This systematic review examined definitions of relapse, remission, and recovery from anorexia nervosa (AN) in previous studies. The review found that definitions varied substantially between studies, with some using weight criteria alone, others using symptom-based criteria alone, and some combining both. Relapse rates reported in studies ranged from 9-52% depending on the definition used and length of follow-up. There was consensus that risk of relapse is highest in the first year following treatment. The review proposes standardized criteria for defining relapse, remission, and recovery in AN to facilitate comparisons between studies.
Week 5 EBP ProjectAppraisal of EvidenceCLC EBP Research .docxcockekeshia
Week 5 EBP Project/Appraisal of Evidence
CLC: EBP Research Table
Citation
Include the APA reference note.
Abstract/Purpose
Craft a 100-150 word summary of the research.
Research/Study
Describe the design of the relevant research or study in the article.
Methods
Describe the methods used, including tools, systems, etc.
Setting/Subject
Identify the population and
the setting in which the study was conducted.
Findings/Results
Identify the relevant findings, including any specific data points that may be of interest to your EBP project.
Variables
Describe the independent and dependent variables in the research/study.
Implication for Practice
Articulate the value of the research to the EBP project your group has chosen.
Independent Variable
Dependent Variable
King-Shier, K.M., Mather, C., &LeBlanc, P. (2013). Understanding the influence of urban or rural living on cardiac patients’ decisions about diet and physical activity: Descriptive decision modeling. International Journal of Nursing Studies, 50(11), 1513-1523. doi: 10.1016/j.ijnurstu.2013.03.003
This research aims to answer to better understand the decision-making process of eating a heart healthy diet and extent of physical activity. Also, are these decisions influenced by whether the subject lives in a rural or urban setting. The research proposal was the cultural issues effected participants decision making as well as place of residence. This research used a previous qualitative research design in which 42 cardiac patients (21 urban, and 21 rural) were interviewed about their diet and physical activity. The researchers then designed a model for interviewing regarding the decision-making process. The combination model was then given and tested with 647 cardiac patients (327 urban and 320 rural) from Canada. The results were based on 93.5% accuracy for diet and 97.5 % accuracy with physical activity. Results indicated that decision-making was less about place of residence and more about perception of control over health including time, effort, or competing priorities, receipt of appropriate clear information, and appeal of the activity.
A three-staged, multi-methods approach was used to develop and analyze the descriptive decision making model that patients use in making decisions regarding their cardiac lifestyle. A cross-sectional survey was used to interview patients one year post-cardiac catherization. These interviews were performed via telephone. A three stage decision tree model was then used to analyze the information offered. The stages were as follows: 1. Factors that were influential in decision making. 2. If and where failure had occurred for patients. 3. Did patients consistently, sometimes, or not at all engage in physical activity and a heart healthy diet. Results were then analyzed using statistical analysis.
Information was gathered from a previous series of qualitative interviews conducted with 42 cardiac patients (21 rural, 21 urban). Based on the infor.
Works Cited Milne, Anne C., Alison Avenell, and Jan Potter. Meta-.docxkeilenettie
Works Cited
Milne, Anne C., Alison Avenell, and Jan Potter. "Meta-Analysis: Protein and Energy Supplementation in Older People."
Annals of Internal Medicine
144.1 (2006): 37-48.
ProQuest.
Web. 1 Oct. 2014.
Meta-Analysis: Protein and Energy Supplementation in Older People Anne C. Milne, MSc; Alison Avenell, MD; and Jan Potter, MBChB Background: Protein and energy undernutrition is common in older people, and further deterioration may occur during illness. Purpose: To assess whether oral protein and energy supplementa tion improves clinical and
nutritional outcomes for older people in the hospital, in an institution, or in the community. Data Sources: Cochrane Central Register of Controlled Trials (CEN TRAL), MEDLINE, EMBASE,
HealthStar, CINAHL, BIOSIS, and CAB abstracts. The authors included English- and non-English-language studies and hand-searched journals, contacted manufacturers, and sought information from trialists. The date of the most recent search of CENTRAL and MEDLINE is June 2005. Study Selection: Randomized and quasi-randomized controlled tri als of oral protein and energy
supplementation compared with placebo or control treatment in older people. Data Extraction: Two reviewers independently assessed trials for inclusion, extracted data, and assessed trial quality. Differences were resolved by consensus. Data Synthesis: Fifty-five trials were included (n = 9187 randomly tions (Peto odds ratio, 0.72 [95% Cl, 0.53 to 0.97]) and reduced mortality (Peto odds ratio, 0.66 [CI, 0.49 to 0.90]) for those un dernourished at baseline. Few studies reported evidence that suggested any change in mortality, morbidity, or function for those given supplements at home. Ten trials reported gastrointestinal disturbances, such as nausea, vomiting, and diarrhea, with oral supplements. Limitations: The quality of most studies, as reported, was poor, particularly for concealment of allocation and blinding of outcome assessors. Many studies were too small or the follow-up time was too short to detect a statistically significant change in clinical out come. The clinical results are dominated by 1 very large recent trial in patients with stroke. Although this was a high-quality trial, few participants were undernourished at baseline. Conclusions: Oral nutritional supplements can improve nutritional status and seem to reduce mortality and complications for under nourished elderly patients in the hospital. Current evidence does not support routine supplementation for older people at home or for well-nourished older patients in any setting. assigned participants). For patients in short-term care hospitals who were given oral supplements, evidence suggested fewer complica-Ann Intern Med. 2006:144:37-48. For author affiliations, see end of text.
www.annals.OIJ
ndernutrition among older people is a continuing source of concern (1, 2). Older people have longer periods of illness and longer hospital stays (3), and data show tha.
Running head SEARCHING AND CRITIQUING THE EVIDENCE1SEARCHING .docxtoltonkendal
Running head: SEARCHING AND CRITIQUING THE EVIDENCE 1
SEARCHING AND CRITIQUING THE EVIDENCE 4
Searching and Critiquing the Evidence
Student’s Name
Institution
Date
Searching and Critiquing the Evidence
There are various research studies that have been done on the outcome of self-care on Type 2 Diabetes Mellitus patients. In most of the studies, the most prevalent results are that self-care is an effective method of improving the health and lifestyle outcomes of Type 2 Diabetes patients. Krishna and Boren (2008) conducted a systematic review of evidence-based studies done between 1996 and 2007. The study analyzed 18 researches done within the selected time period and found that using phone calls and text messages to assist diabetes patients could improve the self-management outcomes. Shrivastava et al. (2013) analyzed the effectiveness of self-management for the diabetes mellitus patients. The study found that self-care helps to reduce the rate of morbidity and mortality among diabetes patients.
In addition, Steinsbekk et al. (2013) conducted a meta-analysis comparing the differences between the outcomes of group based self-management education and routine treatment for Type 2 diabetes patients. The study analyzed 21 studies that included studied on 2833 participants. The results of the meta-analysis showed that group-based self-management education helped to improve the psychosocial, clinical, and lifestyle outcomes among the diabetes patients. Lastly, Tang et al. (2008) examined the impact of social support and quality of life on the self-care behaviors of African American Type 2 diabetes patients. The study followed an observational design with 89 African-American adults, who were aged 40 and above. The study found that social support is vital for self-management to be effective in diabetes treatment.
The selected studies have helped to strengthen the merit of my selected theoretical framework. The theory selected for the study was Dorothea Orem’s Self Care Theory. These studies have helped to demonstrate some important evidence-based facts about the effectiveness of self-care for diabetes patients hence helping to prove the credibility of the theory. The scrutiny of these studies has helped to discover the degree of effectiveness of this theory and the best application methods that can make it an effective approach to improving the outcomes of patients with Type 2 Diabetes Mellitus.
Levels of Evidence in the Articles
The classification of the level of evidence of a given research is important in evidence-based studies because they help to show how accurate, credible, or reliable a research is (Gray, Grove & Sutherland, 2017). The most prevalent evidence in the research articles analyzed is Level II evidence. Level II evidence is one that is obtained from at least one randomized control trial (Moran, Burson & Conrad, 2017). The articles by Krishna and Boren (2008) and Steinsbekk et al. (2013) conducted meta-analyses of various rese ...
A systematic review of the quality of homeopathic clinical trialshome
While a number of reviews of homeopathic clinical trials have been done, all have
used methods dependent on allopathic diagnostic classifications foreign to homeopathic practice.
In addition, no review has used established and validated quality criteria allowing direct comparison
of the allopathic and homeopathic literature.
Week 5 EBP ProjectAppraisal of EvidenceCLC EBP Research .docxcockekeshia
Week 5 EBP Project/Appraisal of Evidence
CLC: EBP Research Table
Citation
Include the APA reference note.
Abstract/Purpose
Craft a 100-150 word summary of the research.
Research/Study
Describe the design of the relevant research or study in the article.
Methods
Describe the methods used, including tools, systems, etc.
Setting/Subject
Identify the population and
the setting in which the study was conducted.
Findings/Results
Identify the relevant findings, including any specific data points that may be of interest to your EBP project.
Variables
Describe the independent and dependent variables in the research/study.
Implication for Practice
Articulate the value of the research to the EBP project your group has chosen.
Independent Variable
Dependent Variable
King-Shier, K.M., Mather, C., &LeBlanc, P. (2013). Understanding the influence of urban or rural living on cardiac patients’ decisions about diet and physical activity: Descriptive decision modeling. International Journal of Nursing Studies, 50(11), 1513-1523. doi: 10.1016/j.ijnurstu.2013.03.003
This research aims to answer to better understand the decision-making process of eating a heart healthy diet and extent of physical activity. Also, are these decisions influenced by whether the subject lives in a rural or urban setting. The research proposal was the cultural issues effected participants decision making as well as place of residence. This research used a previous qualitative research design in which 42 cardiac patients (21 urban, and 21 rural) were interviewed about their diet and physical activity. The researchers then designed a model for interviewing regarding the decision-making process. The combination model was then given and tested with 647 cardiac patients (327 urban and 320 rural) from Canada. The results were based on 93.5% accuracy for diet and 97.5 % accuracy with physical activity. Results indicated that decision-making was less about place of residence and more about perception of control over health including time, effort, or competing priorities, receipt of appropriate clear information, and appeal of the activity.
A three-staged, multi-methods approach was used to develop and analyze the descriptive decision making model that patients use in making decisions regarding their cardiac lifestyle. A cross-sectional survey was used to interview patients one year post-cardiac catherization. These interviews were performed via telephone. A three stage decision tree model was then used to analyze the information offered. The stages were as follows: 1. Factors that were influential in decision making. 2. If and where failure had occurred for patients. 3. Did patients consistently, sometimes, or not at all engage in physical activity and a heart healthy diet. Results were then analyzed using statistical analysis.
Information was gathered from a previous series of qualitative interviews conducted with 42 cardiac patients (21 rural, 21 urban). Based on the infor.
Works Cited Milne, Anne C., Alison Avenell, and Jan Potter. Meta-.docxkeilenettie
Works Cited
Milne, Anne C., Alison Avenell, and Jan Potter. "Meta-Analysis: Protein and Energy Supplementation in Older People."
Annals of Internal Medicine
144.1 (2006): 37-48.
ProQuest.
Web. 1 Oct. 2014.
Meta-Analysis: Protein and Energy Supplementation in Older People Anne C. Milne, MSc; Alison Avenell, MD; and Jan Potter, MBChB Background: Protein and energy undernutrition is common in older people, and further deterioration may occur during illness. Purpose: To assess whether oral protein and energy supplementa tion improves clinical and
nutritional outcomes for older people in the hospital, in an institution, or in the community. Data Sources: Cochrane Central Register of Controlled Trials (CEN TRAL), MEDLINE, EMBASE,
HealthStar, CINAHL, BIOSIS, and CAB abstracts. The authors included English- and non-English-language studies and hand-searched journals, contacted manufacturers, and sought information from trialists. The date of the most recent search of CENTRAL and MEDLINE is June 2005. Study Selection: Randomized and quasi-randomized controlled tri als of oral protein and energy
supplementation compared with placebo or control treatment in older people. Data Extraction: Two reviewers independently assessed trials for inclusion, extracted data, and assessed trial quality. Differences were resolved by consensus. Data Synthesis: Fifty-five trials were included (n = 9187 randomly tions (Peto odds ratio, 0.72 [95% Cl, 0.53 to 0.97]) and reduced mortality (Peto odds ratio, 0.66 [CI, 0.49 to 0.90]) for those un dernourished at baseline. Few studies reported evidence that suggested any change in mortality, morbidity, or function for those given supplements at home. Ten trials reported gastrointestinal disturbances, such as nausea, vomiting, and diarrhea, with oral supplements. Limitations: The quality of most studies, as reported, was poor, particularly for concealment of allocation and blinding of outcome assessors. Many studies were too small or the follow-up time was too short to detect a statistically significant change in clinical out come. The clinical results are dominated by 1 very large recent trial in patients with stroke. Although this was a high-quality trial, few participants were undernourished at baseline. Conclusions: Oral nutritional supplements can improve nutritional status and seem to reduce mortality and complications for under nourished elderly patients in the hospital. Current evidence does not support routine supplementation for older people at home or for well-nourished older patients in any setting. assigned participants). For patients in short-term care hospitals who were given oral supplements, evidence suggested fewer complica-Ann Intern Med. 2006:144:37-48. For author affiliations, see end of text.
www.annals.OIJ
ndernutrition among older people is a continuing source of concern (1, 2). Older people have longer periods of illness and longer hospital stays (3), and data show tha.
Running head SEARCHING AND CRITIQUING THE EVIDENCE1SEARCHING .docxtoltonkendal
Running head: SEARCHING AND CRITIQUING THE EVIDENCE 1
SEARCHING AND CRITIQUING THE EVIDENCE 4
Searching and Critiquing the Evidence
Student’s Name
Institution
Date
Searching and Critiquing the Evidence
There are various research studies that have been done on the outcome of self-care on Type 2 Diabetes Mellitus patients. In most of the studies, the most prevalent results are that self-care is an effective method of improving the health and lifestyle outcomes of Type 2 Diabetes patients. Krishna and Boren (2008) conducted a systematic review of evidence-based studies done between 1996 and 2007. The study analyzed 18 researches done within the selected time period and found that using phone calls and text messages to assist diabetes patients could improve the self-management outcomes. Shrivastava et al. (2013) analyzed the effectiveness of self-management for the diabetes mellitus patients. The study found that self-care helps to reduce the rate of morbidity and mortality among diabetes patients.
In addition, Steinsbekk et al. (2013) conducted a meta-analysis comparing the differences between the outcomes of group based self-management education and routine treatment for Type 2 diabetes patients. The study analyzed 21 studies that included studied on 2833 participants. The results of the meta-analysis showed that group-based self-management education helped to improve the psychosocial, clinical, and lifestyle outcomes among the diabetes patients. Lastly, Tang et al. (2008) examined the impact of social support and quality of life on the self-care behaviors of African American Type 2 diabetes patients. The study followed an observational design with 89 African-American adults, who were aged 40 and above. The study found that social support is vital for self-management to be effective in diabetes treatment.
