Attitudes towards end-of-life issues in disorders of consciousness: a European survey

Previous European surveys showed the support of healthcare professionals for treatment withdrawal [i.e., artificial nutrition and hydration (ANH) in chronic vegetative state (VS) patients]. The recent definition of minimally conscious state (MCS), and possibly research advances (e.g., functional neuroimaging), may have lead to uncertainty regarding potential residual perception and may have influenced opinions of healthcare professionals. The aim of the study was to update the end-of-life attitudes towards VS and to determine the end-of-life attitudes towards MCS. A 16-item questionnaire related to consciousness, pain and end-of-life issues in chronic (i.e., >1 year) VS and MCS and locked-in syndrome was distributed among attendants of medical and scientific conferences around Europe (n = 59). During a lecture, the items were explained orally to the attendants who needed to provide written yes/no responses. Chi-square tests and logistic regression analyses identified differences and associations for age, European region, religiosity, profession, and gender. We here report data on items concerning end-of-life issues on chronic VS and MCS. Responses were collected from 2,475 participants. For chronic VS (>1 year), 66% of healthcare professionals agreed to withdraw treatment and 82% wished not to be kept alive (P < 0.001). For chronic MCS (>1 year), less attendants agreed to withdraw treatment (28%, P < 0.001) and wished not to be kept alive (67%, P < 0.001). MCS was considered worse than VS for the patients in 54% and for their families in 42% of the sample. Respondents’ opinions were associated with geographic region and religiosity. Our data show that end-of-life opinions differ for VS as compared to MCS. The introduction of the diagnostic criteria for MCS has not substantially changed the opinions on end-of-life issues on permanent VS. Additionally, the existing legal ambiguity around MCS may have influenced the audience to draw a line between expressing preferences for self versus others, by implicitly recognizing that the latter could be a step on the slippery slope to legalize euthanasia. Given the observed individual variability, we stress the importance of advance directives and identification of proxies when discussing end-of-life issues in patients with disorders of consciousness.     

Do prolonged grief disorder symptoms predict post-traumatic stress disorder symptoms following bereavement? A cross-lagged analysis

BackgroundBereavement can precipitate different forms of psychopathology, including prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) symptoms. How these symptoms influence each other is unclear. The aim of this study was to examine the temporal relationship of symptoms of PGD and PTSD following bereavement.MethodsWe included 204 individuals, confronted with the loss of a loved one within the past year, who completed self-report measures of PGD and PTSD and again completed these measures one year later. We conducted a cross-lagged analysis to explore cross-lagged and autoregressive relationships.ResultsA significant cross-lagged relationship was found between PGD symptoms at time point 1 (T1) and PTSD symptoms at time point 2 (T2) (β − = 0.270, p < 0.001). Furthermore, PGD symptoms at T1 predicted PGD symptoms at T2 and PTSD symptoms at predicted PTSD symptoms at T2 (β − = 0.617 and β − = 0.458, ps < 0.001, respectively). In addition, PGD and PTSD symptoms were significantly correlated on both time points.ConclusionsWe found that PGD symptoms predict PTSD symptoms after a loss. Potentially, this could help to design new strategies and interventions for bereaved individuals. Additionally, PGD symptom levels predicted PGD symptom levels one year later, independently of the PTSD levels. This finding adds to the accumulating evidence that PGD is a distinct disorder.     

Mirroring of a simple motor behavior in Disorders of Consciousness

ObjectiveIn patients suffering from Disorders of Consciousness (DOC) electrophysiological recordings at bedside could serve as a complimentary and economical tool to improve diagnosis. We utilized a motor observation and imagination paradigm to gain new insights on preserved cognitive processing in DOC.MethodsEEG brain oscillations were analyzed in 10 VS/UWS (Vegetative State/Unresponsive Wakefulness Syndrome) patients and 7 MCS (Minimally Conscious State) patients and 21 controls during observation and imagination of a grasping movement and group statistics were conducted.ResultsWhile control subjects showed a typical desynchronization at 8–15 Hz during observation of a movement, MCS patients presented an analogue response at 8–10 Hz, but exhibited a synchronization at 12–15 Hz. The VS group did not show a systematic response. Imagery-related activation was only sustained for 1500 ms even in control subjects, therefore, limiting conclusions regarding the ability to follow an instruction. Furthermore, a clinically diagnosed VS patient exhibited EEG responses indicative for MCS.ConclusionResults indicate that MCS patients are still able to process an observed motor behavior on a basic sensory and perhaps even pre-motoric level, but seem not to be capable of “mirroring” the movement like healthy participants.Significance“Real-world” tasks as presented here carry the potential to identify residual cognitive functioning in DOC patients and may ultimately help to lower misdiagnosis rates.     

Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials

The purpose of this study was to examine the efficacy of cognitive behavioral therapy (CBT) for anxiety-related disorders based on randomized placebo-controlled trials. We included 41 studies that randomly assigned patients (N = 2,843) with acute stress disorder, generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), panic disorder (PD), posttraumatic stress disorder (PTSD), or social anxiety disorder (SAD) to CBT or a psychological or pill placebo condition. Findings demonstrated moderate placebo-controlled effects of CBT on target disorder symptoms (Hedges’ g = 0.56), and small to moderate effects on other anxiety symptoms (Hedges’ g = 0.38), depression (Hedges’ g = 0.31), and quality of life (Hedges’ g = 0.30). Response rates in CBT compared to placebo were associated with an odds ratio of 2.97. Effects on the target disorder were significantly stronger for completer samples than intent-to-treat samples, and for individuals compared to group CBT in SAD and PTSD studies. Large effect sizes were found for OCD, GAD, and acute stress disorder, and small to moderate effect sizes were found for PTSD, SAD, and PD. In PTSD studies, dropout rates were greater in CBT (29.0%) compared to placebo (17.2%), but no difference in dropout was found across other disorders. Interventions primarily using exposure strategies had larger effect sizes than those using cognitive or cognitive and behavioral techniques, though this difference did not reach significance. Findings demonstrate that CBT is a moderately efficacious treatment for anxiety disorders when compared to placebo. More effective treatments are especially needed for PTSD, SAD, and PD.     

Predictors of PTSD symptoms in adults admitted to a Level I trauma center: A prospective analysis

Trauma centers are an ideal point of intervention in efforts to prevent posttraumatic stress disorder (PTSD). In order to assist in the development of prevention efforts, this study sought to identify early predictors of PTSD symptoms among adults admitted to a Level I trauma center using a novel analytic strategy (Fournier et al., 2009). Upon admission, participants (N = 327) were screened for PTSD symptoms and provided information on potential predictor variables. Their PTSD symptoms were assessed again 3 months later (N = 227). Participants were classified as symptomatic (positive PTSD screen) or asymptomatic (negative PTSD screen) at the follow-up assessment. Multinomial logistic regression showed that age, depression, number of premorbid psychiatric disorders, gunshot wound, auto vs. pedestrian injury, and alcohol use predicted who had PTSD symptoms at FU with 76.3% accuracy. However, when controlling for PTSD severity at baseline, only age, number of premorbid psychiatric disorders, and gunshot wounds predicted PTSD symptoms at FU but with 78.5% accuracy. These findings suggest that psychological prevention efforts in trauma centers may be best directed toward adults who are young, have premorbid psychiatric disorders, and those admitted with gunshot wounds.     

Distinctiveness of symptoms of prolonged grief, depression, and post-traumatic stress in bereaved children and adolescents

Studies among adults have shown that symptoms of prolonged grief disorder (PGD) are distinct from those of bereavement-related depression and post-traumatic stress-disorder (PTSD). This study was an attempt to replicate this finding in two distinct samples of bereaved children (N?=?197; aged 8?C12?years) and adolescents (N?=?135; 13?C18?years), confronted with the death of a parent, sibling or other close relative. Using confirmatory factor analyses, we compared the fit of a one-factor model with the fit of a three-factor model in which symptoms formed three distinct, correlated factors. In both samples, findings showed that the model in which symptoms of PGD, depression, and PTSD loaded on separate factors was superior to a one-factor model and displayed excellent model fit. Summed scores on the PGD, depression, and PTSD items were significantly associated with functional impairment, attesting to the concurrent validity of the PGD, depression, and PTSD factors. The current findings complement prior evidence from adult samples that PGD is a distinct syndrome and suggest that PGD symptoms should be addressed in the assessment and treatment of bereaved children and adolescent seeking help following their loss.     

