lower levels of respiratory sinus arrhythmia (RSA(TF)) during the stress test (p = .02). CONCLUSIONS: In this sample, older depressed subjects with elevated risk for CVD exhibited a hypocortisol response to acute stress. This impaired cortisol response might contribute to chronic inflammation (as reflected in the elevated C-reactive proteins in depressed patients) and in other ways increase CVD risk. The reduced RSA(TF) activity may also increase CVD risk in depressed patients through impaired autonomic nervous system response to cardiophysiological demands.

Association of coping style, pain, age and depression with fatigue in women with primary breast cancer.

Abstract: The purpose of this study was to explore the relative contributions of coping, depression, pain and age, in the experience of cancer related fatigue. A total of 353 women treated for primary breast cancer were assessed within one year of diagnosis using the Profile of Mood States, the Hospital Anxiety and Depression Scale and the mini-Mental Adjustment to Cancer Scale. Fatigue was positively associated with depression and pain, but inversely related to age. In contrast to our expectations, fighting spirit was not associated with less fatigue. A relationship between coping style and cancer-related fatigue was found exclusively for ‘positive reappraisal’, a combination of fighting spirit and fatalism. Detectable only in multivariate analysis together with depression, the results suggest a weak association between coping and fatigue. The relationship between cancer related fatigue, age and coping styles requires further exploration within longitudinal studies. Copyright © 2005 John Wiley & Sons, Ltd.

Effects of quality of life and coping on depression among adults living with HIV/AIDS.

Abstract: This prospective study examined the effect of maladaptive coping strategies and psychological quality of life (QOL) on depression at two time points in a diverse sample of persons living with HIV/AIDS (N = 85). The use of maladaptive coping strategies to deal with the stress of living with HIV/AIDS, particularly engaging in various kinds of avoidant behaviors, was significantly associated with greater depression at baseline and increased depression at three months. QOL was the single most important predictor of depression. In an effort to develop effective clinical methods aimed at decreasing depression among adults living with HIV, future studies need to focus on improving quality of life and increasing adaptive coping strategies associated with the stress of living with HIV/AIDS.

An oligomer-based approach to skeletal diversity in small-molecule synthesis.

Abstract: Access to small molecules of widely varying molecular shapes has been identified as an enabling step in the discovery of biologically active materials. In this communication we introduce an approach to the systematic development of architecturally distinct chemical compounds based upon the assembly of reactive monomers into linear oligomers, each of which encodes a unique molecular framework under a common set of reaction conditions. Certain products of the initial chemical transformation (Ru-catalyzed metathesis reaction) encode additional skeletons upon treatment with a second common set of reagents (Diels−Alder dienophiles). Application of this oligomerization approach has led to the discovery of a previously unreported tandem ene-yne−yne metathesis−6π-electrocyclization−1,5-hydride migration that converts a linear substrate into a complex tricyclic 1,3-diene in a single step. Thus, the reported strategy might serve not only as a generator of skeletally diverse small molecules but also as a discovery p...

Accelerated vascular calcification and relative hypoparathyroidism in incident haemodialysis diabetic patients receiving calcium binders.

Abstract: Background. Vascular calcification and low bone turnover with a relatively low parathyroid hormone (PTH) often coexist in diabetic patients undergoing haemodialysis. Since calcium salts (CaS) are used extensively as primary phosphate binders and have been associated with progressive vascular calcification, we studied the effects of CaS on coronary arteries and parathyroid activity in incident haemodialysis diabetic patients. Methods. We measured the change in coronary artery calcium scores (CACS) with sequential computed tomography in 64 diabetic and 45 non-diabetic patients, randomized to CaS or sevelamer within 90 days of starting haemodialysis. CACS measurements were repeated after 6, 12 and 18 months. Serum intact PTH (iPTH), calcium and phosphorus were serially tested. Results. During the study period, serum phosphate was similar in diabetic and non-diabetic patients. Serum calcium levels were similar at baseline (2.3 � 0.25 mmol/l for both) and increased significantly with CaS treatment (P < 0.05) both in diabetic and non-diabetic patients but not with sevelamer. Diabetic patients treated with CaS showed a significantly greater CACS progression than sevelamer-treated patients (median increase 177 vs 27; P ¼ 0.05). During follow-up, diabetic patients receiving CaS were significantly more likely to develop serum iPTH values <16 pmol/l than diabetic patients treated with sevelamer (33 vs 6%, P ¼ 0.005) and had a lower mean iPTH level (24 þ 16 vs 31 þ 14 pmol/l; P ¼ 0.038). Conclusions. The management of hyperphosphataemia with CaS in haemodialysis diabetic patients is associated with a significantly greater progression of CACS than with sevelamer. These effects are accompanied by iPTH changes suggestive of low bone turnover.