The selected studies have helped to strengthen the merit of my selected theoretical framework. The theory selected for the study was Dorothea Orem’s Self Care Theory. These studies have helped to demonstrate some important evidence-based facts about the effectiveness of self-care for diabetes patients hence helping to prove the credibility of the theory. The scrutiny of these studies has helped to discover the degree of effectiveness of this theory and the best application methods that can make it an effective approach to improving the outcomes of patients with Type 2 Diabetes Mellitus.
Levels of Evidence in the Articles
The classification of the level of evidence of a given research is important in evidence-based studies because they help to show how accurate, credible, or reliable a research is (Gray, Grove & Sutherland, 2017). The most prevalent evidence in the research articles analyzed is Level II evidence. Level II evidence is one that is obtained from at least one randomized control trial (Moran, Burson & Conrad, 2017). The articles by Krishna and Boren (2008) and Steinsbekk et al. (2013) conducted meta-analyses of various rese ...
A systematic review of the quality of homeopathic clinical trialshome
While a number of reviews of homeopathic clinical trials have been done, all have
used methods dependent on allopathic diagnostic classifications foreign to homeopathic practice.
In addition, no review has used established and validated quality criteria allowing direct comparison
of the allopathic and homeopathic literature.
Scholarly research paper. This research paper investigates the patient and how they respond to treatment of spinal injuries over a specified amount of time and how their pain level was affected depending on the form of rehabilitation used. References included.
RESEARCH Open AccessA methodological review of resilience.docxverad6
RESEARCH Open Access
A methodological review of resilience
measurement scales
Gill Windle1*, Kate M Bennett2, Jane Noyes3
Abstract
Background: The evaluation of interventions and policies designed to promote resilience, and research to
understand the determinants and associations, require reliable and valid measures to ensure data quality. This
paper systematically reviews the psychometric rigour of resilience measurement scales developed for use in
general and clinical populations.
Methods: Eight electronic abstract databases and the internet were searched and reference lists of all identified
papers were hand searched. The focus was to identify peer reviewed journal articles where resilience was a key
focus and/or is assessed. Two authors independently extracted data and performed a quality assessment of the
scale psychometric properties.
Results: Nineteen resilience measures were reviewed; four of these were refinements of the original measure. All
the measures had some missing information regarding the psychometric properties. Overall, the Connor-Davidson
Resilience Scale, the Resilience Scale for Adults and the Brief Resilience Scale received the best psychometric
ratings. The conceptual and theoretical adequacy of a number of the scales was questionable.
Conclusion: We found no current ‘gold standard’ amongst 15 measures of resilience. A number of the scales are
in the early stages of development, and all require further validation work. Given increasing interest in resilience
from major international funders, key policy makers and practice, researchers are urged to report relevant validation
statistics when using the measures.
Background
International research on resilience has increased substan-
tially over the past two decades [1], following dissatisfac-
tion with ‘deficit’ models of illness and psychopathology
[2]. Resilience is now also receiving increasing interest
from policy and practice [3,4] in relation to its poten-
tial influence on health, well-being and quality of life
and how people respond to the various challenges of
the ageing process. Major international funders, such
as the Medical Research Council and the Economic
and Social Research Council in the UK [5] have identi-
fied resilience as an important factor for lifelong health
and well-being.
Resilience could be the key to explaining resistance to
risk across the lifespan and how people ‘bounce back’
and deal with various challenges presented from child-
hood to older age, such as ill-health. Evaluation of inter-
ventions and policies designed to promote resilience
require reliable and valid measures. However the com-
plexity of defining the construct of resilience has been
widely recognised [6-8] which has created considerable
challenges when developing an operational definition of
resilience.
Different approaches to measuring resilience across
studies have lead to inconsistencies relating to the nat-
ure of potential risk factors and protective processes,.
Observational Study DesignsA clinical pediatric nurse has .docxpoulterbarbara
Observational Study Designs
A clinical pediatric nurse has noticed a rise in childhood cancer diagnoses among the Hispanic population served by the local clinic. The nurse is concerned about this increase in cancer incidence in the patient population and turns to the literature to explore current research on this topic. The nurse finds through the reading that there appears to be an association between parental smoking and childhood cancer and wonders if this could be the cause of the rise in cases.
This type of suspected association between a risk factor (exposure) and a particular outcome (childhood cancer) can be evaluated using an observational study design. This week, you were introduced to observational study designs used in epidemiology. For this Discussion, you will identify an epidemiologic association of interest (e.g., smoking and lung cancer, obesity and heart disease, hormone replacement/modification therapy and breast cancer) and determine an appropriate observational study design for exploring that association.
To prepare:
Review the different types of observational study designs presented in the Learning Resources: ecologic, cross-sectional, case-control, and cohort.
Carefully examine the characteristics, strengths, and limitations of each design.
Consider an association between a risk factor and a particular health outcome that is of interest to you. Then, select the observational study design you think would be the most appropriate for exploring this association.
Consider how using observational study designs can lead to improvements in population health.
By tomorrow 03/14/2018 12 noon, write a minimum of 550 words in APA format with at least 3 scholarly references from the list of required readings below. Include the level one headings as numbered below:
Post
a cohesive response that addresses the following:
1) Identify the association between the risk factor and health outcome you selected and suggest which observational study design you feel is most appropriate for examining that association.
2) Support your selection of the observational design, noting its strengths and limitations for addressing the health problem.
3) What might you be able to learn by using your selected study design that might lead to improvements in population health? Support your response with evidence from the literature.
Required Readings
Friis, R. H., & Sellers, T. A. (2014). Epidemiology for public health practice (5th ed.). Sudbury, MA: Jones & Bartlett.
Chapter 6, “Study Designs: Ecologic, Cross-Sectional, Case Control”
Chapter 7, “Study Designs: Cohort Studies”
Chapter 6 presents an overview of analytic study designs used in epidemiology, differentiating between experimental studies (which will be addressed next week) and observational studies (the focus of this week). In the chapter, the authors address three varieties of observational studies—ecological, cross-sectional, a ...
This article, "Casting a Wider Net in Behavioral Health Screening in Primary Care" found that the ORS identified more clients for behavioral healthcare consultation than the PHQ-9. A first step toward the upcoming RCT with PCOMS in an integrated setting.
Research process | Meta-analysis research | Systematic review and meta-analysisPubrica
Pubrica’s research and writing teams provide scientific and medical research papers that authors and practitioners may find useful. Pubrica medical writers assist you in creating and rewriting the introduction by informing the reader about the constraints of the selected study subject. Our experts understand the sequence in which the confined subject, problem, and backdrop are followed by the targeted location in which the hypothesis is presented.
Read more @ https://pubrica.com/academy/meta-analysis/critical-review-of-meta-analysis-conducted-in-this-paper/
Visit us @ https://pubrica.com/services/research-services/systematic-review/
Effects of yogic practices on polypharmacy Dr. Balaji P.A Dr. smitha r varne.pdfDrBalaji8
The occurrence and concurrency of Noncommunicable chronic diseases increase
with age, and therefore, the number of medications used increases
correspondingly. Polypharmacy is a scenario in which five medications or more
are consumed concurrently (regardless of dose and duration of consumption),
which leads to reduced quality of life, physical problems, increased drug
interactions, adverse effects, and medical complications and increases the cost
of treatment. Moreover, polypharmacy increases the incidence of falls, frequency
of hospital admission, length of stay, and the death rate among patients, especially
in the elderly population. This would allow therapies like Yoga, pranayama,
and meditation to act as an effective mainstay or adjunctive or alternative therapy
for many disorders, as it can be cost-effective, patient-compliant, and clinically
efficacious with the most negligible side effects. However, very few studies
have focused on the impact of yogic practices on reducing drug dosage or
polypharmacy among patients. Hence, a Medline English literature search was
planned to review all the studies demonstrating a dose-response effect between
yogic practices and the number/dosage of medication reduction in different
disorders. Data extracted and analyzed depicted that the practice of Yoga,
pranayama, and meditation can result not only in reducing the number of
medications but also the dosages in hypertension, type 2 diabetes mellitus,
bronchial asthma, arthritis, sleep disorders, obsessive-compulsive disorder
(OCD), gastrointestinal disorders like constipation and irritable bowel syndrome
Observational research designs are those in which the researcher/investigator merely observes and does not carry out any interventions/actions.
to change the result. The three most common types of observational studies are cross-sectional studies, case-control studies, and cohort (or longitudinal) studies.
In cross-sectional studies, exposure/risk factors and outcomes are determined at a single point in time. You can bid
information on disease prevalence and an overview of likely relationships that can be used to form a hypothesis. Control cases In
studies, participants are selected based on the presence/absence of an outcome and risk factors are identified during the study.
after enrollment of study participants.The relationship between exposure and outcome is reported as an odds ratio. This research; However,
carries a high risk of bias, which should be taken into account when designing the study. Cohort studies are prospective and include participants
were selected based on presence/absence of exposure and results were obtained at the end of the study. This research can deliver The incidence/impact of the disease and the relationship between exposure and outcome are presented as relative risks. They are useful
establish causality.A problem that arises in these studies could be the high fluctuation and dropout of study participants.
Descriptive studies generally describe the magnitude of a problem and characteristics of the population/individuals.
The various types of such studies include
case reports
case series or surveys.
A case report generally describes a patient presenting with an unusual disease, or simultaneous occurrence of more than one condition, or uncommon clinical features in a known disease.
A case series is a collection of similar cases. Such studies, other than providing some advancement to knowledge of a disease, are of limited value. Another method often used in epidemiological health care research is conducting surveys.
Surveys are done during a defined time-period and information on several variables of interest is collected from the target population. They provide estimates of prevalence of the various variables of interest, and their distribution. Such studies could also provide insight into individual opinions and practices. Advantages include ease of conduct and cost efficiency. The disadvantages include low response rates and a variety of biases.
An analytical study tests a hypothesis to determine an association between two or more variables, like causation, risk, or effect. Such studies have two or more study groups for comparison.
The primary focus of this article will be the three most common types of analytical observational studies –
cross-sectional,
case control (also known as retrospective) and
cohort (or longitudinal, also known as prospective) studies.
It may be pertinent to note that the primary objective of most clinical studies is to determine one of the following - burden of disease (prevalence
Review the article by Peter Singer.Complete the followingRe.docxmichael591
Review the article by Peter Singer.
Complete the following:
Record and describe six of your initial impressions of the article in a journal format.
Identify and critically analyze the roots of these impressions, i.e., emotional, value based, or fact based. Record these as part of your journal notes.
Support your statements with examples and appropriate scholarly references.
You can use the Cornell Note-taking tools to complete this assignment. This tool has been widely used to systematically format and organize notes.
.
Review the accounting methods used by Dr. Lopez as illustrated in Ta.docxmichael591
Review the accounting methods used by Dr. Lopez as illustrated in Table 15–1 in this chapter. Contrast the profitability that Dr. Lopez faces by using the cash basis of accounting with the profitability he faces by using the accrual basis of accounting for the month of July. What if Dr. Lopez did not accept third-party insurance and required all patients to pay at the time of service? Would there be any difference between the cash basis and accrual basis of accounting? Why or why not?
Your response should be 200-250 words. You will need to cite two reputable sources.
.
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Scholarly research paper. This research paper investigates the patient and how they respond to treatment of spinal injuries over a specified amount of time and how their pain level was affected depending on the form of rehabilitation used. References included.
RESEARCH Open AccessA methodological review of resilience.docxverad6
RESEARCH Open Access
A methodological review of resilience
measurement scales
Gill Windle1*, Kate M Bennett2, Jane Noyes3
Abstract
Background: The evaluation of interventions and policies designed to promote resilience, and research to
understand the determinants and associations, require reliable and valid measures to ensure data quality. This
paper systematically reviews the psychometric rigour of resilience measurement scales developed for use in
general and clinical populations.
Methods: Eight electronic abstract databases and the internet were searched and reference lists of all identified
papers were hand searched. The focus was to identify peer reviewed journal articles where resilience was a key
focus and/or is assessed. Two authors independently extracted data and performed a quality assessment of the
scale psychometric properties.
Results: Nineteen resilience measures were reviewed; four of these were refinements of the original measure. All
the measures had some missing information regarding the psychometric properties. Overall, the Connor-Davidson
Resilience Scale, the Resilience Scale for Adults and the Brief Resilience Scale received the best psychometric
ratings. The conceptual and theoretical adequacy of a number of the scales was questionable.
Conclusion: We found no current ‘gold standard’ amongst 15 measures of resilience. A number of the scales are
in the early stages of development, and all require further validation work. Given increasing interest in resilience
from major international funders, key policy makers and practice, researchers are urged to report relevant validation
statistics when using the measures.
Background
International research on resilience has increased substan-
tially over the past two decades [1], following dissatisfac-
tion with ‘deficit’ models of illness and psychopathology
[2]. Resilience is now also receiving increasing interest
from policy and practice [3,4] in relation to its poten-
tial influence on health, well-being and quality of life
and how people respond to the various challenges of
the ageing process. Major international funders, such
as the Medical Research Council and the Economic
and Social Research Council in the UK [5] have identi-
fied resilience as an important factor for lifelong health
and well-being.
Resilience could be the key to explaining resistance to
risk across the lifespan and how people ‘bounce back’
and deal with various challenges presented from child-
hood to older age, such as ill-health. Evaluation of inter-
ventions and policies designed to promote resilience
require reliable and valid measures. However the com-
plexity of defining the construct of resilience has been
widely recognised [6-8] which has created considerable
challenges when developing an operational definition of
resilience.
Different approaches to measuring resilience across
studies have lead to inconsistencies relating to the nat-
ure of potential risk factors and protective processes,.
Observational Study DesignsA clinical pediatric nurse has .docxpoulterbarbara
Observational Study Designs
A clinical pediatric nurse has noticed a rise in childhood cancer diagnoses among the Hispanic population served by the local clinic. The nurse is concerned about this increase in cancer incidence in the patient population and turns to the literature to explore current research on this topic. The nurse finds through the reading that there appears to be an association between parental smoking and childhood cancer and wonders if this could be the cause of the rise in cases.
This type of suspected association between a risk factor (exposure) and a particular outcome (childhood cancer) can be evaluated using an observational study design. This week, you were introduced to observational study designs used in epidemiology. For this Discussion, you will identify an epidemiologic association of interest (e.g., smoking and lung cancer, obesity and heart disease, hormone replacement/modification therapy and breast cancer) and determine an appropriate observational study design for exploring that association.
To prepare:
Review the different types of observational study designs presented in the Learning Resources: ecologic, cross-sectional, case-control, and cohort.
Carefully examine the characteristics, strengths, and limitations of each design.
Consider an association between a risk factor and a particular health outcome that is of interest to you. Then, select the observational study design you think would be the most appropriate for exploring this association.
Consider how using observational study designs can lead to improvements in population health.
By tomorrow 03/14/2018 12 noon, write a minimum of 550 words in APA format with at least 3 scholarly references from the list of required readings below. Include the level one headings as numbered below:
Post
a cohesive response that addresses the following:
1) Identify the association between the risk factor and health outcome you selected and suggest which observational study design you feel is most appropriate for examining that association.
