the psychiatric illness iceberg

1. the psychiatric illness iceberg psychiatric morbidity rates per year in the UK: • psychiatric inpatients 0.6% • mental illness services 2.4% • conspicuous psychiatric morbidity 10.2% • recognised morbidity amongst GP attenders 23% • whole community 26 - 31.5% Shah A The burden of psychiatric disorder in primary care International Review of Psychiatry 1992;4:243-50

2. challenge: to respond effectively calming skills problem focused coping time management physical exercise social support

3. relaxation research meta-analysis • 29 prospective randomised controlled trials of PMR published between 1981 and 1992 • 1,206 subjects; males =females; average age 18 to 74 years • chronic headache & migraine (8 studies); cancer chemotherapy (6 studies); essential hypertension (5 studies); other disorders - stress, depression, dysmenorrhea, low back & neck pain, menopausal flushes, immunity Carlson CR et al Efficacy of abbreviated PMR training: a quantitative review of behavioral medicine research J Consult Clin Psychol 1993;61:1059-67

4. relaxation meta-analysis results • number of sessions: it seems that about 12 sessions over 12 weeks is necessary for optimal results • audiotapes: studies that provided practice tapes obtained stronger effects than those that did not • maintenance of improvement: benefits tended to increase between conclusion & follow-up “overall the results of this review present an encouraging picture ... (such) methods have a strong record of efficacy and should be viewed as an experimentally sound treatment intervention … a broad-spectrum tool for treating clinical disorders related to overactivation”

5. autogenic & exercise training various questionnaires • 100 healthy participants aged 25 to 60 years • 25 women & 25 men in each group • eight weeks of training • autogenic training involved one class weekly+practice • exercise training involved two to three classes weekly • assessed by questionnaires and various clinical tests clinical & laboratory tests

6. the two trainings compared + means a statistically significant improvement ++ means a highly statistically significant improvement Carruthers M Health promotion by mental & physical training British Journal of Holistic Medicine 1984;2:136-47

7. progress chart – autogenic group 11.99 average score on Beck Anxiety Inventory 0-7 minimal; 8-15 mild; 16-25 moderate average score on Beck Depression Inventory 0-9 normal; 10-18 mild; 19-29 mod/severe 18.6(12-25) Symptom Severity Scale – trouble in last week 0=not at all; 10=couldn’t be worse BAI – 51% (6-37)17.0 problem severity problem severity 9.2(2-19) BDI – 57% (5-11) 7.4 7.4(4-9) SSS – 57% 3.2(2-4) 0 3 9 18 6 12 15 weeks

8. progress chart – autogenic group 02.00 average score on Beck Anxiety Inventory 0-7 minimal; 8-15 mild; 16-25 moderate average score on Beck Depression Inventory 0-9 normal; 10-18 mild; 19-29 mod/severe Symptom Severity Scale – trouble in last week 0=not at all; 10=couldn’t be worse (3-27)10.7 problem severity problem severity BDI – 49% 6.9(1-12) (1-18) 5.5 BAI – 29% 6.6(3.5-8) 4.9(0-9) SSS – 40% 4.0(0-7) 0 3 9 18 6 12 15 weeks

9. the importance of active coping • Smith RE Effects of coping skills training on generalized self-efficacy and locus of control J Personal Soc Psychol 1989;56:228-33 • Keefe FJ et al Analyzing chronic low back pain: the relative contribution of pain coping strategies Pain 1990;40:293-301 • Newman S et al Patterns of coping in rheumatoid arthritis Psychology and Health 1990;4:187-200 • Holahan CJ et al Life stressors, personal & social resources, and depression: a 4-year structural model J Abnorm Psychol 1991;100:31-8 • Affleck G Daily coping with pain from rheumatoid arthritis: patterns and correlates Pain 1992;51:221-229 • Fawzy FI et al Malignant melanoma. Effects of an early structured psychiatric intervention, coping, and affective state on recurrence & survival 6 years later Arch Gen Psychiatry 1993;50:681-689 • Garcia L et al Psychological factors & vulnerability to psychiatric morbidity after myocardial infarction Psychother Psychosom 1994;61:187-94

10. medium term effects of relaxation • anxiety & panic reduction: Stetter F et al Ambulatory short-term therapy of anxiety patients with autogenic training & hypnosis. Results of treatment & 3 month follow-up Psychother Psychosom Med Psychol 1994;44:226-34 • headache improvement: ter Kuile MM et al Autogenic training and cognitive self-hypnosis for the treatment of recurrent headaches in three different subject groups Pain 1994;58:331-40 • blood pressure, plasma noradrenaline & sympathetic outflow lowering: Blanchard EB Biofeedback treatments of essential hypertension Biofeedback & Self-Reg 1990;15:209-28 • circulatory, hormonal & brain EEG effects: Jevning R et al The physiology of meditation: a review. A wakeful hypometabolic integrated response Neurosci Biobehav Rev 1992;16:415-24 • stress-related disorders helped: Carlson CR et al Efficacy of abbreviated progressive muscle relaxation training: a quantitative review of behavioral medicine research J Consult Clin Psychol 1993;61:1059-67

11. the learning circle of experience genuine, personal experience Kurt Lewin’s model of experiential learning testing implications in new situations observation and reflection time forming ideas & generalizations note the particular importance of here-and-now concrete experience in generating and testing out ideas, and also the importance of the feedback loop in checking whether one is really on track; ineffectiveness is often due to an imbalance between active experience and reflective observation