Long-term follow-up after one-stage reconstruction of dislocated hips in patients with cerebral palsy.

Abstract: Twelve consecutive patients (average age 10.6 years) with 14 dislocated hips underwent one-stage hip reconstruction between 1973 and 1981. The procedure consisted of (1) adductor myotomy and anterior obturator neurectomy, (2) circumferential capsulotomy, iliopsoas and external rotator tenotomies, and ligamentum teres and pulvinar excision, (3) shortening femoral varus derotational osteotomy, (4) acetabuloplasty, and (5) spica immobilization for 4 weeks. All patients were followed clinically and radiographically at an average of 16.7 (range 12.4-19.5) years. No patients were lost to follow-up. Long-term results revealed complete stability in 13 of 14 hips, with no redislocations or subluxations. The one patient with "instability" had undergone bilateral proximal femoral resections for severe arthritis 12 years after left hip reconstruction; at the time of resection, the left hip was stable and reduced. Pain was absent in 13 of 14 hips. There were no problems with perineal care, decubitus formation, or sitting tolerance. Extension and abduction improved an average of 23 degrees and 10 degrees, respectively. Two patients' ambulatory status improved; none deteriorated. The mean center-edge angle was 35 degrees (range 22-50 degrees), and the mean migration percentage was 10.6% (range 0-31%). Complications included one case of degenerative arthritis, one case of painless coxa vara, and three episodes of supracondylar femur fractures. None of these patients developed radiographic evidence of avascular necrosis. In the authors' experience, one-stage hip reconstruction consisting of soft tissue lengthening, open reduction, femoral osteotomy, and pericapsular acetabuloplasty results in a painless, mobile, and stable hip at long-term follow-up that greatly improves the patient's quality of life.

Self-Report and Linguistic Indicators of Emotional Expression in Narratives as Predictors of Adjustment to Cancer

Abstract: Emotional expression and cognitive efforts to adapt to cancer have been linked to better psychological adjustment. However, little is known about the relationship between linguistic indicators of emotional and cognitive coping efforts and corresponding self-report measures of related constructs. In this study, we sought to evaluate the interrelationships between self-reports of emotional suppression and linguistic indicators of emotional and cognitive coping efforts in those living with cancer. Seventy-one individuals attending a community cancer support group completed measures of emotional suppression and mood disturbance and provided a written narrative describing their cancer experience. Self-reports of emotional suppression were associated with more rather than less distress. Although linguistic indicators of both emotional expression and cognitive processing were generally uncorrelated with self-report measures of emotional suppression and mood disturbance, a significant interaction was observed between emotional suppression and use of cognitive words on mood disturbance. Among those using higher levels of emotional suppression, increasing use of cognitive words was associated with greater levels of mood disturbance. These findings have implications for a) the therapeutic use of emotion in psychosocial interventions and b) the use of computer-assisted technologies to conduct content analysis.

A Randomized Controlled Trial of Psychosocial Interventions Using the Psychophysiological Framework for Chinese Breast Cancer Patients

Abstract: This study aimed to investigate the psychophysiological outcomes of different psychosocial interventions for breast cancer patients. Participants were randomly assigned into 3 intervention groups, namely, Body-Mind-Spirit (BMS), Supportive-Expressive (SE), and Social Support Self-Help (SS) groups; a no-intervention group was used as control. Salivary cortisol was used as the physiological stress marker. Distress level, mental adjustment, emotional control, and social support were measured. Data were collected at baseline, 4 month, and 8 month. Preliminary results indicated that BMS intervention produced the greatest and the most sustained effects. It enhanced positive social support, reduced psychological distress, emotional control, and negative mental adjustment. Total salivary cortisol was lowered after 8 months. Most participants in SE groups indicated the treatment helpful, but changes in psychophysiological outcomes were not statistically significant. Participants in SS groups seemed less likely to benefit from the intervention. The no intervention control group indicated a reduction in social support. These outcomes suggest that active professional intervention is more likely to yield therapeutic effects. In particular, psychosocial intervention attending to the spiritual dimension contributes to positive outcomes.

