J ClinEpidemiolVol. 44, No. 10, pp. 1037-1043,1991 Printed in GreatBritain. All rightsreserved
0895-4356/91$3.00+ 0.00 Press plc Copyright0 1991Pergamon
IMPAIRMENT OF PHYSICAL AND PSYCHOSOCIAL FUNCTION IN RECURRENT SYNCOPE MARK LINZER,‘*~* MICHELE PONTINEN,’ DEBORAH T. GOLD,* GEORGE W. DIVINE,‘.~ ALONZO FELDER’~
and W.
BLAIR BROOKS’S
‘Division of General Internal Medicine, Department of Medicine, 2Division of Social and Community Psychiatry, Department of Psychiatry, and ‘Division of Biometry, Department of Community and Family Medicine, Duke University Medical Center, Durham, NC 27710 and
“Division of General Medicine, New England Medical Center, Boston, MA 02111, U.S.A. (Received in revised form 25 March 1991)
Abstract-Physical and psychosocial function have rarely been assessed in syncope. We used two valid and reliable measures of health status, the Sickness Impact Profile (SIP) and the Symptom Checklist 90 (SCL-90-R), to assess functional impairment in 62 patients with recurrent syncope seen in a syncope specialty clinic. Mean total SIP scores were markedly elevated at 17 (SD = 14), indicating a level of impairment similar to severe rheumatoid arthritis and chronic low back pain. SIP psychosocial scores were significantly greater than SIP physical scores (20 vs 11, p < 0.0001). SCL-90-R scores were also high, comparable to those of psychiatric inpatients. Somatization, anxiety and depression dimensions of the SCL-90-R were particularly elevated. SCL-90-R subscale scores were highly correlated with SIP psychosocial scores (all r > 0.4, and p < 0.001). Neither age nor number of comorbid diseases correlated with measures of psychosocial function, suggesting that syncope itself causes psychosocial impairment. Although this was a referral population, these data suggest that function can be seriously impaired by syncope, that the degree of impairment is similar to that reported in other chronic diseases, and that syncope leads to significantly greater psychosocial than physical impairment. Syncope
Psychosocial health
Functional
INTRODUCTION
disability
in an attempt to provide a diagnosis and explanation for their syncopal episodes. However, in up to 50% of such patients, no diagnosis can be made [l, 21. Several studies have shown that patients with recurrent syncope of uncertain origin have a “benign” prognosis in terms of early mortality [3] or sudden death [4,5]. But the morbidity of recurrent syncope can be considerable, with anxiety and/or depressive symptoms resulting from what patients describe as a “fear of fainting” [6]. Functional impairment due to syncope has received little attention in the medical literature. Despite being unable to drive and often unable to work, patients with recurrent syncope and prespecialists
Syncope, a transient loss of consciousness with loss of postural tone, is a puzzling disease for clinicians. Patients are often referred through a complex matrix of diagnostic tests and sub*All correspondence should be addressed to: Dr Mark Linzer, Division of General Medicine, Box 1042, New England Medical Center, 750 Washington Street, Boston, MA 02111, U.S.A. Present addresses: tMr Felder, Medical Center Information Systems, Duke University Medical Center, Durham, NC 27710, U.S.A. fDr Brooks, Division of General Medicine, Department of Medicine, Dartmouth-Hitchcock Medical Center, Hanover, NH, U.S.A.
1037
MARK LINZERet al.
