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Tunnell NC, Corner SE, Roque AD, Kroll JL, Ritz T, Meuret AE. Biobehavioral approach to distinguishing panic symptoms from medical illness. Front Psychiatry 2024; 15:1296569. [PMID: 38779550 PMCID: PMC11109415 DOI: 10.3389/fpsyt.2024.1296569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 03/19/2024] [Indexed: 05/25/2024] Open
Abstract
Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.
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Affiliation(s)
- Natalie C. Tunnell
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Psychiatry & Behavioral Sciences, The University of Kansas Medical Center, Kansas City, KS, United States
| | - Sarah E. Corner
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Andres D. Roque
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Primary Care Department, Miami VA Healthcare System, Miami, FL, United States
| | - Juliet L. Kroll
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Thomas Ritz
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Alicia E. Meuret
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
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Arrarás JI, Cuesta MJ, Peralta V, Gil-Berrozpe GJ, Barrado L, Correa O, Elorza R, González L, Garmendia I, Janda L, Macaya P, Núñez C, Sabater P, Torrejon A. Psychometric analysis of the Psychiatric Diagnostic Screening Questionnaire (PDSQ) and determinants of psychopathology in two outpatient clinics in Navarre (Spain). An Sist Sanit Navar 2023; 46:e1043. [PMID: 37647203 PMCID: PMC10520750 DOI: 10.23938/assn.1043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/28/2023] [Accepted: 06/28/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND The self-report Psychiatric Diagnostic Screening Questionnaire PDSQ is designed to screen Axis I psychiatric disorders. We aim to determine its psychometric properties in Spanish outpatients and assess its relationship with two interviews (for psychopathology and for personality disorders) and clinical/demographic variables. METHODOLOGY We administered the study questionnaire, the Mini International Neuropsychiatric Interview Plus (MINI-Plus), the Standardised Assessment of Personality Abbreviated Scale (SAPAS), and the List of Threatening Experiences Questionnaire (LTE-Q) to 375 patients at two public outpatient centres. Reliability of the study questionnaire was evaluated (Cronbach's alpha, ?) and known-group validity measured by comparing groups based on demographic and clinical variables (binary logistic regression analysis) and MINI-Plus diagnoses (Mann-Whitney U). The diagnostic accuracy of the study questionnaire score was analysed taking the MINI-Plus diagnoses as the gold standard (ROC analysis). RESULTS Internal consistency was adequate across all PDSQ scales (? >0.7; mean ?=0.85). Known-group comparisons were satisfactory. Female and male patients showed higher prevalence of internalizing and externalizing diagnoses, respectively. Younger age, more life events and limitations, higher SAPAS scores, and lower economic levels were linked to a greater number of PDSQ diagnoses. Inter-group differences were found for all PDSQ scales based on the corresponding MINI-Plus diagnoses. Mean values of sensitivity, AUC, and negative predictive value were 88.7, 0.82, and 96.7, respectively. CONCLUSIONS When applied to a sample of Spanish outpatients, the PDSQ exhibits satisfactory psychometric properties and adequate relationships with the psychopathology and personality interviews, and clinical and demographic variables. The study questionnaire is suitable for assessing comorbidity and psychopathology dimensions.
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Affiliation(s)
| | | | | | | | - Laura Barrado
- Mental Health Department. Servicio Navarro de Salud - Osasunbidea. Pamplona. Spain.
| | - Olga Correa
- Mental Health Department. Servicio Navarro de Salud - Osasunbidea. Pamplona. Spain.
| | - Rebeca Elorza
- Mental Health Department. Servicio Navarro de Salud - Osasunbidea. Pamplona. Spain.
| | - Lorea González
- Mental Health Department. Servicio Navarro de Salud - Osasunbidea. Pamplona. Spain.
| | - Irma Garmendia
- Mental Health Department. Servicio Navarro de Salud - Osasunbidea. Pamplona. Spain.
| | - Lucía Janda
- Mental Health Department. Servicio Navarro de Salud - Osasunbidea. Pamplona. Spain.
| | - Patricia Macaya
- Mental Health Department. Servicio Navarro de Salud - Osasunbidea. Pamplona. Spain.
| | - Camino Núñez
- Mental Health Department. Servicio Navarro de Salud - Osasunbidea. Pamplona. Spain.
| | - Pablo Sabater
- Mental Health Department. Servicio Navarro de Salud - Osasunbidea. Pamplona. Spain.
| | - Aileen Torrejon
- Mental Health Department. Servicio Navarro de Salud - Osasunbidea. Pamplona. Spain.
