Fatigue is a distressing, complex, and multidimensional sensation, that is common in individuals with chronic obstructive pulmonary disease (COPD), and impacts negatively on their functioning and quality of life. Limited research has been conducted to examine how various factors may influence the different dimensions of subjective fatigue experienced in these individuals. Four dimensions of subjective fatigue including: emotional, behavioural, cognitive, and physical, were examined in a convenience sample of 42 participants with COPD who attended an outpatient pulmonary rehabilitation program. The primary purpose of this feasibility study was to determine the proportion of individuals experiencing the four dimensions of fatigue, and to examine the relationships between these dimensions of fatigue and various influencing factors (dyspnea, depression, anxiety, sleep quality, activity limitation, heart rate, and oxygen saturation). The secondary purpose was to compare the four dimensions of fatigue by sex, supplemental oxygen use, smoking status, and severity of dyspnea, and to examine the relationships between the four dimensions of fatigue and age, the number of co-morbidities, and the amount of pulmonary rehabilitation received. Self-report questionnaires were used to measure fatigue (Multidimensional Fatigue Inventory MFI), anxiety and depression (Hospital Anxiety and Depression Scale HADS), and sleep quality (Pittsburgh Sleep Quality Index PSQI). Pulmonary rehabilitation health records were accessed to collect data on the remaining variables. The majority of the participants (61.9% - 81.0%) experienced moderate levels of subjective fatigue in all four dimensions. Moderate to severe levels of physical fatigue were experienced in 95.3% of the participants. The only significant relationship was between anxiety and emotional fatigue; all other relationships were statistically insignificant. There were no significant differences between sex, supplemental oxygen use, smoking status, and severity of dyspnea on the four dimensions of subjective fatigue. Many of the participants had probable presence of clinical anxiety (42.9%), where the prevalence of anxiety was nearly twice as high as depression (21.4%). Findings from this study can be used by healthcare professionals to gain a better understanding of fatigue in individuals with COPD who attend pulmonary rehabilitation, and help in developing effective interventions for reducing the distressing effects of fatigue.

Fatigue is a distressing, complex, and multidimensional sensation, that is common in individuals with chronic obstructive pulmonary disease (COPD), and impacts negatively on their functioning and quality of life. Limited research has been conducted to examine how various factors may influence the different dimensions of subjective fatigue experienced in these individuals. Four dimensions of subjective fatigue including: emotional, behavioural, cognitive, and physical, were examined in a convenience sample of 42 participants with COPD who attended an outpatient pulmonary rehabilitation program. The primary purpose of this feasibility study was to determine the proportion of individuals experiencing the four dimensions of fatigue, and to examine the relationships between these dimensions of fatigue and various influencing factors (dyspnea, depression, anxiety, sleep quality, activity limitation, heart rate, and oxygen saturation). The secondary purpose was to compare the four dimensions of fatigue by sex, supplemental oxygen use, smoking status, and severity of dyspnea, and to examine the relationships between the four dimensions of fatigue and age, the number of co-morbidities, and the amount of pulmonary rehabilitation received. Self-report questionnaires were used to measure fatigue (Multidimensional Fatigue Inventory MFI), anxiety and depression (Hospital Anxiety and Depression Scale HADS), and sleep quality (Pittsburgh Sleep Quality Index PSQI). Pulmonary rehabilitation health records were accessed to collect data on the remaining variables. The majority of the participants (61.9% - 81.0%) experienced moderate levels of subjective fatigue in all four dimensions. Moderate to severe levels of physical fatigue were experienced in 95.3% of the participants. The only significant relationship was between anxiety and emotional fatigue; all other relationships were statistically insignificant. There were no significant differences between sex, supplemental oxygen use, smoking status, and severity of dyspnea on the four dimensions of subjective fatigue. Many of the participants had probable presence of clinical anxiety (42.9%), where the prevalence of anxiety was nearly twice as high as depression (21.4%). Findings from this study can be used by healthcare professionals to gain a better understanding of fatigue in individuals with COPD who attend pulmonary rehabilitation, and help in developing effective interventions for reducing the distressing effects of fatigue.