1038
syncope are often reassured by their physicians that their prognosis is benign and that no further evaluation or follow-up is necessary. However, in a previous study, we found that up to 75% of patients with syncope or presyncope reported that they suffered from important syncoperelated functional impairment [6]. Thus, there is an apparent discrepancy between the selfperception of impairment by syncope patients and the perception by physicians and other health care providers. The current study was prompted by the observation that patients with recurrent syncope appeared to be impaired by their syncopal syndrome. Documentation of the severity and type of impairment using formal functional status measures could justify more aggressive diagnostic and therapeutic protocols for this supposedly “benign” disorder. METHODS
Hypotheses
The current hypotheses:
study
tested
the
following
Recurrent syncope is associated with serious functional impairment; Psychosocial impairment in recurrent syncope is more severe than physical impairment; Formal functional status measures are valid in this patient population; and Potential confounders (such as age and comorbid diseases) do not explain the association of syncope and impairment. Study Design Patient accrual
Patients were recruited from the sample of patients referred to the Duke Syncope Clinic and Consultation Service for unexplained syncope. The Syncope Clinic patients were referred from inpatient and outpatient services, local emergency rooms and private physician offices. Patients’ histories of syncope ranged from those with a single unexplained syncopal episode referred from the emergency room to patients with a 20 year history of recurrent syncope unexplained by extensive diagnostic evaluation. Patients were eligible for the current study if they had at least two episodes of syncope or nearsyncope (near loss of consciousness) in the 6 months prior to evaluation. For the remainder of the paper, “syncope” refers to either “syncope”
except where otherwise or “near-syncope”, specified. Patients younger than age 17 and those with clinical evidence of dementia were excluded. Measurements
All eligible patients were asked to participate in the study. After giving informed consent, they were asked to complete three separate questionnaires. The first questionnaire was a 133 item self-administered form that was routinely completed on presentation to the Syncope Clinic as part of an ongoing database of syncope patients seen at Duke Medical Center. This form recorded baseline demographic information, as well as detailed information concerning illness characteristics (i.e. frequency, duration and nature of syncopal episodes). After completing this form, patients underwent a complete history and physical examination, a set of provocative bedside maneuvers [I including hyperventilation and carotid massage, and a formal psychiatric evaluation using a semi-structured clinical interview to determine potential psychiatric causes of syncope [8]. Final diagnoses were assigned according to predetermined strict diagnostic criteria [l]. Patients then completed the following test instruments. The Sickness Impact Projile. The SIP is a 136 item behaviorally based self-report questionnaire that measures sickness-related dysfunction [9]. The SIP yields: (1) a total score, an overall measure of function, (2) two dimension scores that capture physical and psychosocial function, and (3) 12 category scores (ambulation, mobility, body care and movement, social interaction, communication, alertness behavior, emotional behavior, sleep and rest, eating, work, home management, and recreation and past-times). Previous studies utilizing the SIP in patients with low back pain [lo], rheumatoid arthritis [ll], and coronary artery disease [12] have shown it to be a reliable and valid instrument. Construct, convergent and discriminant validity as well as internal consistency are good. Normative SIP scores for the above mentioned patient groups have typically been obtained from speciality clnics, specifically, arthritis [l l] and chronic pain [lo] clinics. The Symptom Checklist 90. The SCL-90-R is a 90 item scale that is a self report index of psychiatric distress [ 131.Symptoms are reported in terms of severity or intensity of impairment. It is sensitive not only to psychiatric distress, but also to stress that results from general medical
Physical and Psychosocial Health in Syncope
1039
Table 1. Characteristics of 62 patients with recurrent syncope
illness [14]. The SCL-90-R is not a measure of personality but is rather a measure of current point-in-time psychological symptoms status. It has high test-retest and internal reliability, has been subjected to formal tests of discriminant and convergent validity, and has been used effectively with chronically ill and elderly patients. The SCL-90-R has 9 primary symptom dimensions: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoia, and psychoticism. There are also three global indices of distress, two of which were used in the current study. The Global Severity Index (GSI) is “the best single indicator of the current level or depth of the disorder” [ 131,and is often utilized when a single summary measure is required. The GSI is derived from the number of symptoms and intensity of distress. The Positive Symptom Distress Index (PSDI) is a measure of disease intensity, “corrected” for number of symptoms. The PSDI is the best measure of intensity of psychological distress. The SIP and SCL-90-R were chosen as well-validated measures of psychological distress (SCL-90-R) and physical and psychosocial function (SIP). Our experience with these measures in pilot studies with syncope patients suggested that these instruments would capture the types of distress and dysfunction arising from this episodic disorder. As part of the 133-item syncope questionnaire, patients also completed a syncope-specific functional status assessment that is the subject of a separate report [ 151. Data analysis. Mean scores were calculated for overall SIP scores and for SIP psychosocial and physical dimension subscores. For the SCL90-R, mean subscale scores were calculated. Paired t-tests were used to compare SIP physical with SIP psychosocial scores. To determine convergent validity of the measures in the syncope patient population, two measures of psycho-
Mean age (SD): Sex (% male): Nature of symptoms Syncope only Syncope plus near-syncope Near-syncope only Median duration of syncope (months): Median number of syncopal episodes: Median number of co-morbid diseases:
49(19) 29% 61% 26% 14% 11 10 2
Table 2. Etiologies for syncope in 62 syncope patients* Cardiac Psychiatric Orthostatic hypotension Vagal Other Neurologic Unknown *Etiologies were assigned strict criteria [l, 81.