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Sung SC, Lim L, Lim SH, Finkelstein EA, Chin SLH, Annathurai A, Chakraborty B, Strauman TJ, Pollack MH, Ong MEH. Protocol for a multi-site randomized controlled trial of a stepped-care intervention for emergency department patients with panic-related anxiety. BMC Psychiatry 2022; 22:795. [PMID: 36527018 PMCID: PMC9756520 DOI: 10.1186/s12888-022-04387-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Approximately 40% of Emergency Department (ED) patients with chest pain meet diagnostic criteria for panic-related anxiety, but only 1-2% are correctly diagnosed and appropriately managed in the ED. A stepped-care model, which focuses on providing evidence-based interventions in a resource-efficient manner, is the state-of-the art for treating panic disorder patients in medical settings such as primary care. Stepped-care has yet to be tested in the ED setting, which is the first point of contact with the healthcare system for most patients with panic symptoms. METHODS This multi-site randomized controlled trial (RCT) aims to evaluate the clinical, patient-centred, and economic effectiveness of a stepped-care intervention in a sample of 212 patients with panic-related anxiety presenting to the ED of Singapore's largest public healthcare group. Participants will be randomly assigned to either: 1) an enhanced care arm consisting of a stepped-care intervention for panic-related anxiety; or 2) a control arm consisting of screening for panic attacks and panic disorder. Screening will be followed by baseline assessments and blocked randomization in a 1:1 ratio. Masked follow-up assessments will be conducted at 1, 3, 6, and 12 months. Clinical outcomes will be panic symptom severity and rates of panic disorder. Patient-centred outcomes will be health-related quality of life, daily functioning, psychiatric comorbidity, and health services utilization. Economic effectiveness outcomes will be the incremental cost-effectiveness ratio of the stepped-care intervention relative to screening alone. DISCUSSION This trial will examine the impact of early intervention for patients with panic-related anxiety in the ED setting. The results will be used to propose a clinically-meaningful and cost-effective model of care for ED patients with panic-related anxiety. TRIAL REGISTRATION ClinicalTrials.gov NCT03632356. Retrospectively registered 15 August 2018.
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Affiliation(s)
- Sharon C. Sung
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857 Singapore
| | - Leslie Lim
- grid.163555.10000 0000 9486 5048Singapore General Hospital, Outram Road, Singapore, 169608 Singapore
| | - Swee Han Lim
- grid.163555.10000 0000 9486 5048Singapore General Hospital, Outram Road, Singapore, 169608 Singapore
| | - Eric A. Finkelstein
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857 Singapore
| | - Steven Lim Hoon Chin
- grid.413815.a0000 0004 0469 9373Changi General Hospital, 2 Simei Street 3, Singapore, 529889 Singapore
| | - Annitha Annathurai
- grid.508163.90000 0004 7665 4668Sengkang General Hospital, 110 Sengkang E Way, Singapore, 544886 Singapore
| | - Bibhas Chakraborty
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857 Singapore ,grid.4280.e0000 0001 2180 6431National University of Singapore, 6 Science Drive 2, Singapore, 117546 Singapore ,grid.26009.3d0000 0004 1936 7961Duke University, 2424 Erwin Road, Suite 1102, Durham, NC 27710 USA
| | - Timothy J. Strauman
- grid.189509.c0000000100241216Duke University Medical Center, 10 Duke Medicine Cir, Durham, NC 27710 USA
| | - Mark H. Pollack
- grid.240684.c0000 0001 0705 3621Rush University Medical Center, 1645 W. Jackson Blvd, Suite 400, Chicago, IL 60612 USA ,grid.476678.c0000 0004 5913 664XSage Therapeutics, 215 First Street, Cambridge, MA 02142 USA
| | - Marcus Eng Hock Ong
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857 Singapore ,grid.163555.10000 0000 9486 5048Singapore General Hospital, Outram Road, Singapore, 169608 Singapore