2) Support your selection of the observational design, noting its strengths and limitations for addressing the health problem.
3) What might you be able to learn by using your selected study design that might lead to improvements in population health? Support your response with evidence from the literature.
Required Readings
Friis, R. H., & Sellers, T. A. (2014). Epidemiology for public health practice (5th ed.). Sudbury, MA: Jones & Bartlett.
Chapter 6, “Study Designs: Ecologic, Cross-Sectional, Case Control”
Chapter 7, “Study Designs: Cohort Studies”
Chapter 6 presents an overview of analytic study designs used in epidemiology, differentiating between experimental studies (which will be addressed next week) and observational studies (the focus of this week). In the chapter, the authors address three varieties of observational studies—ecological, cross-sectional, a ...
This article, "Casting a Wider Net in Behavioral Health Screening in Primary Care" found that the ORS identified more clients for behavioral healthcare consultation than the PHQ-9. A first step toward the upcoming RCT with PCOMS in an integrated setting.
Research process | Meta-analysis research | Systematic review and meta-analysisPubrica
Pubrica’s research and writing teams provide scientific and medical research papers that authors and practitioners may find useful. Pubrica medical writers assist you in creating and rewriting the introduction by informing the reader about the constraints of the selected study subject. Our experts understand the sequence in which the confined subject, problem, and backdrop are followed by the targeted location in which the hypothesis is presented.
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Effects of yogic practices on polypharmacy Dr. Balaji P.A Dr. smitha r varne.pdfDrBalaji8
The occurrence and concurrency of Noncommunicable chronic diseases increase
with age, and therefore, the number of medications used increases
correspondingly. Polypharmacy is a scenario in which five medications or more
are consumed concurrently (regardless of dose and duration of consumption),
which leads to reduced quality of life, physical problems, increased drug
interactions, adverse effects, and medical complications and increases the cost
of treatment. Moreover, polypharmacy increases the incidence of falls, frequency
of hospital admission, length of stay, and the death rate among patients, especially
in the elderly population. This would allow therapies like Yoga, pranayama,
and meditation to act as an effective mainstay or adjunctive or alternative therapy
for many disorders, as it can be cost-effective, patient-compliant, and clinically
efficacious with the most negligible side effects. However, very few studies
have focused on the impact of yogic practices on reducing drug dosage or
polypharmacy among patients. Hence, a Medline English literature search was
planned to review all the studies demonstrating a dose-response effect between
yogic practices and the number/dosage of medication reduction in different
disorders. Data extracted and analyzed depicted that the practice of Yoga,
pranayama, and meditation can result not only in reducing the number of
medications but also the dosages in hypertension, type 2 diabetes mellitus,
bronchial asthma, arthritis, sleep disorders, obsessive-compulsive disorder
(OCD), gastrointestinal disorders like constipation and irritable bowel syndrome
Observational research designs are those in which the researcher/investigator merely observes and does not carry out any interventions/actions.
to change the result. The three most common types of observational studies are cross-sectional studies, case-control studies, and cohort (or longitudinal) studies.
In cross-sectional studies, exposure/risk factors and outcomes are determined at a single point in time. You can bid
information on disease prevalence and an overview of likely relationships that can be used to form a hypothesis. Control cases In
studies, participants are selected based on the presence/absence of an outcome and risk factors are identified during the study.
after enrollment of study participants.The relationship between exposure and outcome is reported as an odds ratio. This research; However,
carries a high risk of bias, which should be taken into account when designing the study. Cohort studies are prospective and include participants
were selected based on presence/absence of exposure and results were obtained at the end of the study. This research can deliver The incidence/impact of the disease and the relationship between exposure and outcome are presented as relative risks. They are useful
establish causality.A problem that arises in these studies could be the high fluctuation and dropout of study participants.
Descriptive studies generally describe the magnitude of a problem and characteristics of the population/individuals.
The various types of such studies include
case reports
case series or surveys.
A case report generally describes a patient presenting with an unusual disease, or simultaneous occurrence of more than one condition, or uncommon clinical features in a known disease.
A case series is a collection of similar cases. Such studies, other than providing some advancement to knowledge of a disease, are of limited value. Another method often used in epidemiological health care research is conducting surveys.
Surveys are done during a defined time-period and information on several variables of interest is collected from the target population. They provide estimates of prevalence of the various variables of interest, and their distribution. Such studies could also provide insight into individual opinions and practices. Advantages include ease of conduct and cost efficiency. The disadvantages include low response rates and a variety of biases.
An analytical study tests a hypothesis to determine an association between two or more variables, like causation, risk, or effect. Such studies have two or more study groups for comparison.
The primary focus of this article will be the three most common types of analytical observational studies –
cross-sectional,
case control (also known as retrospective) and
cohort (or longitudinal, also known as prospective) studies.
It may be pertinent to note that the primary objective of most clinical studies is to determine one of the following - burden of disease (prevalence
Similar to REVIEW Open AccessWhat happens after treatment Asystema.docx (20)
Review the article by Peter Singer.Complete the followingRe.docxmichael591
Review the article by Peter Singer.
Complete the following:
Record and describe six of your initial impressions of the article in a journal format.
Identify and critically analyze the roots of these impressions, i.e., emotional, value based, or fact based. Record these as part of your journal notes.
Support your statements with examples and appropriate scholarly references.
You can use the Cornell Note-taking tools to complete this assignment. This tool has been widely used to systematically format and organize notes.
.
Review the accounting methods used by Dr. Lopez as illustrated in Ta.docxmichael591
Review the accounting methods used by Dr. Lopez as illustrated in Table 15–1 in this chapter. Contrast the profitability that Dr. Lopez faces by using the cash basis of accounting with the profitability he faces by using the accrual basis of accounting for the month of July. What if Dr. Lopez did not accept third-party insurance and required all patients to pay at the time of service? Would there be any difference between the cash basis and accrual basis of accounting? Why or why not?
Your response should be 200-250 words. You will need to cite two reputable sources.
.
Review the 12 principles presented by Hardina et al. in the sectio.docxmichael591
Review
the 12 principles presented by Hardina et al. in the section titled “Humans Service Organizations and Empowerment” in Ch. 4 of
Management of Human Service Programs
. Additional resources may be used.
Discuss
the principles that characterize an empowerment approach to social service management.
Evaluate
how you might apply these principles to the developmental processes of your own dream human service organization.
Write
a 1,050- to 1,400-word paper that applies the principles presented by Hardina et al. to your dream human service organization. Specifically, address the following:
How clients will be included in the organizational decision-making processes
How your dream agency will decrease a sense of powerlessness among consumers and increase access and quality of services for clientele
The measures your dream human service agency will take to ensure diverse cross-cultural needs are met
Consider the following areas of diversity: socioeconomic background, culture, age, gender, sexual identity, spirituality, disability, and other unique differences.
The ideological belief systems of a manager who espouses empowerment for the overall agency, staff members, and clientele
How the concepts of team building and collaboration are met within the organization
The strategies for consistent evaluation of organizational efficacy that includes strategic feedback from clients, community constituency groups, and staff members within the agency
Format
your report consistent with APA guidelines.
.
Review the 10 provided articles then write 3-4 pages to explore .docxmichael591
Review the 10 provided articles then write 3-4 pages to explore the impact of simulation on team training.
Categorize the findings to themes e.g. Leadership, communication, patient safety, situational awareness, mutual support, participant attitude, confidence etc...
cite information in APA 7th edition
.
Review syllabus for further instruction.Issue C.docxmichael591
Review syllabus for further instruction.
Issue C
In a time when most of society sees women achieving equal status and treatment as men in many areas, why does society (justice system, media, communities) treat female sexual offenders differently than male sexual offenders? What basis is there in the law to consider gender when contemplating how an offender is treated?
Explain with specificity and example.
.
Review Questions1. What is liver mortis How might this reveal.docxmichael591
Review Questions
1.
What is liver mortis? How might this reveal information about the time of death?
2.
What three aspects does a forensic autopsy seek information about? Describe each of these aspects?
3.
How can digestion rates give information to forensic scientists about the time of death?
4.
What is mummification?
5.
How can human bones give forensic scientists an indication of age? Describe some of the aspects that would give this information.
Critical Thinking Questions
1.
Imagine that you are at a crime scene. You find skeletal remains, but the skeleton is not complete as some of the smaller bones are missing. The bones are within a twenty feet radius. Based on this information, what would you be able to ascertain about the time of death and the individual who was killed?
2.
Out of the different methods to help determine the time of death, which one do you think is most effective? Why?
3.
Do you think you would like to participate in an autopsy? Why or why not?
4.
If you were a forensic anthropologist and were studying human remains, what information would you look for in the bones? Why would this information be helpful?
5.
What can the distribution of bones tell a forensic scientist? What do you think would be the most challenging aspect of collecting skeletal remains at a crime scene?
.
Review Questions1. What is physical evidence Provide at least.docxmichael591
Review Questions
1.
What is physical evidence? Provide at least three examples in your answer.
2.
Describe three ways that a crime scene can be recorded. What is a benefit of each?
3.
What is a chain of custody? Why is it important?
4.
What three types of photographs are taken at crime scenes? Describe each type?
5.
Why is it important to record the crime scene?
Critical Thinking Questions
1.
Why is it important to secure the crime scene? What do you think would be the most difficult part of doing this?
2.
What type of recording do you think would be the most useful to crime investigators? Why?
3.
What do you think would be the best method of submitting evidence to a crime lab? Why?
4.
What type of evidence do you think would be most difficult to collect? Why?
5.
What does the Fourth Amendment protect against? Do you agree with these restrictions on collecting evidence? Why or why not?
.
Review Questions1. What are the four types of evidence in a cr.docxmichael591
Review Questions
1.
What are the four types of evidence in a criminal investigation?
2.
What are individual characteristics? Give an example of an individual characteristic?
3.
What is the difference between individual characteristics and class characteristics?
4.
What are physical and chemical properties? Give an example of each.
5.
What do forensic scientists do to collect and preserve soil samples?
Critical Thinking Questions
1.
Why do you think forensic scientists are so careful that the tests they do are sensitive, reproducible, and specific? What might happen if they were less careful about this?
2.
Which type of evidence do you think is most useful in an investigation? Why?
3.
Why do you think that forensic scientists continue to look for class characteristics given their limitations?
4.
What do you think would be some of the challenges in collecting and preserving impressions? Why?
5.
If you were on a jury, do you think you would expect individual characteristics in the evidence? Why or why not? What effects might it have if individuals expect to have individuals characteristics presented?
.
Review several of your peers’ posts. Respond to two peers who did no.docxmichael591
Review several of your peers’ posts. Respond to two peers who did not choose the same tool as you.
JOHNNY'S POST:
Select one of the following tools:
Cummings and Worley’s five dimensions of leading and managing change.
Explain how a leader could use this tool in guiding an organizational change.
I believe all leaders could help their organization by learning the five dimensions of leading and managing effective change. As stated in the text, 2016, “Those dimensions include motivating change, creating a vision, developing political support, managing the transition, and sustaining momentum.” (Ch 3.2, Para 20). All five of these dimensions are essential for a business that is going through an organizational change.
As a company evolves and expands over time there will be a time where the leaders of the company will have to implement change to stay effective and up to date. The first step of motivating change is very important because people generally reject change. Leaders must motivate the change otherwise the employee’s will not buy into the concept. Creating a vision helps the company understand what their goals are. Without establishing a vision, it would be impossible for people to know what the goals for the company are. This would lead to confusion and most likely low morale. Political support helps the new change become accepted. If there is a lack of support the new change could fail to gain momentum. The transition of change will not happen overnight. I believe the final two dimensions are often overlooked and not implemented in many companies. If the momentum is not sustained most people will fall back into old habits. It's important that leaders periodically check up on progress and reassure its employee’s that the change is working.
Reference:
Weiss, J. W. (2016).
Organizational change
(2nd ed.). Retrieved from
https://content.ashford.edu/ (Links to an external site.)
SARA'S POST:
Hey Class,
Per Weiss (2016), Cummings and Worley's five dimensions of leading and managing change provide companies reliable guidance and direction for taking steps toward organizational change. These dimensions, motivating change, creating a vision, developing political support, managing the transition, and sustaining momentum, are easy to understand and, if followed correctly, will assist in a smooth transition in what could serve as an otherwise chaotic period (Weiss, 2016).
Motivating Change
I appreciate that Weiss (2016) acknowledges that many people are resistant to change. Often, when employees or stakeholders initially learn about upcoming changes, their first reaction is one of hesitation and insecurity. Employers should offer buy-in to a new direction. Offer a compelling reason for the change, proving the move is positive and beneficial. A one-on-one conversation with employees will provide a sense of security and personalize how the change will impact their position.
Creating a Vision
Many ar.
Review Robin Hood,” in Chapter 5 of Managing the Public Secto.docxmichael591
Review “Robin Hood,” in Chapter 5 of
Managing the Public Sector
.
The story stated that the source of revenue (the rich) was dwindling because the rich were avoiding the forest. Robin considered increasing revenue by assessing a fixed transit tax.
Recommend a contingency plan to increase revenue that would allow Robin Hood to stay true to his mission. Comment on the use and importance of contingency plans by public administrators. Provide an example to illustrate.
.
Review materials and topics are attached、The deadline is 11.docxmichael591
Review materials and topics are attached、
The deadline is 11:00 am Washington time, July 24
Please scan and send it to me in PDF
Edit question's body
it quite urgent. plz check first, make sure u.can handle it. and get less get grade B
.
Review Questions1. What are the three types of fingerprints fo.docxmichael591
Review Questions
1.
What are the three types of fingerprints found in the human population? How often does each occur?
2.
What is a medulla? What do forensic scientists use this for?
3.
What is a precipitin test? What is it used for?
4.
What makes fingerprints individual? How do scientists match a fingerprint to a specific person?
5.
How are fingerprints discovered at crime scenes?
Critical Thinking Questions
1.
Of the three types of physical evidence discussed in this unit, which one do you think you would be most interested in working with in an investigation? Why?
2.
What do you think would be the most challenging aspect of collecting and analyzing hair samples? Why?
3.
Why do you think forensic scientists study bloodstain patterns? What can be learned from them?
4.
Out of the types of evidence discussed in this unit, which one do you think is the most important piece of evidence? Why?
5.
Why was the bite mark evidence so important in the Bundy case? If the case happened today, do you think investigators would have more information to work with?
.
Review several of your classmates’ posts. Provide a substantive .docxmichael591
Review several of your classmates’ posts. Provide a substantive response to at least two of your peers in a minimum of 300 words (each reply), by Day 7 (Monday). Based on your understanding of the reading, add important information to the conversation.
How are your experiences similar to or different than those offered by your peers?
How might damage to different parts of the brain impact various processes related to sensation and perception?
Can you offer additional examples of social or cultural differences in childrearing that might impact outcomes?