16% 16% 8% 5% 5% 2% 48% using
logical distress were assessed for correlation, the SIP psychosocial scores and the SCL-90-R subscale scores. To assess the impact of potential confounders, correlations were computed between the confounders (age and number of comorbid diseases) and SIP psychosocial and physical scores, and SCL-90-R summary scores. RESULTS
Sixty-three patients with recurrent syncope were recruited for study; only 1 patient declined (refusal rate: 1.6%). Patient characteristics are summarized in Table 1. Mean patient age was 49, with 29% male. Sixty-one percent had syncope alone, 26% had syncope plus near-syncope, and 14% had near-syncope alone. The median duration of symptoms was 11 months, with a median number of 10 lifetime syncopal episodes. The median number of comorbid diseases by self-report was 2. Table 2 shows the etiologies of syncope in the study population. Diagnostic testing in the syncope and near-syncope groups
Table 3. Mean SIP Scores in patients with syncope and in comparison studies drawn from the medical literature SIP total Syncope (current study) General population Rheumatoid arthritis Chronic back pain COPD End stage renal disease (chronic peritoneal dialysis)
16.8 3.6 15.6 24 24 14
SIP psychosocial 19.9* 11 25 21 8
SIP physical
Reference
11.1* 14 18 20 11
*p < 0.0001. Psychosocial vs SIP physical scores in syncope patients.
Bergner et al. [9] Deyo et al. [I I] Follick et a/. [IO] McSweeney et al. [ 161 Hart and Evans [ 171
MARK LINZERet al.
1040
Table 4. XL-90-R Dimensional subscales in 62 syncope patients
Somatization Obsessive-compulsive Intersensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism
Mean*
SD
1.30 1.20 0.80 1.14 1.04 0.12 0.76 0.76 0.62
0.84 0.95 0.86 0.91 0.86 0.79 0.81 0.79 0.64
*Mean value 2 1.00 implies significant endorsement of the dimensional subscale.
was similar, except for slightly more cardiac diagnostic testing performed in the subjects with true syncope. Mean total overall SIP scores were 16.8 (SD 14.2). Table 3 compares these scores with those found in healthy normals, rheumatoid arthritis, chronic low back pain, COPD, and end stage renal disease. Mean ages in the comparison populations ranged from 40 to 65. Comorbid conditions in the healthy control sample [9] were minimal, but were seemingly comparable to the syncope subjects in the other references [lo, 11, 16, 171.Table 3 also shows that the SIP psychosocial dimension subscale score was significantly greater than the SIP physical dimension score (p < 0.0001) in the syncope patient population. Of note the “spread” between psychosocial and physical impairment was greater than in any oi the other disorders. SCL-90-R scores were similarly elevated. In syncope patients, the GSI (the summary measure of psychological distress), was elevated at 0.98 (SD 0.73), with normal control scores of 0.31 and psychiatric inpatient scores of 1.30 [13]. PSDI scores, indicating intensity of psychological distress, were also elevated in the syncope subjects at 1.97, with literature normals scores of 1.32 and psychiatric inpatients scores of 2.15. Somatization, obsessivecompulsive, anxiety and depression dimensional subscales of the SCLTable 5. Selected areas of impairment noted by 58 subjects with recurrent syncope’ Activities of daily living: Driving: Employment: Relationships: Anxiety or depression due to syncope:
76% 64% 39% 26% 73%
*“Not applicable” and “not answered” were excluded from calculations; 4 of 62 subjects did not complete this section of the questionnaire.