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Hamel S, Denis I, Turcotte S, Fleet R, Archambault P, Dionne CE, Foldes-Busque G. Anxiety disorders in patients with noncardiac chest pain: association with health-related quality of life and chest pain severity. Health Qual Life Outcomes 2022; 20:7. [PMID: 35012545 PMCID: PMC8751105 DOI: 10.1186/s12955-021-01912-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with noncardiac chest pain (NCCP) report more severe symptoms and lowered health-related quality of life when they present with comorbid panic disorder (PD). Although generalized anxiety disorder (GAD) is the second most common psychiatric disorder in these patients, its impact on NCCP and health-related quality of life remains understudied. This study describes and prospectively compares patients with NCCP with or without PD or GAD in terms of (1) NCCP severity; and (2) the physical and mental components of health-related quality of life. METHODS A total of 915 patients with NCCP were consecutively recruited in two emergency departments. The presence of comorbid PD or GAD was assessed at baseline with the Anxiety Disorder Schedule for DSM-IV. NCCP severity at baseline and at the six-month follow-up was assessed with a structured telephone interview, and the patients completed the 12-item Short-Form Health Survey Version 2 (SF-12v2) to assess health-related quality of life at both time points. RESULTS Average NCCP severity decreased between baseline and the six-month follow-up (p < .001) and was higher in the patients with comorbid PD or GAD (p < .001) at both time points compared to those with NCCP only. However, average NCCP severity did not differ between patients with PD and those with GAD (p = 0.901). The physical component of quality of life improved over time (p = 0.016) and was significantly lower in the subset of patients with PD with or without comorbid GAD compared to the other groups (p < .001). A significant time x group interaction was found for the mental component of quality of life (p = 0.0499). GAD with or without comorbid PD was associated with a lower mental quality of life, and this effect increased at the six-month follow-up. CONCLUSIONS Comorbid PD or GAD are prospectively associated with increased chest pain severity and lowered health-related quality of life in patients with NCCP. PD appears to be mainly associated with the physical component of quality of life, while GAD has a greater association with the mental component. Knowledge of these differences could help in the management of patients with NCCP and these comorbidities.
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Affiliation(s)
- Stéphanie Hamel
- School of Psychology, Université Laval, Pavillon Félix-Antoine-Savard, 2325 rue des Bibliothèques, Quebec, QC G1V 0A6 Canada
- Research Centre of the Centre Hospitalier Affilié Universitaire de Lévis of the Centre Intégré de Santé Et de Services Sociaux de Chaudière-Appalaches, 143 Rue Wolfe, Lévis, QC G6V 3Z1 Canada
| | - Isabelle Denis
- School of Psychology, Université Laval, Pavillon Félix-Antoine-Savard, 2325 rue des Bibliothèques, Quebec, QC G1V 0A6 Canada
- Research Centre of the Centre Hospitalier Affilié Universitaire de Lévis of the Centre Intégré de Santé Et de Services Sociaux de Chaudière-Appalaches, 143 Rue Wolfe, Lévis, QC G6V 3Z1 Canada
- Centre de Recherche Universitaire Sur Les Jeunes Et Les Familles (CRUJeF), 2915 avenue du Bourg-Royal, Quebec, QC G1C 3S2 Canada
| | - Stéphane Turcotte
- Research Centre of the Centre Hospitalier Affilié Universitaire de Lévis of the Centre Intégré de Santé Et de Services Sociaux de Chaudière-Appalaches, 143 Rue Wolfe, Lévis, QC G6V 3Z1 Canada
| | - Richard Fleet
- Research Centre of the Centre Hospitalier Affilié Universitaire de Lévis of the Centre Intégré de Santé Et de Services Sociaux de Chaudière-Appalaches, 143 Rue Wolfe, Lévis, QC G6V 3Z1 Canada
- Department of Family and Emergency Medicine, Université Laval, Pavillon Ferdinand-Vandry, 1050 Avenue de la Médecine, Quebec, QC G1V 0A6 Canada
| | - Patrick Archambault
- Research Centre of the Centre Hospitalier Affilié Universitaire de Lévis of the Centre Intégré de Santé Et de Services Sociaux de Chaudière-Appalaches, 143 Rue Wolfe, Lévis, QC G6V 3Z1 Canada
- Department of Family and Emergency Medicine, Université Laval, Pavillon Ferdinand-Vandry, 1050 Avenue de la Médecine, Quebec, QC G1V 0A6 Canada
| | - Clermont E. Dionne
- CHU de Quebec Research Centre, Saint-Sacrement Hospital, 1050, Chemin Sainte-Foy, Quebec, QC G1S 4L8 Canada
| | - Guillaume Foldes-Busque
- School of Psychology, Université Laval, Pavillon Félix-Antoine-Savard, 2325 rue des Bibliothèques, Quebec, QC G1V 0A6 Canada
- Research Centre of the Centre Hospitalier Affilié Universitaire de Lévis of the Centre Intégré de Santé Et de Services Sociaux de Chaudière-Appalaches, 143 Rue Wolfe, Lévis, QC G6V 3Z1 Canada
- Quebec Heart and Lung Institute Research Centre, 2725 chemin Sainte-Foy, Quebec, QC G1V 4G5 Canada