Peer 1 (Jennie):
Sensation and perception both play a significant role in the sensory of how our brain functions. Perception is the way individuals see things or situations. Viewpoints may vary based on several things, including one’s environment, culture, traditions, and senses. That is when sensations come into play; seeing, touching, hearing, tasting, and feeling are all part of our sensory system. As mentioned by LeFrançois (2020), “Strictly speaking,
sensation
is the immediate response of our senses to sensory stimulation;
perception
is the brain’s interpretation of the signals it receives from its various sensory systems” (chapter 3.1).
Human development includes a variety other than just genes and science. Erik Erikson is a psychologist who has been examining the interaction between genes (nature) and environment (nurture). Different backgrounds impact nutrition and physical development because not every child is raised in similar homes. One household can have customs of bike riding every night and include full servings of vegetables in every meal. Another house might have movie night along with a full bar of snacks and treats on the daily. The nutritional and physical development of the children in each household will be different because of the home environment. Social development is affected by childcare arrangements, culture, and traditions of the parents. The movie
Babies
[Streaming video], demonstrates how culture is a part of this development and precisely how nurture is the primary variable. When it comes to parenting styles and emotional development, the main thing to consider is the parent’s childhood. There are four categories into which parents fall under, each one having a different impact on how children emotionally develop. The different styles are; autonomous, usually, have securely attached children. There is dismissing and preoccupied parents, who typically have insecurely attached children, and unresolved who likely manifest disorganized-disoriented attachment. This development is influenced by both nature and nurture but develops positively or negatively depending on the child’s environment.
The relationship between perception and development is affected by one’s environment, family beliefs, and the way they demonstrate affection. As mentioned in the
Parental ethnotheories of children’s learning
(2010) book, “Features of childhood such as the lon.
Review Public Relations and Social Media Deliberate or Creative S.docxmichael591
Review
Public Relations and Social Media: Deliberate or Creative Strategic Planning
. After reading this article and identifying challenges associated with social media, discuss how organizations can use social media to effectively communicate with internal and external target audiences. Reflect on your own professional experience with social media, and consider the following questions in your response:
How can organizations build trust through social media, both internally and externally?
How can social media be used to address public relations issues?
How can social media be used to support the culture, strategic vision, values, and/or mission of the organization?
.
Review Doing the Right Thing,” in Chapter 5 of Managing the P.docxmichael591
Review “Doing the Right Thing,” in Chapter 5 of
Managing the Public Sector
.
A partial list of large-scale governmental planning activities would have to include at least the following:
Planning for the conservation and use of natural resources.
City planning.
Planning for full employment.
Planning for personal and family security.
Planning for agriculture.
Planning for the improvement of government organization.
Provide one example from the case that addresses one of the planning activities.
Review “Robin Hood,” in Chapter 5 of
Managing the Public Sector
.
The story stated that the source of revenue (the rich) was dwindling because the rich were avoiding the forest. Robin considered increasing revenue by assessing a fixed transit tax.
Recommend a contingency plan to increase revenue that would allow Robin Hood to stay true to his mission. Comment on the use and importance of contingency plans by public administrators. Provide an example to illustrate.
.
Review Questions1. What is DNA Where is it found2. Wha.docxmichael591
Review Questions
1.
What is DNA? Where is it found?
2.
What is mitochondrial DNA?
3.
What is CODIS? How does it work?
4.
What are complimentary base patterns? Why are they important?
5.
What is RFLP? What are some of the limitations of this technique?
Critical Thinking Questions
1.
Why do you think DNA has had such an impact on forensic science?
2.
What do you think would be some of the challenges in collecting DNA evidence? How would you overcome these challenges?
3.
Compare and contrast nuclear DNA with mitochondrial DNA. Which one would you want to use in a criminal investigation if you had the choice?
4.
Which of the DNA typing techniques do you think you would choose if you had to analyze a DNA sample? Why?
5.
What challenges do you think giving expert testimony about DNA would have? How would you try to overcome these challenges?
.
Review Public Relations and Social Media Deliberate or Creati.docxmichael591
Review
Public Relations and Social Media: Deliberate or Creative Strategic Planning
. After reading this article and identifying challenges associated with social media, discuss how organizations can use social media to effectively communicate with internal and external target audiences. Reflect on your own professional experience with social media, and consider the following questions in your response:
How can organizations build trust through social media, both internally and externally?
How can social media be used to address public relations issues?
How can social media be used to support the culture, strategic vision, values, and/or mission of the organization?
.
Review in 400 words or more the video above called Cloud Security My.docxmichael591
Review in 400 words or more the video above called Cloud Security Myths.
Use at least three sources. Include at least 3 quotes from your sources enclosed in quotation marks and cited in-line by reference to your reference list. Example: "words you copied" (citation) These quotes should be one full sentence not altered or paraphrased. Cite your sources.
Stand alone quotes will not count toward the 3 required quotes.
Write in essay format not in bulleted, numbered or other list format.
.
Review of Business Information Systems – Fourth Quarter 2013 V.docxmichael591
Review of Business Information Systems – Fourth Quarter 2013 Volume 17, Number 4
2013 The Clute Institute Copyright by author(s) Creative Commons License CC-BY 159
Dimensions Of Security Threats In Cloud
Computing: A Case Study
Mathew Nicho, University of Dubai, UAE
Mahmoud Hendy, University of Dubai, UAE
ABSTRACT
Even though cloud computing, as a model, is not new, organizations are increasingly
implementing it because of its large-scale computation and data storage, flexible scalability,
relative reliability, and cost economy of services. However, despite its rapid adoption in some
sectors and domains, it is evident from research and statistics, that security-related threats are the
most noticeable barrier to its widespread adoption. To investigate the reasons behind these
threats, the authors used available literature to identify and aggregate information about IS
security threats in cloud computing. Based on this information, the authors explored the
dimensions of the nature of threat by interviewing a cloud computing practitioner in an
organization that uses both the private and public cloud deployment models. From these findings,
the authors found that IS security threats in cloud computing must be defined at different levels;
namely, at the business and technical level, as well as from a generic and cloud-specific threat
perspective. Based on their findings, the authors developed the Cloud Computing Threat Matrix
(CCTM) which provides a two-dimensional definition of threat that enables cloud users to fully
comprehend the concerns so that they can make relevant decisions while availing cloud computing
services.
Keywords: Cloud Computing; Security; Cloud Security Issues Taxonomy; Threat Matrix
INTRODUCTION
ecause a cloud is a collection of inter-connected and virtualized computers (Buyya et al., 2008), the
main enabling technology for cloud computing is virtualization. The basic concept of cloud is based
on the premise that instead of having selected information systems (IS) resources, such as software
and data stored locally on a user’s or organization’s computer systems, these resources can be stored on Internet
servers, called “clouds,” and accessed anytime, anywhere as a paid service on the Internet. Cloud computing has the
potential to bring significant benefits to small- and medium-sized businesses by reducing the costs of investment in
information communication technology (ICT) infrastructure because it enables the use of services, such as
computation, software, data access, and storage by end-users, without the need to know the physical location and
configuration of the system that delivers the services (Mujinga & Chipangura, 2011). However, it has been stated
that organizations adopt cloud computing projects and systems cautiously while maximizing benefits and
minimizing risks (Lawler, Joseph, & Howell-Barber, 2012). Cloud computing is expected to play .
Review of a Bill AssignmentState FloridaSelect an active bil.docxmichael591
Review of a Bill Assignment
State Florida
Select an active bill at the state or federal level that impacts the professional practice of nursing. In a 4 pages paper (excluding the title and reference pages), summarize the provisions of the bill and clearly explain what the bill will accomplish. The paper should be no more than 4 pages, typed in Times New Roman using 12-point font, and double-spaced with 1" margins.
Your review of a bill paper should:
Discuss the major provisions of the bill.
Demonstrate an in-depth understanding of the legislation by explaining the background and all relevant facts.
Discuss any relevant history related to the legislation, pertinent votes, and issues that are stalling the legislation, etc.
Use primary sources for this information.
Identify key supporters and those who do not support the bill. Explain why some of these individuals support the bill and why some do not.
Explore the positions of the key stakeholders in the bill, both pros and cons. Do not make assumptions about potential key stakeholders. Examine this area carefully so you are correctly reflecting the stakeholders positions.
Discuss how the bill would impact a nurse’s ability to provide safe and quality care or to practice to the highest scope of the nursing license.
Explain specific actions that nurses can take to assist with the passage or defeat of the legislation
Use each bulletin as a heading
Use APA format, headings and references as appropriate.
.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
How to Create Map Views in the Odoo 17 ERPCeline George
The map views are useful for providing a geographical representation of data. They allow users to visualize and analyze the data in a more intuitive manner.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
REVIEW Open AccessWhat happens after treatment Asystema.docx
1. REVIEW Open Access
What happens after treatment? A
systematic review of relapse, remission, and
recovery in anorexia nervosa
Sahib S. Khalsa1,2*, Larissa C. Portnoff3, Danyale McCurdy-
McKinnon4 and Jamie D. Feusner5
Abstract
Background: Relapse after treatment for anorexia nervosa (AN)
is a significant clinical problem. Given the level of
chronicity, morbidity, and mortality experienced by this
population, it is imperative to understand the driving forces
behind apparently high relapse rates. However, there is a lack of
consensus in the field on an operational definition
of relapse, which hinders precise and reliable estimates of the
severity of this issue. The primary goal of this paper
was to review prior studies of AN addressing definitions of
relapse, as well as relapse rates.
Methods: Data sources included PubMed and PsychINFO
through March 19th, 2016. A systematic review was
performed following the PRISMA guidelines. A total of (N =
27) peer-reviewed English language studies addressing
relapse, remission, and recovery in AN were included.
Results: Definitions of relapse in AN as well as definitions of
remission or recovery, on which relapse is predicated,
varied substantially in the literature. Reported relapse rates
ranged between 9 and 52%, and tended to increase
with increasing duration of follow-up. There was consensus that
2. risk for relapse in persons with AN is especially
high within the first year following treatment.
Discussion: Standardized definitions of relapse, as well as
remission and recovery, are needed in AN to accelerate
clinical and research progress. This should improve the ability
of future longitudinal studies to identify clinical,
demographic, and biological characteristics in AN that predict
relapse versus resilience, and to comparatively
evaluate relapse prevention strategies. We propose standardized
criteria for relapse, remission, and recovery, for
further consideration.
Keywords: Anorexia nervosa, Treatment, Outcome, Relapse,
Remission, Recovery, Prevention, Eating disorder,
Bulimia nervosa
Plain English Summary
Relapse occurs frequently in individuals receiving treat-
ment for anorexia nervosa. However, there is no com-
mon agreement on how to define relapse. In this study,
we reviewed previous studies of relapse, remission, and
recovery following treatment for anorexia nervosa. We
found that there were many different definitions for
these terms, which resulted in different estimates of re-
lapse rate. To understand what drives relapse it is
important to have a consistent definition across studies.
To help this discussion we propose common criteria for
relapse, remission, and recovery from anorexia nervosa.
Background
Anorexia nervosa (AN) is a serious psychiatric illness
with amongst the highest mortality rates of any mental
disorder—up to 18% in long-term follow-up studies [1–
3]. Most cases emerge during adolescence, and tend to-
4. upwards of 50% relapse within the first year after suc-
cessful hospital treatment [8]. The current lack of robust
and reliable responses to treatment highlights the need
for an improved ability to predict illness trajectories.
The primary focus of this review is on how relapse is
defined following treatment for AN. Since relapse is typ-
ically defined relative to recovery and remission, we also
consider how recovery and remission are defined. Pike
has previously eloquently reviewed relapse, recovery, re-
mission, and response in AN [8]. However, since then 11
studies have addressed this topic. The current review
therefore incorporates these additional publications.
In preparing this review, a lack of clarity and uniform-
ity with regard to how to best define relapse, recovery,
and remission was apparent. This perspective is rein-
forced by a literature review of remission in eating disor-
ders concluding that the definitions and associated rates
vary considerably [9]. Fifteen years ago, a European col-
laboration of experts (COST Action B6) adapted defini-
tions for relapse, recovery, partial and full remission, and
recurrence from the depression literature to AN and bu-
limia nervosa (BN) [10]. Despite rigorous consensus-
building and empirical testing of 233 inpatients with
AN, these criteria have not been uniformly adopted by
the field. To date there are no consensus guidelines
available for clinicians or researchers at the professional
or institutional level providing standardized operational
definitions of relapse, recovery, or remission in AN. This
is limiting. A greater consensus regarding the definition
of these constructs would be of considerable benefit to
clinicians, researchers, patients, and family members, by
allowing all constituents to speak the same language.
We performed a focused review of the extant litera-
5. ture with the primary aim of examining how these
terms have been defined, in order to improve defini-
tions of relapse, recovery and remission in AN.
Reviewing relapse rates was a secondary goal. We
propose a set of standardized criteria for relapse, re-
covery, and remission from AN, which are internally
cohesive and can facilitate longitudinal assessment by
clinicians and researchers.
Methods
Search and study selection
We conducted a systematic qualitative review according
to the PRISMA guidelines, searching the PubMed and
PsychINFO databases. We used keywords for either “an-
orexia nervosa” or “eating disorders” along with “re-
lapse,” or “recovery,” or “remission.” We used an open
search procedure. We also performed the same searches
on Google Scholar to locate relevant articles that the other
search methods possibly overlooked (none were identi-
fied). Our search covered articles that were published
from 1975 to March 19th, 2016. Titles and abstracts were
evaluated and full text was reviewed for relevant stud-
ies. References sections were screened manually for add-
itional studies unidentified via database search.
Eligibility criteria
Participants had to meet ICD-10, DSM-III, IV, or 5 diag-
nostic criteria for AN for inclusion. Studies (n = 1) focus-
ing on binge eating providing relevant information
regarding relapse risk in AN or treatment outcomes of
AN were also included. Studies examining BN and AN
were included, but not those focused solely on BN (n =
2) (except for one [11] that provided treatment informa-
tion pertinent to AN binge-purge (AN-BP) subtype).
6. Omitted studies included those focused on unspecified
eating disorders (n = 2), comorbid psychiatric disorders
(n = 2), or those without clinical descriptions of relapse
or recovery (n = 3). Non-English language articles were
excluded (n = 6).
Data review and study quality assessment
Three authors (LCP, SSK, and JF) independently ex-
tracted the following data from the selected studies: first
author, publication year, country, and whether the study
was related to relapse, recovery, or remission. To evalu-
ate the quality of the studies, we performed a systematic
review of each article using the National Heart, Lung,
and Blood Institute Study Quality Assessment Tool [12].
This tool provides a rating checklist for each study type.
Three authors (LCP, DM, SSK) independently evaluated
each study according to the rating checklist, and ren-
dered a rating of “Good” or “Fair” or “Poor.” Study qual-
ity was determined by comparing ratings agreement,
with consensus required among reviewers. Discrepancies
in study quality rating were reconciled via discussion of
the individual items on the ratings checklist to arrive at
consensus agreement on the quality indicator. Disagree-
ments were resolved through discussion and consensus.
There were no biases or poor methods identified that
warranted exclusion from the review.