Table 6. Convergent measurement tools Correlation of SIP 6 SCL-90-R
validity of psychosocial in 62 syncope patients. psychosocial scores and dimension scores
SCL-90-R subscale:
r
P
Somatization Obsessive-compulsive Depression Anxiety Hostility Phobic anxiety
0.42 0.59 0.62 0.54 0.52 0.43
0.0008 0.0001 0.0001 0.0001 0.0001 0.0006
90-R were all greater than 1.00 (possible range O-4, with 0 = no dysfunction and 4 = total dysfunction), indicating the presence of significant impairment of the syncope patient population on these dimensions (Table 4). Patients were asked to denote the specific aspects of their daily life that were interfered with on account of their syncope (Table 5). Seventy-six percent of subjects said that syncope “interfered with their life or activities of daily living.” Driving and employment were also frequently affected. Relationships with friends, spouse, or other family members were impaired in 26% of subjects. Seventy-three percent noted anxiety or depressed feelings on account of their syncopal syndrome. Table 6 displays the validity assessment for the psychosocial measures used in the current study. As shown in the table, SIP psychosocial and SCL-90-R subscale scores were highly correlated. For all SCL-90-R subscales (6 shown), r values were greater than 0.4, and p < 0.001 for correlation with the SIP psychosocial dimension. In an analysis accounting for the number of comorbid diseases, the high correlations between SCL-90-R scores and SIP psychosocial scores remained unaffected (partial correlation analysis not shown). Table 7 demonstrates the lack of correlation of the SIP psychosocial score with the potential confounders of age and number of comorbid diseases (r = 0.15, 0.12; p > 0.25 and 0.43, respectively). SIP physical dimension scores did show modest to moderate correlation with patient age (r = 0.25, p < 0.05) and number of comorbid diseases (r = 0.43, p < 0.002). No correlations were seen between age, number of comorbid conditions and SCL-90-R scores. A psychiatric etiology for syncope was also examined as a potential confounder. When SIP overall and psychosocial scores and SCL-90-R scores were assessed for the subgroups of patients with and without psychiatric syncope, there were no appreciable differences.
Physical and Psychosocial Health in Syncope
1041
Table 7. Association of potential confounders with SIP and SCL-90-R scores SIP
Age
I
P
No. of comorbid diseases
r P
SCL-90-R
Psychosocial
Physical
GSI*
PSDIt
0.15 0.25
0.25
0895-4356/91$3.00+ 0.00 Press plc Copyright0 1991Pergamon
IMPAIRMENT OF PHYSICAL AND PSYCHOSOCIAL FUNCTION IN RECURRENT SYNCOPE MARK LINZER,‘*~* MICHELE PONTINEN,’ DEBORAH T. GOLD,* GEORGE W. DIVINE,‘.~ ALONZO FELDER’~
and W.
BLAIR BROOKS’S
‘Division of General Internal Medicine, Department of Medicine, 2Division of Social and Community Psychiatry, Department of Psychiatry, and ‘Division of Biometry, Department of Community and Family Medicine, Duke University Medical Center, Durham, NC 27710 and
“Division of General Medicine, New England Medical Center, Boston, MA 02111, U.S.A. (Received in revised form 25 March 1991)
Abstract-Physical and psychosocial function have rarely been assessed in syncope. We used two valid and reliable measures of health status, the Sickness Impact Profile (SIP) and the Symptom Checklist 90 (SCL-90-R), to assess functional impairment in 62 patients with recurrent syncope seen in a syncope specialty clinic. Mean total SIP scores were markedly elevated at 17 (SD = 14), indicating a level of impairment similar to severe rheumatoid arthritis and chronic low back pain. SIP psychosocial scores were significantly greater than SIP physical scores (20 vs 11, p < 0.0001). SCL-90-R scores were also high, comparable to those of psychiatric inpatients. Somatization, anxiety and depression dimensions of the SCL-90-R were particularly elevated. SCL-90-R subscale scores were highly correlated with SIP psychosocial scores (all r > 0.4, and p < 0.001). Neither age nor number of comorbid diseases correlated with measures of psychosocial function, suggesting that syncope itself causes psychosocial impairment. Although this was a referral population, these data suggest that function can be seriously impaired by syncope, that the degree of impairment is similar to that reported in other chronic diseases, and that syncope leads to significantly greater psychosocial than physical impairment. Syncope
Psychosocial health
Functional
INTRODUCTION
disability
in an attempt to provide a diagnosis and explanation for their syncopal episodes. However, in up to 50% of such patients, no diagnosis can be made [l, 21. Several studies have shown that patients with recurrent syncope of uncertain origin have a “benign” prognosis in terms of early mortality [3] or sudden death [4,5]. But the morbidity of recurrent syncope can be considerable, with anxiety and/or depressive symptoms resulting from what patients describe as a “fear of fainting” [6]. Functional impairment due to syncope has received little attention in the medical literature. Despite being unable to drive and often unable to work, patients with recurrent syncope and prespecialists
Syncope, a transient loss of consciousness with loss of postural tone, is a puzzling disease for clinicians. Patients are often referred through a complex matrix of diagnostic tests and sub*All correspondence should be addressed to: Dr Mark Linzer, Division of General Medicine, Box 1042, New England Medical Center, 750 Washington Street, Boston, MA 02111, U.S.A. Present addresses: tMr Felder, Medical Center Information Systems, Duke University Medical Center, Durham, NC 27710, U.S.A. fDr Brooks, Division of General Medicine, Department of Medicine, Dartmouth-Hitchcock Medical Center, Hanover, NH, U.S.A.
