David Spiegel

Bio: David Spiegel is an academic researcher from Stanford University. The author has contributed to research in topics: Medicine & Breast cancer. The author has an hindex of 106, co-authored 733 publications receiving 46276 citations. Previous affiliations of David Spiegel include Tel Aviv University & University of Adelaide.

Psychological Distress and Disease Course for Women With Breast Cancer: One Answer, Many Questions

Abstract: In this issue of the Journal, Tross et al. (7) report on an exceptionally fine study of the relationship between psychological distress and both disease-free and overall survival in women with stage II breast cancer. Their report is noteworthy not only for the rigor of its methods but especially for the open-minded and balanced way in which it is written. The authors found no relationship between psychological distress, as measured by the Symptom Check List-90-Revised (SCL-90-R), and recurrence of disease in or survival of patients with breast cancer. Their study was conducted on a large subsample of patients in the Cancer and Leukemia Group B (CALGB) national clinical trial of adjuvant therapy for stage II breast cancer. Two hundred eighty women, 31% of the total sample, were entered in the study. Even a casual examination of the survival curves for these women shows little support for the idea that distress, as measured by the SCL-90-R, is associated with longer or shorter disease-free or overall survival time. In their report, Tross et al. note the limitations of their study. Although their study was prospective in design, the psychosocial component was apparently retrospective, a useful add-on to an intervention trial. Another important issue is sample bias. The authors were able to assess fewer than a third of the total sample, although it was a sizable number of women. Some of the reasons for this subsample selection, i.e., patient refusal and attrition, might have restricted the range of distress found, thereby reducing the ability of the study to detect a relationship between variance in distress and survival. Indeed, Tross et al. noted that the sample of patients was relatively nondepressed. Being depressed might be a reason for refusal to fill out additional questionnaires. Other reasons, such as a tendency to be uncooperative, have been reported to be associated with longer survival (2). Thus, patients who participated in the study might be self-selected for lacking the depression that might predict poorer outcome or the feistiness that other authors (7,3) have found to predict better outcome.

Hypnotic assessment and treatment of trauma-induced psychoses: the early psychotherapy of H. Breukink and modern views.

Abstract: The role of hypnotizability assessment in the differential diagnosis of psychotic patients is still unresolved. In this article, the pioneering work of Dutch psychiatrist H. Breukink (1860-1928) during the 1920s is used as early evidence that hypnotic capacity is clinically helpful in differentiating highly hypnotizable psychotic patients with dissociative symptomatology from schizophrenics. Furthermore, there is a long tradition of employing hypnotic capacity in the treatment of these dissociative psychoses. The ways in which Breukink used hypnosis for diagnostic, prognostic, and treatment purposes are summarized and discussed in light of both old and current views. He felt that hysterical psychosis was trauma-induced, certainly curable, and that psychotherapy using hypnosis was the treatment of choice. Hypnosis was used for symptom-oriented therapy, as a comfortable and supportive mental state, and for the uncovering and integrating of traumatic memories. For the latter purpose, Breukink emphasized a calm mental state, both in hypnosis and in the waking state, thereby discouraging emotional expression, which he considered dangerous in psychotic patients. In the discussion, special attention is paid to the role and dangers of the expression of trauma-related emotions.

Childhood cancer survivors exposed to total body irradiation are at significant risk for slipped capital femoral epiphysis during recombinant growth hormone therapy.

Abstract: Background Childhood cancer survivors treated with cranial or total body irradiation (TBI) are at risk for growth hormone deficiency (GHD). Recombinant growth hormone (rhGH) therapy is associated with slipped capital femoral epiphysis (SCFE). We compared the incidence of SCFE after TBI versus cranial irradiation (CI) in childhood cancer survivors treated with rhGH. Procedure Retrospective cohort study (1980–2010) of 119 survivors treated with rhGH for irradiation-induced GHD (56 TBI; 63 CI). SCFE incidence rates were compared in CI and TBI recipients, and compared with national registry SCFE rates in children treated with rhGH for idiopathic GHD. Results Median survivor follow-up since rhGH initiation was 4.8 (range 0.2–18.3) years. SCFE was diagnosed in 10 subjects post-TBI and none after CI (P < 0.001). All 10 subjects had atypical valgus SCFE, and 7 were bilateral at presentation. Within TBI recipients, age at cancer diagnosis, sex, race, underlying malignancy, age at radiation, and age at initiation of rhGH did not differ significantly between those with versus without SCFE. The mean (SD) age at SCFE diagnosis was 12.3 (2.7) years and median duration of rhGH therapy to SCFE was 1.8 years. The SCFE incidence rate after TBI exposure was 35.9 per 1,000 person years, representing a 211-fold greater rate than reported in children treated with rhGH for idiopathic GH deficiency. Conclusions The markedly greater SCFE incidence rate in childhood cancer survivors with TBI-associated GHD, compared with rates in children with idiopathic GHD, suggests that cancer treatment effects to the proximal femoral physis may contribute to SCFE. Pediatr Blood Cancer 2013;60:1766–1771. © 2013 Wiley Periodicals, Inc.

How do you feel about cancer now?--survival and psychosocial support.