Results
We identified 27 studies meeting eligibility criteria (see
Fig. 1). An overview of pertinent study characteristics
and definitions of recovery/remission and relapse in AN
are listed in Tables 1 and 2. Definitions of relapse were
fundamental to understanding the reported rates in
these studies. Our review revealed widely varied defini-
tions of relapse and recovery/remission in AN. Defini-
tions of recovery and remission are reviewed first since
7. relapse is predicated upon them.
Definitions of recovery and remission
Recovery typically requires an extended period of time
during which minimal or no criteria for the disorder are
Khalsa et al. Journal of Eating Disorders (2017) 5:20 Page 2 of
12
met, whereas remission requires a shorter duration [13].
The literature can roughly be divided into articles that
(1) define remission/recovery based solely on weight
measurement, (2) define remission/recovery based solely
on symptom reports, (3) define remission/recovery
based solely on weight and symptom reports, i.e., diag-
nostic criteria available at the time. We briefly review
these studies next (Table 1 lists studies providing defini-
tions of partial remission, full remission, and recovery).
Several studies used body mass index (BMI) as the
only criterion for recovery. Cutoffs included a BMI
above 19 [14] or 20 [7, 15]. In contrast, some described
remission based solely on psychiatric symptoms. In one,
full remission was defined as an absence of all symptoms
or only “residual symptoms” for at least 12 weeks, and
partial remission was defined as a reduction of symp-
toms to a sub-diagnostic level for at least 12 weeks [16].
Adopted from the MacArthur guidelines for depression
[13], Keel et al. [17] defined full remission as a Psychi-
atric Status Rating (PSR) score of ≤2 for 8 weeks. Clau-
sen [18] used the same score for 12 weeks, and defined
partial remission as a PSR ≤3 for 12 weeks.
Other articles described outcomes in terms of body
8. weight and menstruation, using terminology such as
“good,” “intermediate,” “poor,” or “died” [19–22]. These
criteria, or modifications of them, are often referred to
as the “Morgan-Russell” criteria [19]. A later version
specified remission as weight ≥85% of ideal body weight,
regular menses, and no bingeing or purging behaviors
[23]. Modifying these criteria, recovery was later defined
as not meeting AN DSM-IV-TR criteria for a minimum
of 8 weeks [24].
Several proposed definitions included both weight and
clinical symptoms. Pike [8] defined remission as ≥90% of
ideal body weight, resumption of menses, absence of
compensatory behaviors, and Eating Disorder Examin-
ation (EDE) [25] subscales within 2 standard deviations
(SD) of normal. Recovery was defined as meeting remis-
sion criteria for at least 8 weeks. Strober et al. [4] de-
fined full recovery as the absence of all criteria for at
least 8 weeks, and partial recovery as a “good outcome”
(weight within 15% of average and normal menstruation)
from the Morgan-Russell criteria [19]. Other studies did
not have a duration criterion for the absence of symp-
toms but used the “good outcome” criteria to define re-
covery [20–22]. Stice’s Eating Disorder Diagnostic Scale
defined remission as BMI ≥17.5, regular menses, and no
subthreshold or full threshold eating disorder [26, 27].
Martin [28] defined recovered as having a global rating
scale of “excellent,” meaning an individual was >90%
ideal weight, had regular menstruation, and normal eat-
ing and social patterns. Eckert et al. [29] defined “recov-
ered” as within 15% of ideal body weight, cyclical
menses, and no significant disturbance in eating or
weight control behaviors or body image disturbance.
Kordy et al. [10] defined full recovery for restricting AN
as a BMI >19 and no extreme fear of weight gain for
9. 12 months (plus no purging and no binges for 12 months
Fig. 1 Prisma diagram
Khalsa et al. Journal of Eating Disorders (2017) 5:20 Page 3 of
12
Table 1 Definitions of recovery and remission, according to
individual studies identified by the literature search
Authors Criteria Duration Study quality
Definitions of Recovery
Martin, 1985 [28] “Excellent”: > 90% of their ideal weight,
regular
menstrual patterns, and eating and social patterns were
normal
Not specified Fair
Norring and Sohlberg, 1993 [34] “Well” defined as having no
eating disorder diagnosis
or remnants of the weight and/or shape preoccupation
Not specified Good
Eckert et al., 1995 [29] ≥85% of ideal body weight, cyclical
menses, and no
significant disturbance in eating or weight control
behavior or body image disturbance
Not specified Good
10. Strober et al., 1997 [4] Free of all criterion symptoms of
anorexia nervosa or
bulimia nervosa
8 weeks Good
Fichter and Quadflieg, 1999 [21] Outcome “good” defined using
Morgan-Russell criteria Not specified Fair
Pike, 1998 [8] ≥90% of ideal body weight or BMI ≥20,
resumption of
menses, absence of binge eating or compensatory
behaviors, Eating Disorder Examination subscales within
2 SD of normal
8 weeks Fair
Herzog, et al., 1999 [32] Absence of all symptoms or 1–2
residual symptoms—
Psychiatric Status Rating (PRS) score of 1 or 2
8 weeks Good
Lowe et al., 2001 [22] Outcome “good” defined using Morgan-
Russell and PSR 1 Not specified Good
Kordy et al., 2002 [10] AN-R: BMI > 19, no extreme fear of
weight gain
AN-BP: BMI > 19, no extreme fear of weight gain, no
vomiting or laxative abuse, no binges
12 months Good
Carter et al., 2004 [15] BMI above 20 Not specified Good
Walsh et al., 2006 [14] BMI above 19 No information Good
11. Eisler et al., 2007 [20] Outcome “good” defined using Morgan-
Russell criteria Not specified Good
Bodell and Mayer, 2011 [24] No DSM–IV criteria of AN 8
weeks Fair
Bardone-Cone et al., 2010 [30] Full recovery: BMI ≥ 18.5,
absence of binge-eating,
purging or fasting for at least 3 months, not meeting
criteria for current eating disorder, all EDE-Q subscales
within 1 SD of normal
Partial recovery: same as above, but not needing to
satisfy EDE-Q criterion
Not specified Good
Carter et al., 2012 [7] BMI of 20 and reported no more than one
BP episode
before the end of treatment.
2 weeks BMI and no BP
behaviors over the previous
28 days at the end of treatment
Good
Definitions of Full Remission
Morgan and Hayward, 1988 [23] ≥85% of ideal body weight,
regular menses, and no
binge eating or purging behaviors
Not specified Fair a
Pike, 1998 [8] ≥90% of ideal body weight or BMI ≥20,
12. resumption of
menses, absence of binge eating or compensatory
behaviors, EDE subscales within 2 SD of normal
Not specified Fair
Stice et al., 2000 [27] BMI ≥17.5, regular menses, and no
current
subthreshold or full threshold eating disorder
Not specified Good a
Kordy et al., 2002 [10] AN-R: BMI > 19, no extreme fear of
weight gain
AN-BP: BMI > 19, no extreme fear of weight gain, no
vomiting or laxative abuse, no binges
12 weeks Good
Keel et al., 2005 [17] Absence of all symptoms or 1–2 residual
symptoms—PSR score ≤2
8 weeks Good
Clausen, 2008 [18] PSR score ≤2 12 weeks Good
Helverskov et al., 2010 [16] Absence of all symptoms/1–2
Residual symptoms—PSR
score of 1 or 2
12 weeks Good
Khalsa et al. Journal of Eating Disorders (2017) 5:20 Page 4 of
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13. Table 1 Definitions of recovery and remission, according to
individual studies identified by the literature search (Continued)
Definitions of Partial Remission
Lowe et al., 2001 [22] Outcome “improved” defined using
Morgan-Russell
criteria and PSR 2, 3, or 4
Not specified Good
Kordy et al., 2002 [10] AN-R: BMI > 17.5
AN-BP: BMI > 17.5 in addition to ≤1 binge per week
and no vomiting or laxative abuse
4 weeks Good
Clausen, 2008 [18] PSR score ≤3 12 weeks Good
Helverskov et al., 2010 [16] PSR score of 3 12 weeks Good
a No NHLBI systematic criteria available to rate this study
type; quality rating reflects consensus agreement between two
rater assessments
Table 2 Definitions of relapse, according to individual studies
identified by the literature search
Authors Criteria Duration Study quality
Definitions of Relapse
Isager et al., 1985 [33] Loss of ≥15% of weight acquired during
course of
treatment (if resulting in weight ≤50 kg)
14. Any point in time within a 1 year
period
Good
Martin, 1985 [28] If the patient required further psychiatric
treatment
after discharge during follow–up period
Not specified Fair
Norring and Sohlberg, 1993 [34] “Ill” defined as having an
eating disorder Not specified Good
Eckert et al., 1995 [29] Loss of ≥15% of average body weight
(based on
Metropolitan Height-Weight Chart, 1959), after
achieving normal body weight
Any point after achieving normal
weight during inpatient treatment
or the follow up period
Good
Strober et al., 1997 [4] Full (“syndromal”) relapse: weight
<85% of ideal body
weight and recurrence of psychological symptoms
Partial (“subsyndromal”) relapse: recurrence of psycho-
logical symptoms but ≥85% of ideal body weight
Not specified Good
Fichter and Quadflieg, 1999 [21] Outcome “poor” defined using
Morgan-Russell criteria Not specified Fair
15. Pike 1998 [8] BMI ≤ 18.5 or weight ≤85% of ideal body weight;
a
minimum 1 SD increase on the Eating Disorder Evaluation;
loss of menstrual functioning if it has been previously
normal; increase in restriction leading to weight loss;
and possibly increased binge eating, compensatory
behavior, or associated medical problems
Not specified Fair
Herzog, et al., 1999 [32] Return to full criteria symptoms and/or
Psychiatric
Status Rating (PSR) score of 5 or 6
8 weeks following a state of full
recovery
Good
Lowe et al., 2001 [22] Outcome “poor” defined using Morgan-
Russell criteria
and PSR score of 5 or 6
Not specified Good
Kordy et al., 2002 [10] Change from partial or full remission to
full syndrome
according to DSM-IV
Not specified Good
Carter, et al., 2004 [15] BMI below 17.5 and/or at least one
episode of binge
eating/purging behavior per week
3 consecutive months Good
16. Keel, et al., 2005 [17] Return to full criteria symptoms and/or
PSR score of 5 or 6 Not specified Good
Walsh et al., 2006 [14] BMI below 16.5 for 2 consecutive
weeks, or severe
medical complications, or risk of suicide, or development
of another psychiatric disorder requiring treatment
2 consecutive weeks (low BMI) Good
Eisler et al., 2007 [20] Outcome “poor” defined using Morgan-
Russell criteria Not specified Good
Clausen, 2008 [18] PSR score ≥3 3 months Good
Bodell and Mayer, 2011 [24] Poor outcome, BMI ≤18.5 (using
modified Morgan-
Russell criteria)
Not specified Fair
Helverskov, et al., 2010 [16] Return to full criteria symptoms
and/or PSR score of 5 or 6 Not specified Good
Carter et al., 2012 [7] BMI < 17.5 or at least one episode of
binge eating/
purging behavior per week
3 consecutive months Good
McFarlane et al., 2015 [31] AN: BMI < 18.5
AN-BP: average 4 episodes of bingeing and/or vomiting
per month, or BMI < 18.5
3 consecutive months Good
17. Khalsa et al. Journal of Eating Disorders (2017) 5:20 Page 5 of
12
for AN-BP). They defined full remission for both sub-
types as meeting the same criteria for 3 months. Partial
remission was a BMI >17.5 and ≤1 binge per week and
no vomiting or laxative abuse for 1 month in AN-BP.
Another proposed definition of full recovery was a BMI
≥18.5, absence of binging, purging, or fasting for at least
3 months, not meeting criteria for a current eating dis-
order, and all EDE-Questionnaire (EDE-Q) subscales
within 1 SD of normal [30]. They defined partial recov-
ery as the same without the EDE-Q criterion.
Definitions of relapse
Different definitions of relapse were identified (see
Table 2). Some definitions were dependent on weight or
BMI measures including: BMI < 16.5 for 2 weeks [14],
and BMI < 17.5 [7, 15] or <18.5 [31] for three consecu-
tive months. Other definitions included 15% loss of aver-
age body weight after achieving normal body weight,
either during the index hospitalization or any time dur-
ing the 10-year follow-up period [29]. Strober et al. [4]
similarly defined relapse as <85% ideal body weight,
which could occur post-discharge or post-recovery. Fur-
thermore, relapse could be partial if the individual had
recurrence of psychological symptoms but sustained
85% of ideal weight, or full relapse if both psychological
symptoms returned and body weight dropped to less
than 85%. Several groups [19–22, 24] defined relapse as
Morgan-Russell criteria of “poor” (BMI ≤18.5).
Other definitions of relapse were dependent on psy-
18. chiatric symptoms or a combination of psychiatric
symptoms and weight changes. Kordy et al. [10] used
a definition of change from DSM-IV partial or full re-
mission to full syndrome. Clausen [18] defined relapse
as PSR ≥ 3 or PSR ≤ 2 after 3 months remission. Re-
lapse has also been defined as meeting full syndrome
criteria (PSR ≥ 5) after 8 weeks of remission [17, 32]
and after 12 weeks of remission [16]. Pike’s [8] more
in-depth definition of relapse includes weight loss,
EDE increase, medical issues, and a return of disor-
dered eating, whereas Martin’s [28] is the simplest,
requiring only that an individual needs psychiatric
intervention.
Rates of Relapse
Relapse rates of AN were highly variable ranging from a
low of 9% to a high of 52% following treatment, with the
majority of studies reporting rates greater than 25% [4,
7, 10, 14–18, 21, 22, 24, 28, 29, 32–34]. Studies suggest
that adolescents [4, 20, 28] and individuals with restrict-
ing subtype AN [7, 29] have a lower likelihood of re-
lapse. The first year is the most critical, with particular
risk of relapse occurring as early as 3 months post-
treatment [4, 7, 15, 32]. Not surprisingly, those who re-
cover fully have lower relapse rates (9%) than those who
only partially recover (35%) [10]. Together, these results
suggest that while most patients experience brief epi-
sodes of recovery, a large proportion relapse. Moreover,
the risk is particularly high within the first year.
Follow-Up Variability
There was substantial variability in the literature for
follow-up procedures. Initial evaluation time points
ranged from 4 weeks to 17 months post-treatment [4, 7,
14, 15, 17, 20, 28, 32, 35]. Some studies utilized only a
19. single follow-up time point [15, 28], whereas others
followed patients across multiple time points [4, 7, 14,
17, 20, 32, 35]. Some studies had regular follow-up visits
(e.g., every 4 weeks [14], 3 months [7]), whereas others
had irregularly spaced follow-ups (e.g., 2, 6 and 12 year
follow up [35]).
Variable follow-up intervals could complicate estima-
tions of relapse rates, since relapse rates can vary by dur-
ation of the study follow-up. According to this view,
shorter follow-up durations might be associated with
lower relapse rates than longer durations. We identified
articles supporting this possibility. For example, relapse
in a study measuring at 6 months was lower (9% for fully
recovered and 35% for partially recovered) [10] versus
studies measuring at 1-year (27–70%) [7, 14] (see
Table 3). Relapse rates also varied by remission criteria,
with stricter remission criteria displaying lower relapse
rates than less stringent criteria. This is evidenced by
two 10-year longitudinal studies. Eckert and colleagues
[29] reported higher relapse rates (42%) with less strin-
gent relapse criteria and Strober and colleagues [4] re-
ported lower relapse rates (29.5%) with stricter relapse
criteria.
