SynopsisForty-six patients with chest pain but normal or near-normal coronary arteries were assessed using standardized interviews and rating scales at the time of angiography, after 1 year, and again 11·4 years later. Psychological morbidity was substantial and enduring: 61% of patients were designated as psychiatric cases at angiography and 49% at 11·4 years. Both at the time of angiography, and 1 year later, levels of morbidity were significantly greater than in a control group of 53 patients with coronary artery disease. Anxiety disorders were common at all three interviews, with panic disorder (15% of patients) the most common current diagnosis at final follow-up. Current somatoform disorders were diagnosed in 9 patients (22%), and 11 (27 %) reported previous episodes of major depression. Psychological morbidity was associated with continuing chest pain, which was reported in 74% of patients, and with ongoing functional incapacity. These findings suggest that, in a sub-group of these patients, psychological factors contribute in part to the development of chest pain and other physical symptoms, and are also important in maintaining the disorder over long periods. Further research is now required to identify more fully the nature of these psychological factors, and how they interact with cardiac and non-cardiac physical pathology. There is also an urgent need to examine the clinical and economic benefits of specific psychological interventions.
We used a psychological treatment package (education, relaxation, breathing training, graded exposure to activity and exercise, and challenging automatic thoughts about heart disease) to treat 60 patients who had continuing chest pain despite cardiological reassurance following haemodynamically normal angiography. The treatment was delivered in six sessions over eight weeks to groups of up to six patients. The patients kept daily records of chest pain episode frequency and nitrate use. Questionnaires were used to assess anxiety, depression and disability. Exercise tolerance was tested by treadmill electrocardiography, with capnographic assessment of hyperventilation. The results were compared with waiting-list controls. Treatment significantly reduced chest pain episodes (p < 0.01) from median 6.5 to 2.5 per week. There were significant improvements in anxiety and depression scores (p < 0.05), disability rating (p < 0.0001) and exercise tolerance (p < 0.05), and these were maintained at six month follow-up. Treatment reduced the prevalence of hyperventilation from 54% to 34% (p < 0.01) but not the prevalence of ECG-positive exercise tests. Patients continuing to attribute their pain to heart disease had poorer outcomes. Group psychological treatment for non-cardiac chest pain is feasible, reduces pain, psychological morbidity and disability, and improves exercise tolerance.
Novel psychoactive substances can produce significant toxicity and data from poisons centres may be used to indirectly detect new 'legal highs' that are causing clinical toxicity.
Every 22 minutes in the United Kingdom, a child is bereaved of a parent, making up some 24,000 a year. An even greater number experience the loss of a grandparent. There is a limited, but growing, body of research into the impact of grief and bereavement on young children and how their support needs might be met. This article expands upon research with primary school teachers articulating something of their knowledge and experience in encountering bereaved children. The mixed methodology research includes quantitative and qualitative data that incorporate teachers' responses to the fictionalised narrative of a bereaved 6-yearold. The discussion elucidates teachers' confidence -or reluctance -in broaching the topic, highlighting the lack of specific training within teacher education for understanding and supporting bereaved children. Compassionate understanding is offered to some children, but many others detect a wall of silence, which, when encountered in early childhood, can have detrimental consequences for their personal, social and academic development. The article calls for policy and practice that will ameliorate this situation.
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