1037
MARK LINZERet al.
1038
syncope are often reassured by their physicians that their prognosis is benign and that no further evaluation or follow-up is necessary. However, in a previous study, we found that up to 75% of patients with syncope or presyncope reported that they suffered from important syncoperelated functional impairment [6]. Thus, there is an apparent discrepancy between the selfperception of impairment by syncope patients and the perception by physicians and other health care providers. The current study was prompted by the observation that patients with recurrent syncope appeared to be impaired by their syncopal syndrome. Documentation of the severity and type of impairment using formal functional status measures could justify more aggressive diagnostic and therapeutic protocols for this supposedly “benign” disorder. METHODS
Hypotheses
The current hypotheses:
study
tested
the
following
Recurrent syncope is associated with serious functional impairment; Psychosocial impairment in recurrent syncope is more severe than physical impairment; Formal functional status measures are valid in this patient population; and Potential confounders (such as age and comorbid diseases) do not explain the association of syncope and impairment. Study Design Patient accrual
Patients were recruited from the sample of patients referred to the Duke Syncope Clinic and Consultation Service for unexplained syncope. The Syncope Clinic patients were referred from inpatient and outpatient services, local emergency rooms and private physician offices. Patients’ histories of syncope ranged from those with a single unexplained syncopal episode referred from the emergency room to patients with a 20 year history of recurrent syncope unexplained by extensive diagnostic evaluation. Patients were eligible for the current study if they had at least two episodes of syncope or nearsyncope (near loss of consciousness) in the 6 months prior to evaluation. For the remainder of the paper, “syncope” refers to either “syncope”
except where otherwise or “near-syncope”, specified. Patients younger than age 17 and those with clinical evidence of dementia were excluded. Measurements
All eligible patients were asked to participate in the study. After giving informed consent, they were asked to complete three separate questionnaires. The first questionnaire was a 133 item self-administered form that was routinely completed on presentation to the Syncope Clinic as part of an ongoing database of syncope patients seen at Duke Medical Center. This form recorded baseline demographic information, as well as detailed information concerning illness characteristics (i.e. frequency, duration and nature of syncopal episodes). After completing this form, patients underwent a complete history and physical examination, a set of provocative bedside maneuvers [I including hyperventilation and carotid massage, and a formal psychiatric evaluation using a semi-structured clinical interview to determine potential psychiatric causes of syncope [8]. Final diagnoses were assigned according to predetermined strict diagnostic criteria [l]. Patients then completed the following test instruments. The Sickness Impact Projile. The SIP is a 136 item behaviorally based self-report questionnaire that measures sickness-related dysfunction [9]. The SIP yields: (1) a total score, an overall measure of function, (2) two dimension scores that capture physical and psychosocial function, and (3) 12 category scores (ambulation, mobility, body care and movement, social interaction, communication, alertness behavior, emotional behavior, sleep and rest, eating, work, home management, and recreation and past-times). Previous studies utilizing the SIP in patients with low back pain [lo], rheumatoid arthritis [ll], and coronary artery disease [12] have shown it to be a reliable and valid instrument. Construct, convergent and discriminant validity as well as internal consistency are good. Normative SIP scores for the above mentioned patient groups have typically been obtained from speciality clnics, specifically, arthritis [l l] and chronic pain [lo] clinics. The Symptom Checklist 90. The SCL-90-R is a 90 item scale that is a self report index of psychiatric distress [ 131.Symptoms are reported in terms of severity or intensity of impairment. It is sensitive not only to psychiatric distress, but also to stress that results from general medical