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Figura A, Kuhlmann SL, Rose M, Slagman A, Schenk L, Möckel M. Mental health conditions in older multimorbid patients presenting to the emergency department for acute cardiac symptoms: Cross-sectional findings from the EMASPOT study. Acad Emerg Med 2021; 28:1262-1276. [PMID: 34309134 DOI: 10.1111/acem.14349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/02/2021] [Accepted: 07/03/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND This study aimed to (1) examine the proportion of patients presenting to an emergency department (ED) for acute cardiac symptoms with comorbid mental health conditions (MHCs) comprising current depression, generalized anxiety disorder, and panic disorder; (2) compare cardiac patients with and without MHCs regarding sociodemographic, medical, and psychological characteristics; and (3) examine recognition and treatment rates of MHCs. METHODS Multimorbid patients, aged ≥50 years, presenting to an inner-city ED with acute cardiac symptoms including chest pain, dyspnea, and palpitations, completed validated self-report instruments assessing MHCs and a questionnaire collecting psychosocial and medical information. In addition, routine medical data were extracted from the electronic health record. RESULTS A total of 641 patients were included in the study. Mean (±SD) age was 68.8 (±10.8) years and 41.7% were female. Based on screening instruments, 28.4% of patients were affected with comorbid MHCs. Patients reported clinically significant symptoms of depression (23.3% PHQ-9 ≥10), generalized anxiety disorder (12.2% GAD-7 ≥10), and panic disorder (4.7% PHQ-PD). Patients with MHCs were more likely to be younger, female, lower educated, and unemployed. The presence of MHCs was associated with higher cardiac symptom burden and subjective treatment urgency as well as more psychosocial distress (PHQ-stress) and impaired quality of life (SF-12v2). Of all patients, 15.6% were identified with new or unrecognized MHCs. CONCLUSIONS MHCs are prevalent in nearly one-third of patients presenting with cardinal cardiac symptoms. Thus, the ED visit offers an opportunity to identify and refer patients with MHCs to appropriate and timely care after exclusion of life-threatening conditions.
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Affiliation(s)
- Andrea Figura
- Department of Psychosomatic Medicine Charité–Universitätsmedizin Berlin Berlin Germany
| | - Stella L. Kuhlmann
- Division of Emergency and Acute Medicine (Campus Virchow‐Klinikum, Campus Charité Mitte) Charité–Universitätsmedizin Berlin Berlin Germany
| | - Matthias Rose
- Department of Psychosomatic Medicine Charité–Universitätsmedizin Berlin Berlin Germany
| | - Anna Slagman
- Division of Emergency and Acute Medicine (Campus Virchow‐Klinikum, Campus Charité Mitte) Charité–Universitätsmedizin Berlin Berlin Germany
| | - Liane Schenk
- Institute of Medical Sociology and Rehabilitation Science Charité–Universitätsmedizin Berlin Berlin Germany
| | - Martin Möckel
- Division of Emergency and Acute Medicine (Campus Virchow‐Klinikum, Campus Charité Mitte) Charité–Universitätsmedizin Berlin Berlin Germany
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Foldes-Busque G, de Lafontaine MF, Turcotte S, Denis I. Are Patients at Risk for Developing Panic Disorder After an Emergency Department Visit With Noncardiac Chest Pain? J Acad Consult Liaison Psychiatry 2021; 63:23-31. [PMID: 34352451 DOI: 10.1016/j.jaclp.2021.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/16/2021] [Accepted: 07/22/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Panic disorder (PD) is common in emergency department (ED) patients with noncardiac chest pain (NCCP). The literature suggests that initially PD-free patients may be at increased risk of developing PD in the months or years following an ED visit. OBJECTIVES This study aims to determine the incidence of PD in the 2 years following an ED visit with NCCP and to identify predictors of incident PD. METHODS This study was conducted using a longitudinal, observational design. Five hundred and eighty-five patients with NCCP (without PD) were recruited in two EDs. They underwent an interview and completed a series of questionnaires assessing anxiety disorders, perceived social support, psychological distress, anxiety sensitivity, comorbidities, and stressful life events. PD was assessed 6 months, 1 year, and 2 years after the initial interview. RESULTS PD incidence was 11.1% (95% confidence interval: 8.7-13.9) in the two years following the baseline assessment. Anxiety sensitivity (odds ratio = 1.08; 95% confidence interval: 1.04-1.11; P < .001) and stress related to life events (odds ratio = 1.14; 95% confidence interval: 1.06-1.24; P = .001) significantly predicted incident PD. CONCLUSIONS Patients with NCCP are at high risk for developing PD in the 2 years following an ED visit with NCCP. Anxiety sensitivity and stress related to life events may be promising clinical targets for preventive interventions.