Discussion
The main finding of this review is that there are almost
as many definitions of relapse, remission, and recovery
as there are studies of them. To help rectify this state of
affairs, we suggest that the eating disorders research and
clinical communities evaluate, test, and ultimately adopt
standardized definitions for relapse, remission, and re-
covery. Depression [13], bipolar disorder [36], and
schizophrenia [37] researchers already utilize standard-
ized definitions of these constructs. Consensus guide-
lines for response, partial response, remission, recovery,
20. and relapse in obsessive compulsive disorder were also
recently proposed [38]. However, we could identify no
such definitions for AN across organizational websites,
including: the Academy for Eating Disorders, Eating Dis-
orders Research Society, National Eating Disorders As-
sociation, and the European Council on Eating
Disorders.
Standardizing how relapse and recovery are defined in
research could substantially improve our understanding
Khalsa et al. Journal of Eating Disorders (2017) 5:20 Page 6 of
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T
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78. of the pathophysiology of AN and help ground studies
of efficacy and effectiveness, as argued previously [39,
40]. Consensus would increase the quality of meta-
analytic studies. It would facilitate multi-site compari-
sons, which are necessary to improve statistical power for
studying this relatively rare condition. Precise and consist-
ent terminology would also enhance communication
amongst researchers, clinicians, and caregivers.
We propose a unifying framework with potential defi-
nitions for recovery, remission, and relapse to energize
the discussion (see Fig. 2). These definitions are intern-
ally logical, consistent, and conducive to longitudinal
assessment of AN. We advocate the adoption of stan-
dardized definitions for partial and full recovery and
partial and full relapse. DSM-5 defines partial and full
remission, but not partial or full recovery, and the dur-
ation requirement is vague (“a sustained period”) [41].
We propose that definitions of relapse in AN should en-
compass both clinical symptoms and signs such as BMI
measures,1 as has been proposed for definitions of re-
covery [42], to more comprehensively capture the dis-
order. Importantly, our suggested criteria for recovery,
remission, and relapse include objective measures (BMI;
observable behaviors of restricting, binging, and pur-
ging), subjective measures (fear of gaining weight, dis-
turbance of body image), standardized ratings (EDE),
and specific durations of follow-up (1, 3, 6, and
12 months) that are conducive to utilization across both
clinical and research settings (see Fig. 3).
It is worth noting that the proposed approach shares
79. certain similarities with previous efforts to identify pat-
terns of recovery in AN. For example, the Psychiatric
Status Rating (PSR) scale represented a single six-item
clinician rating based on DSM-III criteria [43]. Lower
scores on this scale, such as a 1, indicated ‘usual self’ or
the absence of meeting diagnostic criteria, whereas
higher scores, such as a 6, indicated presence of ‘definite
criteria, severe.’ The PSR is similar to our proposed
Fig. 2 Proposed standardized definitions of relapse, remission,
and recovery. These standardized definitions were synthesized
from the different
criteria for relapse, remission, and recovery in individual
studies identified by our systematic review. We include a
graphical representation of
these definitions as a useful heuristic tool for conceptualizing
the major transition points (relapse in red, remission in yellow,
recovery in green)
while at the same time underscoring the continuum of pathology
existing within each stage. Note 1: since weight and height
normally increase
until age 20 in pediatric and adolescent populations, age- and
gender- adjusted BMI percentiles for determining expected body
weight (EBW) are
more appropriate in these subgroups, as demonstrated by [52].
Note 2: determination of ideal body weight is complex, and
subject to consideration
of racial, ethnic, demographic, and cultural factors [53]. Note 3:
Symptoms and behaviors are discrete variables, which are
rated/ascertained by the
clinician based on all available clinical information
Khalsa et al. Journal of Eating Disorders (2017) 5:20 Page 8 of
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80. approach in the sense that both require clinician ratings,
and both load upon features of AN that are relevant to
diagnostic criteria in terms of weight status, symptom
burden, and ongoing behaviors. However, our proposed
criteria diverge principally with respect to (1) a focus on
defining stages of relapse, remission, and recovery, (2)
reliance upon a standardized and clinically validated
interview (EDE), and (3) utilization of terminology (par-
tial or full relapse, partial or full remission, partial or full
recovery) that are transparent and can be utilized uni-
formly with patients, caregivers, and clinicians. Our EDE
cutoff selection for partial relapse (greater than or equal
to 2 SD below normal) is also consistent with the ‘cutoff
point a,’ which as previously suggested by Jacobsen et al.
[44], represents a conservative and stringent approach to
determining clinically significant changes.
Due to the highest risk of relapse being in the first
year [4, 17, 20, 32, 33] and relapse often occurring as
early as 3 months post-treatment [4, 7, 15, 32], we rec-
ommend that longitudinal studies conduct follow up as-
sessments no less than every 3 months for the first year,
and every 6 months thereafter for longer studies. With-
out standardized definitions, a refined understanding of
the specific outcomes posed by putative risk factors, and
guidance on measurement, we are in danger of adding
more variability to this literature. Clinically, standardized
definitions for relapse, remission and recovery, com-
bined with consistent monitoring, would help provide
consistent and relevant feedback to patients and family
members regarding their level of risk.
There are several important limitations to consider
when interpreting this review. There is an inherent diffi-
culty identifying the true risk factors predicting AN re-
81. lapse given the disparate definitions of relapse and
recovery provided to date, potentially giving our review
the appearance that it is challenged by a lack of synthe-
sis. We argue that this challenge is precisely what future
studies would overcome by adopting and adhering to
one set of standards. Secondly, our interpretations are
restricted to the somewhat obvious conclusions that AN
is: (1) characterized by high relapse rates, (2) that re-
lapse rates increase with follow-up lengths, and (3)
there are few reliable predictors. While it seems nearly
impossible to glean generalizations from such hetero-
geneous findings, this highlights the necessity for con-
sensus and standardized definitions. It is important to
emphasize that while the current review has focused
on AN, based in part, on our own research efforts, we
believe that similar consensus standards are needed for
other eating disorders such as bulimia nervosa, binge
eating disorder, and unspecified eating disorder. Al-
though advancing such definitions are beyond the
scope of our qualitative review, we hope that highlight-
ing this disparity will provoke further discussion and
progress. Finally, adding a meta-analytic approach
could derive ‘quantitative data’ characterizing out-
comes, but at this point, would not be additively in-
formative given the aforementioned limitations. This
approach would be useful for a future analysis of ag-
gregated studies using uniform definitions.
Fig. 3 Illness trajectories across a 2 year time period for three
hypothetical individuals with AN exhibiting different illness
courses. One individual
with an uncomplicated course shows a consistent transition from
full relapse to full remission to full recovery. Another
individual shows a complicated
course marked by partial remission, partial relapse, and partial
recovery, followed by a decline to full remission. A third
82. individual shows a complicated
course with no recovery marked by intermittent bouts of full
relapse punctuated by partial relapse and partial remission. For
an analogous depiction of
illness trajectory based on actual patients, see Kordy et al., [10]
Khalsa et al. Journal of Eating Disorders (2017) 5:20 Page 9 of
12
The value of reaching consensus
It will be important to carefully consider the value of
reaching consensus on definitions of relapse, remission,
and recovery, who will benefit, and how a consensus
would be best achieved. It is hard to imagine a lasting
consensus without the support of eating disorder organi-
zations. These include organizations which are science-
oriented (e.g., Eating Disorder Research Society (EDRS)
[45], Academy for Eating Disorders (AED) [46] Euro-
pean Council on Eating Disorders (ECED) [47]),
clinician-oriented (AED, National Eating Disorders As-
sociation (NEDA) [48], and International Association of
Eating Disorders Professionals (IAEDP) [49]), and pa-
tient and caregiver-oriented (e.g., Families Empowered
and Supporting Treatment of Eating Disorders (FEAST)
[50], National Alliance on Mental Illness (NAMI) [51],
AED, and NEDA).
It is also necessary to prospectively consider the po-
tential challenges to achieving a consensus. In this
regard, the highly interdisciplinary perspectives required
in the research and treatment of eating disorders
(pediatrics, family medicine, psychiatry, psychology, nu-
trition and dietetics, social work, licensed therapy and
counseling, and nursing) results in complex and often
83. diverging multifactorial models, which risks a fracturing
of consensus regarding these conditions.
Concrete suggestions for harmonizing this discussion
include (1) the development of conference symposia, (2)
cross-organization workgroups or task forces, and (3)
the generation of consensus statements focused on the
topic. Other practical considerations include feasibility
assessments. For example, follow up frequency will al-
ways be of concern, and conducting monthly, quarterly,
and perhaps even bi-annual follow-ups requires re-
sources that may be infeasible for certain research
groups. We would argue that follow up assessment oc-
curring at any frequency should use a standardized ap-
proach that is comparable to other laboratories. In-
person assessments might be supplemented by phone in-
terviews, and/or the remote collection of collateral infor-
mation from family members, and we observed evidence
of this pragmatic approach in the literature surveyed in
this paper.
Conclusion
The heterogeneity and severity of AN presentation poses
challenges to understanding why relapse occurs, and
how to prevent it. We posit that the eating disorders
community will benefit from considering, testing, and
adopting standardized definitions for relapse, remission,
and recovery. To galvanize this movement, we have
attempted to provide a unifying framework with internally
logical and consistent definitions. This framework is con-
ducive to longitudinal clinical and research assessment,
not only for AN, but for bulimia nervosa, binge eating dis-
order, unspecified eating disorder, and other eating disor-
ders. Without consensus, uncertainty and variability in the
reported recovery, remission, and relapse rates will persist.
84. Standardizing definitions in AN is a critical first step in
identifying at-risk individuals, and can ultimately advance
the development and evaluation of treatments for this life-
threatening illness.
Endnotes
1Since weight and height normally increase until age
20 in pediatric and adolescent populations, age- and
gender- adjusted BMI percentiles for determining ex-
pected body weight (EBW) are more appropriate in
these subgroups (see Le Grange et al., [52]).
Abbreviations
AN: Anorexia nervosa; BMI: Body mass index; BN: Bulimia
nervosa;
DSM: Diagnostic and statistical manual of mental disorders;
EDE: Eating
Disorder Examination; EDNOS: Eating disorder not otherwise
specified;
PSR: Psychiatric Status Rating
Acknowledgments
We would like to thank Michael Strober for helpful discussions
and
comments on the manuscript, Courtney Sheen for administrative
support
with performing the literature review, and Francesca Morfini for
assistance
with manuscript retrieval.
Funding
This research was supported by NIMH grant numbers
R01MH093535 and
R01MH105662 to Jamie D. Feusner, and by NIMH grant number
K23MH112949 to Sahib S. Khalsa. Dr. Khalsa also received
85. support from The
William K. Warren Foundation and a NARSAD Young
Investigator Award.
Availability of data and materials
This review paper was developed on previously published data
that can be
obtained from the original source studies.
Authors’ contributions
JDF, LCP and SSK conceived the research idea, SSK, LCP, DM
and JDF drafted
and edited the manuscript. All authors have read and approved
the final
manuscript before submission.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable
Ethics approval and consent to participate
Not applicable
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional
claims in
published maps and institutional affiliations.
Author details
1Laureate Institute for Brain Research, 6655 S Yale Ave, Tulsa,
OK 74136, USA.
2Oxley College of Health Sciences, The University of Tulsa,
1215 South
Boulder Ave W, Tulsa, OK 74119, USA. 3Department of
86. Clinical Psychology,
Teachers College, Columbia University, 525 W 120th St, New
York, NY 10027,
USA. 4Department of Pediatrics, The University of California
Los Angeles, 757
Westwood Plaza, Los Angeles, CA 90095, USA. 5Department of
Psychiatry and
Biobehavioral Sciences, The University of California Los
Angeles, Semel
Institute of Neuroscience and Human Behavior, 760 Westwood
Plaza, Los
Angeles, CA 90024, USA.
Khalsa et al. Journal of Eating Disorders (2017) 5:20 Page 10
of 12
Received: 28 January 2017 Accepted: 19 April 2017
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97. reliability of a structured interview for diagnostic assessment
of DSM-5 somatic symptom disorder and illness anxiety
disorder
Erland Axelssona, Erik Anderssona, Brjánn Ljótssona, Daniel
Wallhed Finnb and Erik
Hedmana,c
aDivision of psychology, Department of Clinical neuroscience,
Karolinska institutet, Stockholm, Sweden;
bCapio psykiatri nacka, Stockholm, Sweden; cosher Center for
integrative Medicine, Department of Clinical
neuroscience, Karolinska institutet, Stockholm, Sweden
Introduction
The fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5;
American Psychiatric Association, 2013) has introduced several
revisions of its predecessor
(DSM-IV; American Psychiatric Association, 2000). One is that
the DSM-IV somatoform
disorders, including hypochondriasis and somatization disorder,
have been abandoned.
There were multiple reasons for this. The somatoform disorders
were considered difficult to
understand, and—despite their narrow criteria—showed a
tendency to overlap (Dimsdale
et al., 2013). Additionally, a common view was that these
disorders overemphasized the
presence of medically unexplained symptoms, i.e. that a medical
explanation for the patient’s
symptoms had to be ruled out for a psychiatric diagnosis to be
made (Dimsdale et al., 2013).
This praxis drew an unnecessarily sharp line between “medical”
and “psychiatric” patients.
98. ABSTRACT
Somatic symptom disorder (SSD) and illness anxiety disorder
(IAD)
are two new diagnoses introduced in the DSM-5. There is a need
for
reliable instruments to facilitate the assessment of these
disorders.
We therefore developed a structured diagnostic interview, the
Health
Preoccupation Diagnostic Interview (HPDI), which we
hypothesized
would reliably differentiate between SSD, IAD, and no
diagnosis.
Persons with clinically significant health anxiety (n = 52) and
healthy
controls (n = 52) were interviewed using the HPDI. Diagnoses
were
then compared with those made by an independent assessor,
who
listened to audio recordings of the interviews. Ratings generally
indicated moderate to almost perfect inter-rater agreement, as
illustrated by an overall Cohen’s κ of .85. Disagreements
primarily
concerned (a) the severity of somatic symptoms, (b) the
differential
diagnosis of panic disorder, and (c) SSD specifiers. We
conclude that
the HPDI can be used to reliably diagnose DSM-5 SSD and
IAD.