Concurrent and prospective associations of intolerance of uncertainty with symptoms of prolonged grief,posttraumatic stress,and depression after bereavement

This study examined associations of Prospective IU and Inhibitory IU with symptom-levels of Prolonged Grief Disorder (PGD), Posttraumatic Stress-Disorder (PTSD), and depression in a sample of bereaved individuals. Specifically, 265 bereaved individuals completed measures of IU, PGD, PTSD, and depression in the first year after the death of a loved one; 134 participants again completed symptom-measures six months later. Cross-sectional analyses showed that Inhibitory IU (but not Prospective IU) was positively associated with symptom-levels of PTSD and depression (but not PGD), even when controlling for neuroticism, worry, and rumination. Prospective analyses showed that Prospective IU (but not Inhibitory IU) at baseline, predicted PGD severity six months later (but not PTSD or depression at follow-up) while controlling for baseline symptom-levels. The findings support the notion that IU is a vulnerability factor for different emotional problems, including those developing after the death of a loved one. Clinical implications of these findings are discussed.     

Evoked potential correlates of Post-Traumatic Stress Disorder in refugees with history of exposure to torture

The presence and magnitude of information processing deviations associated with Post-Traumatic Stress Disorder (PTSD) are far from being well-characterized. In this study we assessed the auditory and visually evoked cerebral responses in a group of Iraqi refugees who were exposed to torture and developed PTSD (N = 20), Iraqi refugees who had been exposed to similar trauma but did not develop PTSD (N = 20), and non-traumatized controls matched for age, gender, and ethnicity (N = 20). We utilized two paired-stimulus paradigms in auditory and visual sensory modalities, respectively. We found significantly smaller amplitudes of both the auditory P50 and the visual N75 responses in PTSD patients compared to controls, reflecting decreased response to simple sensory input during a relatively early phase of information processing (interval 50–75 ms post stimulus). In addition, deficient suppression of the P50/N75 response to repeating stimuli at this early stage in both modalities is indicative of difficulty in filtering out irrelevant sensory input. Among associations between electrophysiological and clinical measures, a significant positive correlation was found between dissociation score and P50 S1 amplitudes (p = 0.024), as well as stronger auditory P50 gating correlated with higher quality-of-life index scores (p = 0.013). In addition, smaller amplitudes of N150 visual evoked response to S1 showed a significant association with higher avoidance scores (p = 0.015). The results of this study highlight the importance of early automatic auditory and visual evoked responses in probing the information processing and neural mechanisms underlying symptomatology in PTSD.     

Psychiatric disorders among disaster bereaved: an interview study of individuals directly or not directly exposed to the 2004 tsunami

Background: Few studies have explored the long‐term mental health consequences of disaster losses in bereaved, either exposed to the disaster themselves or not. This study examined the prevalence and predictors of mental disorders and psychological distress in bereaved individuals either directly or not directly exposed to the 2004 tsunami disaster. Method: A cross‐sectional study of 111 bereaved Norwegians (32 directly and 79 not directly exposed) was conducted 2 years postdisaster. We used a face‐to‐face structured clinical interview to diagnose current posttraumatic stress disorder (PTSD) and depression (major depressive disorder, MDD) and a self‐report scale to measure prolonged grief disorder (PGD). Results: The prevalence of psychiatric disorders was twice as high among individuals directly exposed to the disaster compared to individuals who were not directly exposed (46.9 vs. 22.8 per 100). The prevalence of disorders among the directly exposed was PTSD (34.4%), MDD (25%), and PGD (23.3%), whereas the prevalence among the not directly exposed was PGD (14.3%), MDD (10.1%), and PTSD (5.2%). The co‐occurrence of disorders was higher among the directly exposed (21.9 vs. 5.2%). Low education and loss of a child predicted PGD, whereas direct exposure to the disaster predicted PTSD. All three disorders were independently associated with functional impairment. Conclusions: The dual burden of direct trauma and loss can inflict a complex set of long‐term reactions and mental health problems in bereaved individuals. The relationship between PGD and impaired functioning actualizes the incorporation of PGD in future diagnostic manuals of psychiatric disorders. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Trouble stress post traumatique,dépression et anxiété chez les parents d’enfant(s) atteint(s) d’épilepsie