Physical and Psychosocial Health in Syncope
1039
Table 1. Characteristics of 62 patients with recurrent syncope
illness [14]. The SCL-90-R is not a measure of personality but is rather a measure of current point-in-time psychological symptoms status. It has high test-retest and internal reliability, has been subjected to formal tests of discriminant and convergent validity, and has been used effectively with chronically ill and elderly patients. The SCL-90-R has 9 primary symptom dimensions: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoia, and psychoticism. There are also three global indices of distress, two of which were used in the current study. The Global Severity Index (GSI) is “the best single indicator of the current level or depth of the disorder” [ 131,and is often utilized when a single summary measure is required. The GSI is derived from the number of symptoms and intensity of distress. The Positive Symptom Distress Index (PSDI) is a measure of disease intensity, “corrected” for number of symptoms. The PSDI is the best measure of intensity of psychological distress. The SIP and SCL-90-R were chosen as well-validated measures of psychological distress (SCL-90-R) and physical and psychosocial function (SIP). Our experience with these measures in pilot studies with syncope patients suggested that these instruments would capture the types of distress and dysfunction arising from this episodic disorder. As part of the 133-item syncope questionnaire, patients also completed a syncope-specific functional status assessment that is the subject of a separate report [ 151. Data analysis. Mean scores were calculated for overall SIP scores and for SIP psychosocial and physical dimension subscores. For the SCL90-R, mean subscale scores were calculated. Paired t-tests were used to compare SIP physical with SIP psychosocial scores. To determine convergent validity of the measures in the syncope patient population, two measures of psycho-
Mean age (SD): Sex (% male): Nature of symptoms Syncope only Syncope plus near-syncope Near-syncope only Median duration of syncope (months): Median number of syncopal episodes: Median number of co-morbid diseases:
49(19) 29% 61% 26% 14% 11 10 2
Table 2. Etiologies for syncope in 62 syncope patients* Cardiac Psychiatric Orthostatic hypotension Vagal Other Neurologic Unknown *Etiologies were assigned strict criteria [l, 81.
16% 16% 8% 5% 5% 2% 48% using
logical distress were assessed for correlation, the SIP psychosocial scores and the SCL-90-R subscale scores. To assess the impact of potential confounders, correlations were computed between the confounders (age and number of comorbid diseases) and SIP psychosocial and physical scores, and SCL-90-R summary scores. RESULTS
Sixty-three patients with recurrent syncope were recruited for study; only 1 patient declined (refusal rate: 1.6%). Patient characteristics are summarized in Table 1. Mean patient age was 49, with 29% male. Sixty-one percent had syncope alone, 26% had syncope plus near-syncope, and 14% had near-syncope alone. The median duration of symptoms was 11 months, with a median number of 10 lifetime syncopal episodes. The median number of comorbid diseases by self-report was 2. Table 2 shows the etiologies of syncope in the study population. Diagnostic testing in the syncope and near-syncope groups
Table 3. Mean SIP Scores in patients with syncope and in comparison studies drawn from the medical literature SIP total Syncope (current study) General population Rheumatoid arthritis Chronic back pain COPD End stage renal disease (chronic peritoneal dialysis)
16.8 3.6 15.6 24 24 14
SIP psychosocial 19.9* 11 25 21 8
SIP physical
Reference
11.1* 14 18 20 11
*p < 0.0001. Psychosocial vs SIP physical scores in syncope patients.
Bergner et al. [9] Deyo et al. [I I] Follick et a/. [IO] McSweeney et al. [ 161 Hart and Evans [ 171
MARK LINZERet al.