KEYWORDS
health anxiety; illness
anxiety disorder; reliability;
somatic symptom disorder;
somatization
99. ARTICLE HISTORY
received 24 november 2015
accepted 1 March 2016
CONTACT erland axelsson [email protected]
Supplemental data for this article can be accessed here
http://dx.doi.org/10.1080/16506073.2016.1161663
mailto:[email protected]
http://dx.doi.org/10.1080/16506073.2016.1161663
260 E. AxELSSon ET AL.
As a result, some diagnosed with a somatoform disorder (e.g.
hypochondriasis) took offense
at their somatic symptoms “being all in their head” (American
Psychiatric Association,
2013; Dimsdale et al., 2013). It was also hard for clinicians to
determine how many medical
tests were necessary for a somatoform diagnosis (Dimsdale et
al., 2013). These difficulties
were likely among the reasons why the somatoform disorders
were seldom diagnosed in
clinical practice (American Psychiatric Association, 2013;
Dimsdale et al., 2013; Rief &
Martin, 2014).
The DSM-IV somatoform disorders have now been replaced
with the DSM-5 somatic
symptom and related disorders. Of these, somatic symptom
disorder (SSD) and illness
anxiety disorder (IAD) are likely to be most commonly
diagnosed (American Psychiatric
Association, 2013). In SSD the patient has (A) at least one
100. somatic symptom (e.g. a local-
ized pain) that causes significant distress or functional
impairment. Related to the patient’s
somatic symptoms is an excessive psychological reaction,
involving either (B1) dispro-
portionate interpretations of the somatic symptoms, (B2)
anxiety about health or somatic
symptoms, (B3) excessive time and energy devoted to health or
somatic symptoms, or a
combination of these B criteria. Although it is not necessary
that one and the same somatic
symptom is continuously present, (C) the state of being
symptomatic has to have been
persistent (“typically [for] more than 6 months”; American
Psychiatric Association, 2013).
There are three specifiers for SSD. The (I) with predominant
pain specifier is given when
the patient’s somatic symptoms primarily involve pain. The (II)
persistent specifier is given
in the case of severe symptoms, marked impairment, and a
duration longer than 6 months.
The (III) current severity specifier can be defined as either
mild, moderate, or severe. Mild
implies that only one B criterion (B1, B2, or B3) is fulfilled,
moderate means that at least
two B criteria are fulfilled, and severe means that at least two B
criteria are fulfilled and
that there are either numerous somatic complaints or one very
severe somatic symptom.
The core criterion of illness anxiety disorder (IAD) is (A) “a
preoccupation with having
or acquiring a serious illness” (American Psychiatric
Association, 2013). There are (B) no
or only mild somatic symptoms, and if the patient is likely to
101. develop a medical condition,
his or her preoccupation with health has to be excessive. The
patient has (C) a high level
of health-related anxiety and is easily worried about his or her
health. Due to this fear, (D)
the patient displays excessive health-related behaviors, such as
repeated symptom-checking
or avoidance of doctor visits. The (E) health preoccupation has
been present for at least
six months and is (F) not better explained by another
psychiatric syndrome. IAD may be
specified as care-seeking type (indicating frequent use of
medical care) or care-avoidant type
(indicating rare use of medical care).
In contrast to the DSM-IV somatoform disorders, the criteria of
SSD and IAD do not
require that the patient’s somatic symptoms are medically
unexplained. Even if the somatic
symptoms that are central to the health preoccupation are
explained by a somatic disease,
the patient may be given a diagnosis of SSD or IAD under the
condition that the patient’s
response to his or her somatic symptoms is significant and
excessive. A patient with recur-
rent dizziness due to poorly managed diabetes might for
example be given a diagnosis of SSD
if the dizziness is coupled with a persistent and disproportional
fear of multiple sclerosis.
Although both SSD and IAD involve a preoccupation with
health, there are also three
important differences between these disorders. Firstly, SSD
presupposes at least one somatic
symptom (medically explained or not), which leads to
significant distress or disruption of
102. daily life. In contrast, IAD is given when there are no, or only
minimal, somatic symptoms
CognITIvE BEHAvIouR THERAPy 261
related to the health preoccupation. Secondly, whereas IAD
requires health anxiety (defined
here as a fear of having or acquiring a severe illness), SSD—
strictly speaking—does not.
Thirdly, IAD—like DSM-IV hypochondriasis—requires that the
patient’s complaints have
been present for at least six months, whereas the SSD duration
criterion is more loosely
formulated.
According to the DSM-5, roughly 75% of those meeting
diagnostic criteria for DSM-IV
hypochondriasis will now be classified as having SSD, whereas
about 25% will have IAD
(American Psychiatric Association, 2013). SSD is also meant to
replace both DSM-IV som-
atization disorder, undifferentiated somatoform disorder and
pain disorder (Dimsdale et
al., 2013). Under our interpretation, a typical health anxiety
patient either has SSD or IAD,
but not a combination of the two. In the case of an enduring and
excessive fear of severe
illness, the key question is typically whether the patient’s
somatic symptoms are mild enough
to warrant a diagnosis of IAD (rather than SSD). If significant
health anxiety is coupled
with recurring somatic symptoms that are reasonably distinct,
the patient should typically
be given a diagnosis of SSD (but not IAD). In rare cases,
103. patients with significant health
anxiety might not qualify for either of the two diagnoses. This
could, for example, be the
case if the patient has a persistent fear of severe illness, but
neither somatic symptoms nor
excessive health-related behaviors.
In the DSM-5 field trials, SSD (then referred to as “complex
somatic symptom disorder
revised”) demonstrated substantial inter-rater reliability
(κ = .61), but was never assessed
together with IAD (Freedman et al., 2013). Over and above
these field trials, to our knowl-
edge, only four studies have attempted to study DSM-5 SSD
and/or IAD, but in doing so
have relied exclusively on post hoc classification based on self-
assessment questionnaires
(Bailer et al., 2016; Häuser, Bialas, Welsch, & Wolfe, 2015;
van Dessel, van der Wouden,
Dekker, & van der Horst, 2016; Voigt et al., 2012).
Since structured interviews are known to enhance the reliability
of psychiatric diagnostic
procedures (Basco et al., 2000; Grove, Andreasen, McDonald-
Scott, Keller, & Shapiro, 1981;
Kranzler et al., 1995), there is a need for reliable diagnostic
instruments to aid clinicians
in assessing new diagnoses introduced in the DSM-5. We
therefore aimed to develop and
investigate the psychometric properties of a structured interview
for DSM-5 SSD and IAD.
We hypothesized that this new interview would prove reliable in
differentiating between
SSD, IAD, and no diagnosis (ND).
Methods
104. Participants
The present study included both participants with severe health
anxiety and healthy controls
as respondents for diagnostic interviews. All respondents were
recruited via newspaper
advertisements and subsequent self-referral via the Internet. The
healthy control respond-
ents (n = 52) were compensated with two lottery tickets for their
participation. Respondents
with severe health anxiety (n = 52) were not compensated in
this manner, but instead applied
for a clinical trial of cognitive behavior therapy. Information
concerning this clinical trial
was sent to health care providers in Stockholm and Gothenburg,
Sweden. The clinical trial
had 214 applicants that were interviewed. From these applicants
we randomly selected a
262 E. AxELSSon ET AL.
sample stratified for age so that it would match the age
distribution of the healthy control
group. Participant data is presented in Table 1.
Materials
The Health Anxiety Inventory (HAI) is a well-established self-
report measure of health anx-
iety; primarily of cognitive and emotional factors associated
with DSM-IV hypochondriasis
(Salkovskis, Rimes, Warwick, & Clark, 2002). The HAI
comprises 64 items, each with a scale
105. of 4 alternatives (e.g. between “I do not worry about my
health.” and “I spend most of my
time worrying about my health.”), rendering a total HAI score
between 0 and 192. The HAI
has good psychometric properties when administered via the
Internet (Hedman et al., 2015).
The Mini-International Neuropsychiatric Interview 6 (MINI;
Sheehan et al., 1998) is
a structured diagnostic interview for the assessment of common
psychiatric disorders,
including anxiety disorders and major depressive disorder. In
the present study, diagnostic
assessments were based on all MINI modules except that for
antisocial personality disorder.
We developed the Health Preoccupation Diagnostic Interview
(HPDI) with the aim of
discriminating between DSM-5 SSD and IAD, and also to
discriminate persons with SSD
or IAD from persons without these disorders (the interview is
presented in Appendix 1).
Items for the HPDI were formulated, discussed, and revised by
clinical psychologists with
extensive experience in assessing and treating DSM-IV
hypochondriasis. A first draft of
the instrument was pilot tested in a small sample of patients
seeking help for psychiatric
disorders in the mental health department of a community health
center.
After this test phase, items were further revised to increase
accuracy and usability.
The interview finally encompassed 42 items, of which 24 were
questions to the respond-
ent and 18 to the interviewer. For each diagnostic criterion, the
106. general principle was
that the HPDI would first provide the interviewer with one or
more questions to extract
pertinent information from the respondent (e.g. “Have you
recently been worried about
having or developing a serious illness?”, “Which illnesses have
you been afraid of having
or developing?”), and then prompt the interviewer to decide if
the corresponding cri-
terion was met (e.g. “Does the patient show a preoccupation
with having or acquiring
a serious illness?”).
Table 1. Description of respondents.
Note. the p-values are based on Student’s t-test and χ²-test. Cta,
clinical trial applicants; hai, health anxiety inventory; hC,
healthy controls; iaD, illness anxiety disorder; nD, no
diagnosis; SSD, somatic symptom disorder.
aDiagnosis according to the interviewer.
Combined sample
(N = 104)
Clinical trial applicants
(n = 52)
Healthy controls
(n = 52)
CTA vs HC
age, range 18–73 20–69 18–73
age, mean (SD) 40.5 (13.1) 38.5 (12.9) 42.4 (13.1) p = .14
Female, n (%) 76 (73%) 40 (77%) 36 (69%) p = .38
107. hai, range 10–150 75–150 10–62
hai, mean (SD) 70.2 (41.6) 107.8 (21.6) 32.7 (12.1) p < .01
SSD, n (%)a 42 (40%) 42 (81%) 0 (0%)
p < .01iaD, n (%)a 7 (7%) 7 (14%) 0 (0%)
nD, n (%)a 55 (53%) 3 (6%) 52 (100%)
CognITIvE BEHAvIouR THERAPy 263
Procedure
All respondents, both clinical trial applicants and healthy
controls, completed the HAI via
the Internet. They were then asked routine clinical questions
(such as “Do you have—or
have you ever had—a somatic disease out of the ordinary?”) and
assessed for psychiat-
ric syndromes using the MINI followed by the HPDI. This was
done through telephone
interviews, which is a reliable method of diagnostic assessment
(Rohde, Lewinsohn, &
Seeley, 1997). All interviews were recorded using a digital
voice recorder with an external
telephone pick-up microphone. We then applied the procedure
of Skre, Onstad, Torgersen,
and Kringlen (1991), by which an independent assessor blind to
the diagnoses made by the
interviewer listened to the recorded interviews and, using the
HPDI, determined if patients
met diagnostic criteria for SSD or IAD.
In order to ensure that the assessor was blind to previous
108. diagnoses, the interviewer
was instructed not to inform the respondent of any diagnostic
considerations. As long as
the respondent expressed even a vague tendency to identify with
the diagnostic criteria
probed, the interviewer strived to always complete the full
HPDI, in order not to reveal
any diagnostic decisions. This included assessing most IAD
items regardless of whether an
SSD diagnosis had previously been made or not. To prevent
diagnostic ratings from being
steered by sample-related expectations (e.g. that healthy
controls would not qualify for a
diagnosis), the assessor was also blind to whether respondents
belonged to the clinical trial
applicant sample or the healthy control sample. In order to
ensure this, all audio files were
assigned randomized identification numbers and date stamps
were removed.
Both the interviewer and the assessor had access to the DSM-5
and were instructed to
consult it when needed. If the assessor required information
about the presence of comorbid
psychiatric syndromes (e.g. whether or not a certain respondent
suffered from panic dis-
order) in order to make a decision concerning the presence of
SSD or IAD, relevant results
of the MINI interview were provided (this occurred in 7 of all
104 cases).
There was also a second assessor who listened to the recorded
interviews. This assessor
proposed a combined diagnosis of SSD and IAD in 41 (39%) of
all 104 cases. Combining
SSD and IAD should only be possible in cases where (a) SSD
109. does not involve significant
health anxiety (a fear of severe illness), but rather some other
form of health preoccupation
(e.g. kinesiophobia due to pain), and (b) there is a significant
health anxiety which is either
unrelated to somatic symptoms or only coupled with mild
somatic symptoms (so that an
IAD diagnosis can be made). Since the present study involved
healthy controls and a sig-
nificantly health anxious sample, SSD unrelated to health
anxiety was expected to be rare,
and the combination of SSD and IAD therefore highly unlikely.
Since the second assessor
clearly misunderstood the DSM-5 diagnostic criteria, data from
this assessor was excluded
from further analysis but is available from the authors on
request.
After completing the reliability study, we made minor
alterations to the HPDI in order
to make it more user-friendly. SSD item 2, SSD item 8, and IAD
item 4 were somewhat
simplified, as their latter parts were made optional and put in
parentheses. We also made
clear that the follow-up question of SSD item 5 should be posed
if the patient’s somatic
symptoms are not know to be explained by a serious disease. As
SSD item 13 was rarely
understood by the respondents, the phrase “During the present
episode, how long have you
felt distressed or hindered” was changed to “How long have you
been concerned.” IAD item
9 was altered in a similar way. In order to enhance the
reliability of the SSD pain specifier,
110. 264 E. AxELSSon ET AL.
a new question was added (SSD item 14). Finally, in order to
prevent misunderstandings
similar to that of the second assessor, we added a reminder to
consider IAD in the case of
mild somatic symptoms. We think it highly unlikely that these
minor simplifications will
in any way have a negative impact on the reliability of the
instrument.
Clinicians
All telephone interviews were conducted by the same
interviewer, a resident clinical psy-
chologist with experience of conducting about 120 diagnostic
telephone interviews with
persons seeking treatment for health anxiety. The interviewer
received supervision by a
doctoral-level licensed psychologist specialized in diagnosis
and treatment of health anxiety.
The assessor whose ratings were included in the main analysis
was a psychology student
in the final year of the master level psychology program. During
the project, the assessor
periodically discussed diagnostic principles (e.g. guidelines for
differential diagnosis) with
other members of the research team. However, in order to
ensure assessment integrity,
specific cases were never mentioned.
Statistical analysis
Cohen’s κ was calculated for the inter-rater agreement on SSD
vs. IAD vs. ND cases, using
111. the SPSS version 22.0 (IBM Corp., Armonk, NY). As omnibus
reliability estimates (such
as the κ) are sometimes hard to interpret (Cicchetti & Feinstein,
1990), we also calculated
(a) the absolute number of cases agreed, (b) the percentage of
cases agreed, (c) the number
of cases agreed per class (e.g. the number of SSD diagnoses that
overlapped), and (d) the
proportion of agreed cases per class (e.g. the percentage of SSD
diagnoses that overlapped).