Previous research into the accuracy of referrals for glaucoma has shown that a large number of referrals to the Hospital Eye Service are false positive. Research in areas of healthcare other than ophthalmology has shown that psychological distress can be caused by false positive referrals. The present study aimed to evaluate the quality of referrals to the HES for all ocular pathologies, and also to quantify the proportion of these referrals that were false positive. Any commonality between false positive referrals was investigated. The psychological effect of being referred to the HES was also evaluated using the Hospital Anxiety and Depression Scale (HADS) and State-Trait Anxiety Inventory (STAI). Both scales were validated in this population with Rasch analysis before use. A final aim was to develop an improvement to the present referral pathway in order to reduce numbers of false positive referrals. The accuracy of referrals to the HES appears to improve as clinicians become more experienced, and greater numbers of false positive referrals are generated by female clinicians. Optometrists refer patients with a wide range of ocular diseases and in most cases include both fundus observations and visual acuity measurements in their referrals. GPs mainly refer patients with anterior segment disorders, particularly lid lesions, based on direct observation and symptoms. Illegibility and missing clinical information reduce the quality of many optometric referrals. Patients referred to the HES experience raised levels of anxiety as measured by the STAI and raised levels of depression as measured by the HADS-Depression subscale. As a method of assessing psychological distress, the questionnaires HADS-T (all items), STAI-S (State subscale) and STAI-T (Trait subscale) show good discrimination between patients when administered to a population of new ophthalmic outpatients, despite all having a floor effect. Subsequently a referral refinement service was developed which reduced numbers of unnecessary referrals and reduced costs for the NHS.

Previous research into the accuracy of referrals for glaucoma has shown that a large number of referrals to the Hospital Eye Service are false positive. Research in areas of healthcare other than ophthalmology has shown that psychological distress can be caused by false positive referrals. The present study aimed to evaluate the quality of referrals to the HES for all ocular pathologies, and also to quantify the proportion of these referrals that were false positive. Any commonality between false positive referrals was investigated. The psychological effect of being referred to the HES was also evaluated using the Hospital Anxiety and Depression Scale (HADS) and State-Trait Anxiety Inventory (STAI). Both scales were validated in this population with Rasch analysis before use. A final aim was to develop an improvement to the present referral pathway in order to reduce numbers of false positive referrals. The accuracy of referrals to the HES appears to improve as clinicians become more experienced, and greater numbers of false positive referrals are generated by female clinicians. Optometrists refer patients with a wide range of ocular diseases and in most cases include both fundus observations and visual acuity measurements in their referrals. GPs mainly refer patients with anterior segment disorders, particularly lid lesions, based on direct observation and symptoms. Illegibility and missing clinical information reduce the quality of many optometric referrals. Patients referred to the HES experience raised levels of anxiety as measured by the STAI and raised levels of depression as measured by the HADS-Depression subscale. As a method of assessing psychological distress, the questionnaires HADS-T (all items), STAI-S (State subscale) and STAI-T (Trait subscale) show good discrimination between patients when administered to a population of new ophthalmic outpatients, despite all having a floor effect. Subsequently a referral refinement service was developed which reduced numbers of unnecessary referrals and reduced costs for the NHS.

Aim: The aim of this thesis was to investigate experiences of receiving notification of an abnormal Pap smear result and its impact on women’s health-related quality of life as well as to investigate women’s awareness of human papillomavirus.   Methods: In total, 176 women and 20 healthcare professionals participated. Data were collected through individual interviews (I, II) and a questionnaire (IV) including the instrument Functional Assessment of Chronic Illness Therapy – Cervical Dysplasia (FACIT-CD) and Hospital Anxiety and Depression Scale (HADS). For the translation and cross-cultural adaptation of the FACIT-CD, and for evaluation of its linguistic validity and reliability, cognitive debriefing interviews and a questionnaire consisting of the Swedish instrument FACIT-CD was used. Data were analysed by content analysis (I, II) and by using statistical analysis (III, IV), while one part (III) was analysed according to FACIT translation methodology.     Results: Women receiving notification of an abnormal Pap smear result have good overall HRQoL; they become anxious but not depressed. Reasons for anxiety were mainly that women misinterpreted the result as cancer, which could lead to lower attendance for further investigation, treatment and follow-up. To cope with the anxiety, women sought emotional support and information. They primarily used the Internet for information but also turned to healthcare professionals for information needs. Moreover, women had low awareness of HPV, its sexually transmitted nature, and its relationship to abnormal Pap smear results and cervical cancer. An awareness of HPV as a sexually transmitted infection did not lead to higher level of anxiety or more depression symptoms or worse HRQoL, compared to not being aware. Finally, the Swedish FACIT-CD is equivalent to the English version and linguistically valid and exhibited good internal consistency reliability.   Conclusion: Women have low awareness of HPV and abnormal Pap smear results, whereupon they misinterpret their test result as cancer. It is of importance that women understand their test result, in order to minimise anxiety as well as to maintain high attendance for investigation, treatment and follow-up of abnormalities.