1040
Table 4. XL-90-R Dimensional subscales in 62 syncope patients
Somatization Obsessive-compulsive Intersensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism
Mean*
SD
1.30 1.20 0.80 1.14 1.04 0.12 0.76 0.76 0.62
0.84 0.95 0.86 0.91 0.86 0.79 0.81 0.79 0.64
*Mean value 2 1.00 implies significant endorsement of the dimensional subscale.
was similar, except for slightly more cardiac diagnostic testing performed in the subjects with true syncope. Mean total overall SIP scores were 16.8 (SD 14.2). Table 3 compares these scores with those found in healthy normals, rheumatoid arthritis, chronic low back pain, COPD, and end stage renal disease. Mean ages in the comparison populations ranged from 40 to 65. Comorbid conditions in the healthy control sample [9] were minimal, but were seemingly comparable to the syncope subjects in the other references [lo, 11, 16, 171.Table 3 also shows that the SIP psychosocial dimension subscale score was significantly greater than the SIP physical dimension score (p < 0.0001) in the syncope patient population. Of note the “spread” between psychosocial and physical impairment was greater than in any oi the other disorders. SCL-90-R scores were similarly elevated. In syncope patients, the GSI (the summary measure of psychological distress), was elevated at 0.98 (SD 0.73), with normal control scores of 0.31 and psychiatric inpatient scores of 1.30 [13]. PSDI scores, indicating intensity of psychological distress, were also elevated in the syncope subjects at 1.97, with literature normals scores of 1.32 and psychiatric inpatients scores of 2.15. Somatization, obsessivecompulsive, anxiety and depression dimensional subscales of the SCLTable 5. Selected areas of impairment noted by 58 subjects with recurrent syncope’ Activities of daily living: Driving: Employment: Relationships: Anxiety or depression due to syncope:
76% 64% 39% 26% 73%
*“Not applicable” and “not answered” were excluded from calculations; 4 of 62 subjects did not complete this section of the questionnaire.
Table 6. Convergent measurement tools Correlation of SIP 6 SCL-90-R
validity of psychosocial in 62 syncope patients. psychosocial scores and dimension scores
SCL-90-R subscale:
r
P
Somatization Obsessive-compulsive Depression Anxiety Hostility Phobic anxiety
0.42 0.59 0.62 0.54 0.52 0.43
0.0008 0.0001 0.0001 0.0001 0.0001 0.0006
90-R were all greater than 1.00 (possible range O-4, with 0 = no dysfunction and 4 = total dysfunction), indicating the presence of significant impairment of the syncope patient population on these dimensions (Table 4). Patients were asked to denote the specific aspects of their daily life that were interfered with on account of their syncope (Table 5). Seventy-six percent of subjects said that syncope “interfered with their life or activities of daily living.” Driving and employment were also frequently affected. Relationships with friends, spouse, or other family members were impaired in 26% of subjects. Seventy-three percent noted anxiety or depressed feelings on account of their syncopal syndrome. Table 6 displays the validity assessment for the psychosocial measures used in the current study. As shown in the table, SIP psychosocial and SCL-90-R subscale scores were highly correlated. For all SCL-90-R subscales (6 shown), r values were greater than 0.4, and p < 0.001 for correlation with the SIP psychosocial dimension. In an analysis accounting for the number of comorbid diseases, the high correlations between SCL-90-R scores and SIP psychosocial scores remained unaffected (partial correlation analysis not shown). Table 7 demonstrates the lack of correlation of the SIP psychosocial score with the potential confounders of age and number of comorbid diseases (r = 0.15, 0.12; p > 0.25 and 0.43, respectively). SIP physical dimension scores did show modest to moderate correlation with patient age (r = 0.25, p < 0.05) and number of comorbid diseases (r = 0.43, p < 0.002). No correlations were seen between age, number of comorbid conditions and SCL-90-R scores. A psychiatric etiology for syncope was also examined as a potential confounder. When SIP overall and psychosocial scores and SCL-90-R scores were assessed for the subgroups of patients with and without psychiatric syncope, there were no appreciable differences.
Physical and Psychosocial Health in Syncope
1041
Table 7. Association of potential confounders with SIP and SCL-90-R scores SIP
Age
I
P
No. of comorbid diseases
r P
SCL-90-R
Psychosocial
Physical
GSI*
PSDIt
0.15 0.25
0.25