The latter was done by dividing the number of agreed cases
within each class (e.g. the
number of SSD diagnoses agreed on) by the mean number of
cases assigned to the class
(e.g. the total number of SSD diagnoses made by both raters,
divided by two). Such a ratio
may be thought of as a “positive predictive value” indicating
how likely a diagnosis (e.g. of
SSD) determined by one rater was to be endorsed by the other
rater. Kappa values and the
corresponding indexes of agreement were also calculated for the
inter-rater agreement on
SSD and IAD diagnostic specifiers. Verbal interpretations of
Cohen’s κ followed the cate-
gorical divisions of Landis and Koch (1977). Hence, “poor”
means κ < 0.00, “slight” means
0.00 ≤ κ ≤ 0.20, “fair” means 0.21 ≤ κ ≤ 0.40, “moderate”
means 0.41 ≤ κ ≤ 0.60, “substantial”
means 0.61 ≤ κ ≤ 0.80, and “almost perfect” means
0.81 ≤ κ ≤ 1.00.
Results
Choosing between SSD, IAD, and ND, the interviewer and the
assessor agreed in 95 (91%)
of all 104 cases. No respondent was diagnosed with both SSD
112. and IAD by the same clini-
cian. Kappa values and proportion of agreed cases are presented
in Table 2. As shown in
Table 3, agreement on diagnosis specifiers was almost perfect
concerning IAD specifiers,
moderate concerning the SSD pain specifier, and slight to fair
concerning the SSD persis-
tence and severity specifiers. Post hoc weighted κ estimates for
the severity specifier were
roughly similar.
CognITIvE BEHAvIouR THERAPy 265
With regard to diagnosis, the interviewer and the assessor
disagreed over nine cases. Five
of these were rated as SSD by the interviewer and IAD by the
assessor. This was primarily
due to disagreement about which somatic symptoms should be
considered mild enough
to permit an IAD—rather than an SSD—diagnosis. Three cases
were rated as SSD by the
Table 2. reliability estimates of inter-rater agreement on SSD,
iaD, and nD.
Note. iaD, illness anxiety disorder; nD, no diagnosis; SSD,
somatic symptom disorder.
anot applicable due to division by zero.
bnumber of cases agreed divided by the average total number of
cases per rater. in other words, the likelihood of a diagnosis
by one rater to be endorsed by the other rater (see “Statistical
analysis”).
113. Combined sample Clinical trial applicants Healthy controls
agreement, total (SSD vs. iaD vs. nD)
Cohen’s κ .85 .59 n/a a
agreed, n (%) 95 (91.3%) 43 (82.7%) 52 (100%)
Disagreed, n (%) 9 (8.7%) 9 (17.3%) 0 (0%)
agreement, positive cases
agreed SSD, n (%b) 34 (88%) 34 (88%) 0 (n/a a)
agreed iaD, n (%b) 6 (67%) 6 (67%) 0 (n/a a)
agreed nD, n (%b) 55 (97%) 3 (67%) 52 (100%)
agreement, SSD vs. non-SSD
Cohen’s κ .82 .56 n/a a
agreed, n (%) 95 (91.3%) 43 (82.7%) 52 (100%)
Disagreed, n (%) 9 (8.7%) 9 (17.3%) 0 (0%)
agreement, iaD vs. non-iaD
Cohen’s κ .64 .60 n/a a
agreed, n (%) 97 (93.3%) 45 (86.5%) 52 (100%)
Disagreed, n (%) 7 (6.7%) 7 (13.5%) 0 (0%)
agreement, nD vs. non-nD
Cohen’s κ .94 .64 n/a a
agreed, n (%) 101 (97.1%) 49 (94.2%) 52 (100%)
Disagreed, n (%) 3 (2.9%) 3 (5.8%) 0 (0%)
Table 3. reliability estimates of inter-rater agreement on SSD
and iaD specifiers.
Note. estimates are based on cases where the interviewer and
the assessor agreed on an SSD or iaD diagnosis. iaD, illness
anxiety disorder; SSD, somatic symptom disorder.
114. anot applicable due to division by zero.
bnumber of cases agreed divided by the average total number of
cases per rater. in other words, the likelihood of a specifier
by one rater to be endorsed by the other rater (see “Statistical
analysis”).
Specifier Cohen’s κ Agreed per choice, n (%) Agreed per class,
n (%b)
SSD (n = 34)
Mild .08 11 (32%) 1 (18%)
vs Moderate 4 (29%)
vs Severe 6 (39%)
predominantly pain .45 30 (88%) 2 (50%)
vs not predominantly pain 28 (93%)
persistent .30 24 (71%) 5 (50%)
vs not persistent 19 (79%)
iaD (n = 6)
Care-seeking 1 6 (100%) 4 (100%)
vs Care avoidant 2 (100%)
vs no specifier 0 (n/aa)
266 E. AxELSSon ET AL.
interviewer and ND by the assessor. Two of these were cases of
panic disorder, where
disagreement arose as to whether an additional diagnosis of
SSD should be made or not,
and one case mainly had to do with the clinicians disagreeing on
115. whether the patient’s
health anxiety returned with sufficient frequency to warrant a
diagnosis. The remaining
disagreement—where the interviewer suggested IAD and the
assessor SSD—stemmed from
different views on whether the somatic symptoms of the
respondent were frequent enough
to warrant an SSD—rather than an IAD—diagnosis.
In the clinical trial applicant sample, 11 out of 52 respondents
(21%) reported presently
having at least one organic disease “out of the ordinary.” The
only conditions that were
referred to by more than one respondent were hypothyroidism
(n = 3) and fibromyalgia
syndrome (n = 2). Other medical conditions included a benign
brain tumor, hiatus hernia,
irritable bowel syndrome, immunodeficiency, an unspecified
benign brain malformation,
spinal disc herniation, severe asthma, severe migraine, and
vulvar vestibulitis. Among the
healthy controls, only one respondent reported having a medical
condition worthy of men-
tioning (hypothyroidism).
Discussion
This study investigated the psychometric properties of the
Health Preoccupation Diagnostic
Interview (HPDI): a new structured interview for diagnosing
DSM-5 SSD and IAD. The
results suggest that the HPDI can be a reliable diagnostic
instrument for assessing health
anxiety in terms of SSD and IAD. An important strength of this
study was that the clinicians
who assigned diagnoses did not undergo any special training to
116. increase rating concordance.
This means that the presented estimates are likely to mirror
what would be attainable in
clinical practice. To our knowledge, this study is the first to
show that these new DSM-5
diagnoses can be simultaneously assessed with acceptable inter-
rater reliability.
The overall (SSD vs. IAD vs. ND) agreement was almost perfect
for the combined sample,
moderate for the clinical sample, and perfect (κ not applicable)
for the healthy controls.
Notably, as the assessor was blind to respondent recruitment
procedures, sample differ-
ences in diagnostic ratings cannot be explained by mere
expectancy: e.g. that the assessor
expected non-clinical respondents not to meet diagnostic
criteria. The results are in line
with previous reliability estimates for many diagnoses made
with the Structured Clinical
Interview for DSM-IV Axis I Disorders (SCID I; Lobbestael,
Leurgans, & Arntz, 2011; Skre
et al., 1991) but slightly lower than the reliability estimates of
most MINI modules (Sheehan
et al., 1998). Additional standardization of the assessment
procedure could possibly further
enhance the psychometric properties of the HPDI. In the present
study, disagreement as to
whether a diagnosis of SSD or IAD should be made primarily
arose due to different views on
how severe certain somatic symptoms were. Therefore, if more
precise definitions of “mild”
or “minimal” somatic symptoms were established, many
disagreements could probably be
avoided. For research purposes, the use of multiple co-operating
raters and/or introductory
117. rating concordance checks could also be used to further enhance
reliability figures.
Although there was almost perfect agreement on the IAD
specifiers, i.e. care seeking or
care avoidant subtypes, and moderate agreement on the SSD
pain specifier, there was much
higher disagreement on the SSD severity and persistence
specifiers. We see two likely reasons
for this. Firstly, as pointed out by Rief and Martin (2014), the
names of these specifiers are
surprising. Most strikingly, as SSD criterion C ensures that
most SSD patients have had
CognITIvE BEHAvIouR THERAPy 267
their symptoms for six months or longer, the persistence
specifier is primarily a measure of
symptom severity and functional impairment. That is, the
persistence specifier is—at least in
most cases—not a measure of persistency at all. Similarly, the
SSD severity specifier seemed
only vaguely related to the respondent’s degree of suffering and
impairment.
Secondly, expanding on our previous suggestions for further
operationalization of “mild”
somatic symptoms, what exactly is a “severe” or “very severe”
somatic symptom? And how
many are “multiple” somatic complaints? We deliberately
refrained from making such clar-
ifications, in order not to arbitrarily divert from the DSM-5
criteria. Unfortunately, these
criteria do not seem to in and of themselves provide sufficient
118. guidance for the assessment
of the above-mentioned specifiers. Simply put, we suspect that
the SSD severity and persis-
tence specifiers, as phrased in DSM-5, are too vague and
counterintuitive to be sufficiently
reliable. In future revisions of the DSM, we strongly suggest
that these specifiers be better
operationalized.
The primary limitation of this study was that only two
clinicians’ assessments could be
compared. Even though the assessor was blind to the respondent
recruitment procedure,
the interviewer was not, and might therefore—although
instructed not to do so—have
steered the interview based on expectancy (so that individuals
of the non-clinical sample
were treated differently than individuals of the clinical trial
applicant sample). There is also
a possibility that reliability figures had been different (either
better or worse) if the assessor
had conducted separate diagnostic interviews instead of
listening to audio files.
Even though the structured diagnostic interview covered many
common differential
diagnoses of SSD and IAD (such as major depressive disorder,
panic disorder, generalized
anxiety disorder, and obsessive-compulsive disorder), several
conditions of the DSM were
not surveyed in such a systematic manner. Of particular interest,
the remaining somatic
symptom and related disorders (e.g. conversion disorder and the
psychological factors
affecting other medical conditions category), as well as sexual
dysfunction disorders (e.g.
119. genito-pelvic pain/penetration disorder) were not routinely
assessed using separate prompts
or modules.
There were also limitations with regard to sampling. Since the
two samples of this study
(health anxious versus non-clinical respondents) were recruited
through different channels,
it is likely that the clinicians’ (the interviewer’s and the
assessor’s) ability to distinguish
between diagnostic (SSD or IAD) cases and ND cases was
slightly overestimated. Since
IAD was more rare than SSD and ND, reliability estimates for
IAD are also likely less gen-
eralizable than those for SSD and ND. The presented findings
nevertheless indicate that
the HPDI shows great promise in diagnosing both SSD and IAD.
Although the HPDI likely makes the diagnostic procedure
easier, it is worth underscoring
that structured diagnostic interviews (like the HPDI) demand
that their user is familiar with
the diagnoses being assessed (in this case DSM-5 SSD and
IAD). This may seem obvious,
but was made even more evident by the misunderstanding on
behalf of one of two assessors
in the present study (see “Procedure”). The criteria of SSD and
IAD may seem counterintu-
itive, not least since most clinicians are not used to classifying
somatic symptoms in terms
of severity. Nevertheless, as we have seen, determining somatic
symptom severity is often
important to differentiate SSD from IAD. A thorough
understanding of common differential
diagnoses, such as anxiety and obsessive-compulsive spectrum
disorders, is also required
120. in order to make a valid diagnosis.
268 E. AxELSSon ET AL.
We conclude that the HPDI can be a reliable instrument for
diagnosing DSM-5 SSD and
IAD. It should, however, only be used by clinicians familiar
with the DSM-5, and is not suit-
able for assessing the SSD severity and persistence specifiers.
The psychometric properties of
the HPDI should preferably be further investigated in additional
patient groups (e.g. mixed
psychiatric samples, patients with chronic pain, patients
suffering from severe illness, and
samples involving more patients with IAD). Since the
completion of this study, modules for
SSD and IAD have been included in the Structured Clinical
Interview for DSM-5 (SCID-
5; American Psychiatric Association, 2015) and Anxiety and
Related Disorders Interview
Schedule for DSM-5 (ADIS-5; Brown & Barlow, 2014), but the
psychometric properties
of these modules have—to our knowledge—not yet been
evaluated. A promising SSD B
criteria symptom questionnaire has also been developed by
Toussaint et al. (2016). We
warmly welcome all efforts that help shed further light on SSD,
IAD, and the relationship
between these disorders. Free use of the HPDI is encouraged in
order to achieve this end.
Authors’ contributions
Conception and design: primarily EAx and EH. Procedure and
121. data acquisition: EAx,
EAn, BL, and EH. All authors—EAx, EAn, BL, DWF, and EH—
contributed significantly
to the analysis, interpretation, and writing process. All authors
read and approved the final
manuscript.
Acknowledgment
We thank MSc Rebecka Bratt for her skillful and invaluable
contributions to this project.
Disclosure statement
The authors declare that they have no conflicts of interest.
Funding
This research was funded by Karolinska Institutet and
Stockholm County Council, which had no
role in the design, realization, or publication of the study.
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http://dx.doi.org/10.1017/S0033291702005822
127. integrative Medicine, Department of Clinical
neuroscience, Karolinska institutet, Stockholm, Sweden
Introduction
The fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5;
American Psychiatric Association, 2013) has introduced several
revisions of its predecessor
(DSM-IV; American Psychiatric Association, 2000). One is that
the DSM-IV somatoform
disorders, including hypochondriasis and somatization disorder,
have been abandoned.
There were multiple reasons for this. The somatoform disorders
were considered difficult to
understand, and—despite their narrow criteria—showed a
tendency to overlap (Dimsdale
et al., 2013). Additionally, a common view was that these
disorders overemphasized the
presence of medically unexplained symptoms, i.e. that a medical
explanation for the patient’s
symptoms had to be ruled out for a psychiatric diagnosis to be
made (Dimsdale et al., 2013).
This praxis drew an unnecessarily sharp line between “medical”
and “psychiatric” patients.
ABSTRACT
Somatic symptom disorder (SSD) and illness anxiety disorder
(IAD)
are two new diagnoses introduced in the DSM-5. There is a need
for
reliable instruments to facilitate the assessment of these
disorders.
We therefore developed a structured diagnostic interview, the
Health
Preoccupation Diagnostic Interview (HPDI), which we
128. hypothesized
would reliably differentiate between SSD, IAD, and no
diagnosis.
Persons with clinically significant health anxiety (n = 52) and
healthy
controls (n = 52) were interviewed using the HPDI. Diagnoses
were
then compared with those made by an independent assessor,
who
listened to audio recordings of the interviews. Ratings generally
indicated moderate to almost perfect inter-rater agreement, as
illustrated by an overall Cohen’s κ of .85. Disagreements
primarily
concerned (a) the severity of somatic symptoms, (b) the
differential
diagnosis of panic disorder, and (c) SSD specifiers. We
conclude that
the HPDI can be used to reliably diagnose DSM-5 SSD and
IAD.
KEYWORDS
health anxiety; illness
anxiety disorder; reliability;
somatic symptom disorder;
somatization
ARTICLE HISTORY
received 24 november 2015
accepted 1 March 2016
CONTACT erland axelsson [email protected]
Supplemental data for this article can be accessed here
http://dx.doi.org/10.1080/16506073.2016.1161663
mailto:[email protected]
http://dx.doi.org/10.1080/16506073.2016.1161663