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Hintergrund: Bei der Interaktion zwischen Herz und Psyche wird als ein psychophysiologischer Mechanismus eine Veränderung der Modulationsfähigkeit des autonomen Nervensystems angenommen, die mittels HRV (=heart rate variability) widergespiegelt werden kann. Der Zusammenhang zwischen negativer Befindlichkeit und reduzierter HRV scheint jedoch entgegen häufig publizierten Annahmen nicht konsistent. Außerdem wurde zur zeitlichen Stabilität der HRV-Messungen über eine längere Periode von mehreren Jahren sowie zum Zusammenhang zwischen diastolischer Dysfunktion und HRV bisher noch nicht sehr umfangreich geforscht. Methoden: Es wurden 111 Patienten (60 % M., 70 +/- 17 J.) mit kardiovaskulären Risikofaktoren aus einer Kohortenstudie des Kompetenznetzes Herzinsuffizienz (KNHI) untersucht. Kurzzeit-HRV-Messungen (5 min) wurden in den folgenden drei Phasen durchgeführt: Sechs-Minuten-Gehtest, 6/min Taktatmung und Ruhephase. Zum einen wurde mittels Echokardiographie eine diastolische Dysfunktion bestimmt und den Herzfrequenz- (Hr) und HRV-Werten gegenübergestellt. Zum anderen wurden Selbstbeurteilungsfragebögen zur Befindlichkeit, im Speziellen Depressivität und Angst (HADS), Vitaler Erschöpfung (Maastricht Fragebogen) und gesundheitsbezogener Lebensqualität (SF-36), verwendet und Korrelationen mit den Hr- und HRV-Werten berechnet. Anhand eines Teilkollektivs von 24 Pat. wurden Längsschnittanalysen (Zeitintervall 2-4 J.) zur Hr und HRV durchgeführt. Ergebnisse: Es konnten keine (einheitlich) signifikanten Korrelationen zwischen Befindlichkeit und Hr/HRV festgestellt werden, ebenso nicht für ein Teilpatientenkollektiv ohne Betablockereinnahme. In den Längsschnittanalysen zeigten sich auf Gruppenebene eine relative Stabilität der HRV-Werte und auf individueller Ebene hingegen nur eine geringe bis mäßige Stabilität, und zwar auch bei weitgehend unverändertem kardialem Zustand. Für diese individuellen Veränderungen der HRV-Werte konnte keine Ursache eruiert werden. Hingegen bildete sich bezüglich der Herzfrequenz (Hr) eine deutlich höhere Stabilität im zeitlichen Verlauf ab. Beim Vergleich der HRV-Parameter zwischen zwei Patientengruppen mit und ohne isolierte diastolische Dysfunktion zeigte sich eine nicht signifikant reduzierte HRV bei Patienten mit isolierter diastolischer Dysfunktion. Diskussion: Die Zusammenhänge von Befindlichkeit mit der Hr und der HRV scheinen entgegen häufig publizierten Annahmen nicht konsistent. Die vielen Einflussfaktoren auf die HRV sowie die komplexen Eigenschaften des autonomen Nervensystems stellen eine mögliche Erklärung für die uneinheitlichen Ergebnisse zur HRV dar. In früheren Studien könnte es sich zumindest partiell angesichts jeweils multipler untersuchter Assoziationen um Scheinsignifikanzen handeln. In zukünftigen Studien wäre es sinnvoll bezüglich der HRV strikt zwischen Kurz- und Langzeit-HRV-Messungen und bezüglich der Befindlichkeit zwischen psychischen und körperlichen Symptomen zu unterscheiden. Auch sollte der Einfluss von Medikamenteneinnahmen (herzwirksame Medikamente, Antidepressiva) kontrolliert werden. In den Längsschnittanalysen war bei einer Gruppengröße von nur 24 Patienten die statistische Power für weiter gehende Analysen unzureichend. Der Zusammenhang zwischen diastolischer Dysfunktion und HRV wurde bisher noch nicht sehr umfangreich erforscht, weshalb dieses Ergebnis einen interessanten weiteren Baustein in der aktuellen Forschung darstellt.