Palliative care: Clinical practice guidelines in oncology

Abstract: Michael H. Levy, MD, PhD; Anthony Back, MD; Costantino Benedetti, MD; J. Andrew Billings, MD; Susan Block, MD; Barry Boston, MD; Eduardo Bruera, MD; Sydney Dy, MD; Catherine Eberle, MD; Kathleen M. Foley, MD; Sloan Beth Karver, MD; Sara J. Knight, PhD; Sumathi Misra, MD; Christine S. Ritchie, MD, MSPH; David Spiegel, MD; Linda Sutton, MD; Susan Urba, MD; Jamie H. Von Roenn, MD; and Sharon M. Weinstein, MD

The life tape project: increasing family social support and symbolic immortality with a brief existential intervention for cancer patients and their families.*

Abstract: Cancer poses a powerful threat to the emotional equilibrium of patients and their families. A key role of the family and medical team is to provide a supportive environment as the patient confronts the reality of death. Few interventions have been developed to help families support patients in dealing with fears of death and dying. We present one such approach, the Life Tape Project (LTP), that helps bring families closer together, increases communication, and acts as an existential intervention leading to greater sense of legacy, meaning, self-awareness, identity, and connection. Additionally, the results of a pilot study exploring the benefits of the LTP are presented, and we describe symbolic immortality, an aspect of existential coping, to illuminate how existential and social support factors can work together to benefit patients and their families.

Disengagement and social support moderate distress among women with a family history of breast cancer.

Abstract: Using a cross-sectional, exploratory design, this pilot study analyzed the relationships between familial history of breast cancer and psychological distress in order to evaluate who is more distressed and to assess the possible need for intervention. Coping style, social support, and family relations were investigated as potential moderators of these relationships. Participants were 45 women with a familial history of breast cancer recruited from the Family Registry for Breast Cancer (FRBC) at the Northern California Cancer Center (NCCC). Contrary to previous reports of similar cohorts, the overall level of psychological distress in this cohort was comparable to normative samples. The number of relatives with breast cancer was related to distress as measured by the State-Trait Anxiety Inventory (STAI) scale, but there was no significant differentiation in distress associated with the number of first-degree as compared to second- and third-degree relatives with breast cancer. Having more relatives that had died from breast cancer was associated with greater distress on a number of measures. The number of first-degree relative deaths, including maternal death, was also associated with distress. Positive and network support, disengagement coping responses, and family cohesion were each significant moderators of the impact of family history on distress. This association between distress and disengagement is similar to that found in metastatic breast cancer patients themselves, and the findings suggest a subgroup that merits and might respond to more intensive intervention to provide support and facilitate emotional expression.

Anemia management in chronic kidney disease: what have we learned after 17 years?

Abstract: Anemia management remains controversial in patients with chronic kidney disease (CKD). The overwhelming conclusion from retrospective data analyses show a strong correlation between higher hemoglobin values and improved outcomes, including mortality, hospitalization, left ventricular hypertrophy, and quality of life. However, the evidence available from two large prospective trials in CKD comparing hemoglobin values near the current target of 11-12 g/dl with normalization or near normalization were stopped, as there was a trend toward worsening outcomes in the higher hemoglobin groups. This disparity suggests that patients who have or achieve high hemoglobin values on low doses or no erythropoietin may be inherently different from the general CKD population. Therefore targeting to a hemoglobin value above the current recommendation with intermittent erythropoietin seems unwarranted until randomized prospective trials demonstrate both safety and efficacy.

Improving methods of assessing natural killer cell cytotoxicity.

Abstract: Natural killer (NK) cells are a class of lymphocytes important in immune resistance to viral and other serious diseases. The cytotoxic function, or ‘killing activity’ of NK cells has become important in studies of the effects of stress and other psychosocial factors on physical health. Unfortunately, research on NK cell function has been plagued by discrepancies in the methods of interpreting NK cytotoxicity data. We briefly review some of the variations in measuring NK cell activity and present a new model for interpreting these results, introducing maximal target cell lysis (A) and the slope of the cytolytic curve (k) as parameters that attempt to make full use of the information and the statistical power in NK cell cytotoxicity data. Examples of these interpretation methods are presented using NK cytotoxicity data from a group of metastatic breast cancer patients. This approach will be useful in applications of NK cell measurement in psychoneuroimmunology research. Copyright © 2006 John Wiley & Sons, Ltd.

Wedding hypnosis to the radiology suite.