Abstract: This study by Evans and Connis (Comparison of Brief Group Therapies for Depressed Cancer Patients, page 306) compares two types of group psychotherapy for depressed cancer patients who are also receiving radiation therapy. It contributes to a growing literature indicating that group psychotherapy is effective in helping cancer patients better cope with their disease. As the authors note, a number of studies have shown that group psychotherapy can help reduce anxiety and depression, decrease pain, and may even influence survival time (1). The Evans and Connis study is a second generation study in that it does not really address the question, "Does group psychotherapy work?" Rather, it provides a randomized comparison of two types of group therapy-one focusing on cognition and the other on social support and affective expression. This kind of systematic exploration of the types of intervention that are most effective is much needed in the field now. There is sufficient evidence that such treatments work. By itself that is no longer an interesting question. How they work is the next question. The authors call for process analysis, which would be helpful as well, but systematic comparison of different types of intervention is a useful contribution. The authors found that the support group method was more effective than cognitive behavioral treatment, although both were superior to the findings in the control group. In particular, it was only the social support group participants who showed significantly improved scores on somatization and depression, as well as global severity of distress, on the SCL-90-R. The authors speculate that the reason for this differential effectiveness was some possible stress induced by the cognitive behavioral method. Although this is possible, it may well be that emotional expression, a major component of the social support intervention employed by the authors, has a powerful and positive therapeutic effect. There is a literature suggesting that cancer patients are, if anything, rather emotionally suppressive (2-3) and that cancer patients who give vent to feelings do better medically (4). Whether or not cancer patients differ from others in this regard, there is reason to believe that the ability to express strong feelings in a supportive group setting would have positive therapeutic benefit. Expression of emotion has the potential to facilitate a shift from emotion-focused coping, in which the patient is simply trying to manage intense and unpleasant affect, to problemfocused coping, in which the discomfort is acknowledged but can lead to various means of addressing or even resolving some of the causes of the negative emotion. In our psychosocial treatment laboratory, we have obtained recent evidence that attempts to suppress emotion are counterproductive. Metastatic breast cancer patients who rated themselves as high in emotional suppression on the Courtauld Emotional Control Scale (5) turned out to have higher total mood disturbance scores on the Profile of Mood States (6) than those who were low in affect suppression. In other words, suppression of adverse affect does not work. It seems to increase, rather than reduce, dysphoria. The patient who suffers constant intrusion of her fear of death may be relieved by the opportunity to discuss that fear with others in a similar situation. As one support group member commented, "The world hasn't changed, but I feel less alone with my feelings about it." It is indeed interesting that similar results were obtained in a study of cognitive behavioral versus supportive expressive group therapy for HIV infected individuals (7). In that study also, both interventions were helpful, but there was advantage for the supportive intervention. The fact that similar results are found in the treatment of two different groups of medically ill people suggests that the finding is a valid and robust one. Indeed, a sense of isolation, especially with uncomfortable affect, may compound disease-related anxiety and depression. Any cancer patient naturally fears death, even though many are cured of the disease. But, one way in which we conceptualize death is isolation (8). Death is the ultimate aloneness: removal from loved ones. Anything that makes

PTSD and Vietnam Veterans

Abstract: In his Perspective “Psychiatric casualties of war” (18 Aug., p. [923][1]), R. J. McNally notes that a new study by B. P. Dohrenwend et al. (“The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods,” Reports, 18 Aug., p. [979][2]) revised downward from 15.2

疟原虫var基因转换速率变化导致抗原变异[英]／Paul H, Robert P, Christodoulou Z, et al//Proc Natl Acad Sci U S A

Abstract: 抗原变异可使得多种致病微生物易于逃避宿主免疫应答。表达在感染红细胞表面的恶性疟原虫红细胞表面蛋白1（PfPMP1）与感染红细胞、内皮细胞、树突状细胞以及胎盘的单个或多个受体作用，在黏附及免疫逃避中起关键的作用。每个单倍体基因组var基因家族编码约60种成员，通过启动转录不同的var基因变异体为抗原变异提供了分子基础。

The Benefits of Being Present: Mindfulness and Its Role in Psychological Well-Being

Abstract: Mindfulness is an attribute of consciousness long believed to promote well-being. This research provides a theoretical and empirical examination of the role of mindfulness in psychological well-being. The development and psychometric properties of the dispositional Mindful Attention Awareness Scale (MAAS) are described. Correlational, quasi-experimental, and laboratory studies then show that the MAAS measures a unique quality of consciousness that is related to a variety of well-being constructs, that differentiates mindfulness practitioners from others, and that is associated with enhanced selfawareness. An experience-sampling study shows that both dispositional and state mindfulness predict self-regulated behavior and positive emotional states. Finally, a clinical intervention study with cancer patients demonstrates that increases in mindfulness over time relate to declines in mood disturbance and stress. Many philosophical, spiritual, and psychological traditions emphasize the importance of the quality of consciousness for the maintenance and enhancement of well-being (Wilber, 2000). Despite this, it is easy to overlook the importance of consciousness in human well-being because almost everyone exercises its primary capacities, that is, attention and awareness. Indeed, the relation between qualities of consciousness and well-being has received little empirical attention. One attribute of consciousness that has been much-discussed in relation to well-being is mindfulness. The concept of mindfulness has roots in Buddhist and other contemplative traditions where conscious attention and awareness are actively cultivated. It is most commonly defined as the state of being attentive to and aware of what is taking place in the present. For example, Nyanaponika Thera (1972) called mindfulness “the clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception” (p. 5). Hanh (1976) similarly defined mindfulness as “keeping one’s consciousness alive to the present reality” (p. 11). Recent research has shown that the enhancement of mindfulness through training facilitates a variety of well-being outcomes (e.g., Kabat-Zinn, 1990). To date, however, there has been little work examining this attribute as a naturally occurring characteristic. Recognizing that most everyone has the capacity to attend and to be aware, we nonetheless assume (a) that individuals differ in their propensity or willingness to be aware and to sustain attention to what is occurring in the present and (b) that this mindful capacity varies within persons, because it can be sharpened or dulled by a variety of factors. The intent of the present research is to reliably identify these inter- and intrapersonal variations in mindfulness, establish their relations to other relevant psychological constructs, and demonstrate their importance to a variety of forms of psychological well-being.

Standards of Medical Care in Diabetes

Abstract: XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.