HINTERGRUND: Die meist wöchentlich stattfindende Lipidapherese (LA) kommt bei Patienten mit therapierefraktärer Hyperlipoproteinämie sekundärpräventiv zum Einsatz. Während umfangreiche Informationen zu deren Effizienz und Sicherheit vorliegen, fehlen valide Erhebungen zum subjektiven Befinden von Lipidapheresepatienten (LAP) und deren Erleben der invasiven extrakorporalen Behandlung. METHODEN: Diese monozentrisch durchgeführte Untersuchung schloss 23 LAP mit nachgewiesener KHK sowie 32 hospitalisierte nicht-extrakorporal behandelte KHK-Patienten (NEKP) und 31 Hämodialysepatienten (HDP) ein. Es erfolgten alters-, geschlechts- und morbiditätsadjustierte Vergleiche von gesundheitsbezogener Lebensqualität (GLQ) mittels PLC (Profil der Lebensqualität chronisch Kranker), Angst und Depressivität (HADS-D=deutsche Version der Hospital Anxiety and Depression Scale; Cutoff jeweils >7), Krankheitsverarbeitung (FKV-LIS=Freiburger Fragebogen zur Krankheitsverarbeitung) sowie des bei LAP und HDP anhand von Interviews erfassten Erlebens der extrakorporalen Behandlung. ERGEBNISSE: Von den LAP hatten 39.1% einen auffälligen HADS-D-Wert für Angst und 17.4% für Depressivität. Sowohl hinsichtlich dieser Symptome als auch der psychischen und sozialen GLQ waren die LAP den NEKP nicht unterlegen, während sie eine signifikant bessere physische GLQ aufwiesen. Im Vergleich mit den HDP zeigte sich eine jeweils teilweise signifikant bessere physische, psychische und soziale GLQ bei den LAP. Sie waren zudem signifikant weniger depressiv und tendenziell weniger ängstlich. Gegenüber den HDP gaben die LAP eine signifikant geringere Belastung (5.3 vs. 2.7 von 10) durch ihre extrakorporale Behandlung an. 72% nahmen die LA-Therapie als entlastend wahr (gegenüber 69% bei den HDP) und 70% würden sie uneingeschränkt weiterempfehlen. Unter den LAP dominierten eher vorteilhafte Krankheitsverarbeitungsmechanismen, worin sie sich allerdings nicht von den NEKP und HDP unterschieden. SCHLUSSFOLGERUNG: Die Akzeptanz der LA durch die Patienten und deren im Vergleich gute GLQ sowie psychische Befindlichkeit sind beachtlich. Durch die effektive ’Blutreinigung’ allein sind diese Ergebnisse jedoch nicht zu erklären. So drängen sich Fragen zu weiteren, auch psychischen, Wirkmechanismen der LA-Therapie auf.