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Affiliation(s)
- Guillaume Foldes-Busque
- School of Psychology, Université Laval, Québec, QC, Canada; Research Centre of the Chaudière-Appalaches Integrated Center for Health and Social Services, Lévis, QC, Canada; Research Centre of the Quebec Heart and Lung Institute, Québec, QC, Canada.
| | - Marie-France de Lafontaine
- School of Psychology, Université Laval, Québec, QC, Canada; Research Centre of the Chaudière-Appalaches Integrated Center for Health and Social Services, Lévis, QC, Canada; Research Centre of the Quebec Heart and Lung Institute, Québec, QC, Canada
| | - Stéphane Turcotte
- Research Centre of the Chaudière-Appalaches Integrated Center for Health and Social Services, Lévis, QC, Canada
| | - Isabelle Denis
- School of Psychology, Université Laval, Québec, QC, Canada; Research Centre of the Chaudière-Appalaches Integrated Center for Health and Social Services, Lévis, QC, Canada; Centre de recherche universitaire sur les jeunes et les familles (CRUJeF), QC, Canada
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Şahin S, Uyanık M. The impact of occupation-based problem-solving strategies training in women with breast cancer. Health Qual Life Outcomes 2019; 17:104. [PMID: 31208425 PMCID: PMC6580619 DOI: 10.1186/s12955-019-1170-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/02/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND By identifying the occupations of women with breast cancer who have performance problems, to examine the impact of the application of occupation-based problem-solving strategies (OB-PSS) training on cancer-related fatigue, depression, and quality of life. METHODS The study comprises 22 women outpatients in the clinic. Socio- demographic and Clinical Features Information Collection Form, Canadian Occupational Performance Measure (COPM), Cancer Fatigue Scale (CFS), Beck Depression Inventory (BDI), The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C-30 and BR23 (EORTC QOL-C30 - EORT QOL-BR23) tests have been applied to survivors. OB-PSS training was conducted on a face-to-face basis once a week for 6 weeks. RESULTS When activity distribution results in accordance with the performance areas are studied, women with breast cancer were seen to suffer problems mostly in their most productive areas (housework management). As a means of solving these performance problems, they developed adaptive strategies like including additional new steps to these activities. Statistically meaningful results have been obtained between measurements before and after the treatment process through all tests (p < 0.01). CONCLUSIONS OB-PSS provides positive gains in women with breast cancer in terms of a reduction in the degree of cancer-related fatigue and depression, and a progress in performance and satisfaction levels particularly in activities where performance problems are experienced and an improvement in quality of life. OB-PSS training could be used as an appropriate rehabilitation approach for coping with problems in women' life with breast cancer.
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Affiliation(s)
- Sedef Şahin
- Faculty of Health Sciences, Department of Occupational Therapy, Hacettepe University, Samanpazarı, 06100 Ankara, Turkey
| | - Mine Uyanık
- Faculty of Health Sciences, Department of Occupational Therapy, Hacettepe University, Samanpazarı, 06100 Ankara, Turkey
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