Abstract: Lang and colleagues (this issue) have demonstrated that hypnosis, the oldest form of psychotherapy in Western culture, can be successfully wedded to one of the newest medical interventions, core needle biopsy for breast cancer diagnosis (Lang et al., 2006). This auspicious union should make for a happy marriage. Lang demonstrated that the adjunctive use of hypnosis by trained members of the procedure team resulted in substantially less anxiety and a reduction in pain, compared to two other randomized conditions: routine care and sympathetic assistance. The improvement in anxiety with hypnosis was striking. Surprisingly, the differences in pain were more modest, but by and large pain ratings were relatively low in the routine care condition, leaving less room for improvement. The highest pain ratings occurred in the longest procedures. After more than an hour the hypnotic analgesia was clearly superior to that obtained in standard care or the nonspecific empathy conditions. Something old. Hypnosis has been utilized as a treatment since the late 18th Century. The field formally began with Franz Anton Mesmer, a Viennese physician who believed that he could induce changes in patients’ aberrant magnetic fields through a technique he initially called ‘animal magnetism.’ He moved to Paris and achieved sufficient success treating a variety of maladies that jealousy emerged from French physicians who were losing patients to Mesmer, and to death, since the primary form of medical treatment at the time was bloodletting. The King commissioned an investigative panel, which concluded that ‘‘Mesmerism’’ was due to nothing more than ‘‘heated imagination.’’ The Commission was in many ways right, and they were quite respectful of the power of suggestion and imagination. Hypnosis is, in fact, a state of highly focused attention, with a constriction in peripheral awareness and a heightened responsiveness to social cues (Spiegel and Spiegel, 2004). It is

Atypical scoliosis in a 14-year-old girl.

Abstract: An asymptomatic 14-year-old girl presented for the evaluation of scoliosis. There was no family history of a spinal deformity. On physical examination, she had right thoracic curvature with a mild trunk shift to the right. She was noticeably lordotic in the thoracic region. Her neurologic examination was normal, including the presence of symmetric abdominal reflexes. Based on an atypical curve (Fig 1), magnetic resonance imaging (MRI) was ordered (Figs 2–4). Laboratory studies all were normal, including a complete blood count with a manual differential, an erythrocyte sedimentation rate, serum electrolytes, a urinary homovanillic acid, and a urinary vanillylmandelic acid. Based on the history, physical findings, laboratory tests, and imaging studies, what is the differential diagnosis? From the *Shriners Hospitals for Children/Twin Cities, and the St. Paul Children’s Hospital, Minneapolis, MN. Each of the authors certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent arrangements, etc.) that might pose a conflict of interest in with the submitted article. Each author certifies that his institution has approved reporting of this case and that all investigations were conducted in conformity with ethical principles of research. Correspondence to: David A. Spiegel, MD, Division of Orthopaedic Surgery, Children’s Hospital of Philadelphia, 2 Floor Wood Building, 34 Street and Civic Center Blvd., Philadelphia, PA 19104. Phone: 215-590-1527; E-mail: spiegeld@email.chop.edu. DOI: 10.1097/01.blo.0000203486.98335.ff CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 447, pp. 270–276 © 2006 Lippincott Williams & Wilkins

Achieving targets for bone and mineral metabolism: the impact of cinacalcet HCl in clinical practice.

Abstract: Achieving the K/DOQI targets for bone and mineral metabolism has proven difficult with the use of vitamin D analogues and phosphate binders. The introduction of cinacalcet HCl provided a new tool with a novel therapeutic mechanism of action. The purpose of this study was to evaluate the effect of the introduction of combination algorithm for managing secondary hyperparathyroidism (SHPT) on phosphorus, calcium, and biointact parathyroid hormone (PTH). The 61 patients who dialyzed in the facility from January 2004 (baseline) and who remained in the facility as of April 2005 (follow-up) were included in the study. In the baseline period, 37 (61%) of the patients received paricalcitol at some time during the 3-month observation period. In the follow-up period, 19% or 31% of the patients received cinacalcet HCl. Of those not receiving cinacalcet HCl, 67% had PTH at or below target, 17% were felt to be noncompliant with oral meds, 7% had low calcium, and 10% either could not get the medication or were not switched to the combination pathway. Compared with the baseline period, the percent of patients who met the PTH target increased from 19.7% to 37.7%, p<0.05. The percent of patients meeting all 4 targets increased from 14.8% to 24.6%, although this did not reach statistical significance. The introduction of cinacalcet HCl into a treatment algorithm for management of SHPT resulted in a significant increase in the percentage of patients achieving the PTH target while maintaining the other mineral metabolism targets.