Magister Psychologiae - MPsych / This study utilised secondary data from a larger study that looked at individuals that are already infected by HIV which is entitled Implicative personal dilemmas and cognitive conflicts in health decision making in HIV positive adults and adults with AIDS. The primary aim of the larger study was to examine the cognitive construction of the individual and how they utilised their individual resources to construct who they are and how they perceived the difficulties and challenges that they face and the decisions they make regarding their health. HIV and AIDS is a debilitating disease and it affects millions worldwide. South Africa, presently, has the largest burden of this disease with those between the ages of 15 – 49 years of age being most affected. As previously mentioned the decisions that individuals make can impact on their health. Decisions to take necessary precautions such as protected sex during sexual intercourse can decrease the progression of the disease. Decisions made regarding abstinence of risky behaviour as well as being committed to taking medication could also positively impact health. People living with HIV and AIDS find it difficult to adjust to the challenges that this disease presents. Depression is often experienced due to the changes in self image and perception. Studies show that females are twice more likely to experience depression than men. There has however been no conclusive evidence showing the reason for this, however, the perception of stress based on gender could shed some light on this matter and how these perceptions can increase the likelihood of women being more vulnerable to depression. Due to the limitation of this study, it will only look at depression as it relates to HIV and AIDS. Psychological problems such as depression can hamper the adjustment process and the effect of depression is evident in that it can lower the CD 4 + cells. Not only are those living with HIV and AIDS affected by depression, but they also have a lifetime prevalence to depression. It is important to have an effective screening tool for depression so that the detection of this disease can be made and effective treatment can be implemented to enhance health. The sample consisted of 113 adult participants that have already been diagnosed with HIV and AIDS. The primary aim of this study was to compare the Beck’s Depression Inventory II (BDI II) and the Hospital Anxiety and Depression Scale –(the Depression component) (HADS-D) as a screening tool for depression. Exploratory Factor Analysis revealed a 5 factor structure which accounted for 60.14 % of the total variance. The HADS yielded one factor accounting for 14.33% of total variance. The BDI II has proven to be more a reliable measure of depression with 0.89 according to the Cronbach’s Alpha co efficient opposed to 0.375 as per the HADS-D. The secondary aim was to establish the sociodemographic and disease profiles of the participants under study. / South Africa

There is a significant comorbidity between anxiety/depression and functional gastrointestinal syndromes, such as irritable bowel syndrome (IBS) and functional dyspepsia. The pathophysiological link between emotions and the gut is not known. A model of an emotional motor system (EMS) which reacts to interoceptive and exteroceptive stress has been proposed. EMS consists of specific brain structures including anterior cingulate cortex (ACC), amygdala, hippocampus and hypothalamus and mediates their communication to the rest of the body (including the gastrointestinal tract) through the hypothalamus-pituitary-adrenal (HPA) axis, the autonomic nervous system (ANS) and by a pain modulation system. The aim of this thesis was to test the EMS model by studying the relationship between symptoms of anxiety and depression and IBS-like symptoms in patients with recurrent unipolar depression, in patients with IBS and in a sample of a normal Swedish population. The peripheral limb of EMS (ANS, HPA axis and the pain modulations system) was tested in patients with IBS and control subjects. Spectral heart rate variability was used to investigate ANS function in patients with refractory IBS and in healthy controls. The HPA axis function was tested by a weight adjusted low dose dexamethasone suppression test in control subjects. The influence of catecholamine degradation on pain modulation was tested by analyzing val158met catechol-o-methyl transferase (COMT) polymorphism in patients with IBS and in control subjects. We found a significant relationship between symptoms of anxiety/depression and IBS-like symptoms in patients with recurrent unipolar depression, in patients with IBS and in a sample of the normal population. Interestingly, patients with recurrent unipolar depression in remission had no more IBS-like symptoms than controls, indicating that the gastrointestinal symptoms may resolve when depression is treated to remission. Patients with IBS have an increased mid-frequency power in rest and in supine position (after tilt test) compared to healthy controls indicating an increased sympathetic ANS drive. The symptoms of diarrhea and early satiety has in the litterature been associated to the stimulation of corticotropin releasing hormone (CRH) receptors and was also in our study related to HPA axis function tested by a low dose dexamethasone test. Interestingly both hypo- and hyperfunction of the HPA axis was related to these symptoms in control subjects. The val158met COMT polymorphism was associated to IBS-like symptoms. Control subjects with IBS-like symptoms (defined by the upper quartile in total GSRS-IBS score) had a higher frequency of the met/met and a significantly lower frequency of the val/met genotype. Also patients with IBS tended to have a lower frequency of the heterozygous val/met genotype so we conclude that this genotype may be protective against IBS/IBS like symptoms. In addition, the val/val genotype in patients with IBS was associated to diarrhea symptoms. Conclusions: Our results support the model of an emotional motor system in the genesis of functional gastrointestinal symptoms by the finding of the association of IBS-like symptoms and mood disturbances, and by finding alterations in the peripheral limbs of EMS (ANS, HPA axis and catecholamines) in subjects with IBS and IBS-like symptoms.