IntroductionPost-traumatic Stress Disorder (PTSD), depression and anxiety are the most common psychiatric consequences among parents of children with epilepsy.ObjectivesWe aimed to investigate the prevalence and predictors of PTSD, depression and anxiety in a sample of parents of children with epilepsy.MethodsA survey of 135 parents of children with epilepsy, treated in the pediatric neurology department at the Sfax Teaching Hospital in Tunisia, was conducted in the last quarter of 2019. The PTSD Checklist for DSM-5 and the Hospital Anxiety and Depression Scale (HADS) were used to assess, respectively, PTSD, depression and anxiety in parents. Associations with clinical and demographic variables with PTSD, depression and anxiety were evaluated in a logistic regression model.ResultsResults revealed PTSD rates of 20.7%, depression rates of 28.9% and anxiety rates of 55.6%. The main factors associated with PTSD on multivariable analysis were female gender (P = 0.026, ORa = 13.1), insufficient involvement of partner in disease management (P < 10^?3, ORa = 12.1) and duration of epilepsy less than 12 months (P = 0.001; ORa = 0.1). Female gender (P = 0.006, ORa = 18.1) and restriction of social life (P = 0.006, ORa = 4.1) were associated with depression. Factors associated with anxiety were insufficient involvement of partner in disease management (P = 0.03, ORa = 4.6) and PTSD (P = 0.005, ORa = 9.1).ConclusionThese findings suggest that clinicians should pay more attention to psychological health of parents of children with epilepsy and help healthcare providers to develop preventive and intervention strategies for parents of such children.     

Connectivity biomarkers can differentiate patients with different levels of consciousness

ObjectiveIn the present study, we searched for resting-EEG biomarkers that distinguish different levels of consciousness on a single subject level with an accuracy that is significantly above chance.MethodsWe assessed 44 biomarkers extracted from the resting EEG with respect to their discriminative value between groups of minimally conscious (MCS, N = 22) patients, vegetative state patients (VS, N = 27), and – for a proof of concept – healthy participants (N = 23). We applied classification with support vector machines.ResultsPartial coherence, directed transfer function, and generalized partial directed coherence yielded accuracies that were significantly above chance for the group distinction of MCS vs. VS (.88, .80, and .78, respectively), as well as healthy participants vs. MCS (.96, .87, and .93, respectively) and VS (.98, .84, and .96, respectively) patients.ConclusionsThe concept of connectivity is crucial for determining the level of consciousness, supporting the view that assessing brain networks in the resting state is the golden way to examine brain functions such as consciousness.SignificanceThe present results directly show that it is possible to distinguish patients with different levels of consciousness on the basis of resting-state EEG.     

Evolution of psychological condition in caregivers of patients with disorders of consciousness: a longitudinal study

The aim of this study is to evaluate mood disorders and needs in caregivers of disorders of consciousness (DOC) patients during the admission to Neurorehabilitation Unit. A total of 80 caregivers was enrolled and divided in two groups (caregivers of vegetative state–VS patients and caregivers of minimally conscious state–MCS patients). Paired sample t tests were carried out to test differences between baseline observation (T0) and after 6 months (T1). Caregivers of VS patients showed an improvement between T0 and T1 especially, in vitality, mean health, Beck Depression Inventory (BDI-II), Spielberger State-Trait Anxiety Inventory-Y (STAI-Y), Prolonged Grief Disorder (PG 12) and Caregiver Needs Assessment (CNA). On the other hand, caregivers of MCS patients showed a significant improvement in: BDI II, STAI Y and CNA. These data confirmed that the presence of psychological problems, the quality of life and the psychological wellbeing of caregivers of DOC patients improved over the time.     

The association of posttraumatic stress disorder,complex posttraumatic stress disorder,and borderline personality disorder from a network analytical perspective

BackgroundPosttraumatic Stress Disorder (PTSD), Complex PTSD, and Borderline Personality Disorder (BPD) share etiological risk factors and an overlapping set of associated symptoms. Since the ICD-11 proposal for trauma-related disorders, the relationship of these disorders has to be clarified. A novel approach to psychopathology, network analysis, allows for a detailed analysis of comorbidity on symptom level.MethodsSymptoms were assessed in adult survivors of childhood abuse (N = 219) using the newly developed ICD-11 Trauma-Questionnaire and the SCID-II. The psychopathological network was analyzed using the network approach.ResultsPTSD and Complex PTSD symptoms were strongly connected within disorders and to a lesser degree between disorders. Symptoms of BPD were weakly connected to others. Re-experiencing and dissociation were the most central symptoms.ConclusionsMental disorders are no discrete entities, clear boundaries are unlikely to be found. The psychopathological network revealed central symptoms that might be important targets for specific first interventions.     

Death by request in Switzerland: Posttraumatic stress disorder and complicated grief after witnessing assisted suicide

BackgroundDespite continuing political, legal and moral debate on the subject, assisted suicide is permitted in only a few countries worldwide. However, few studies have examined the impact that witnessing assisted suicide has on the mental health of family members or close friends.MethodsA cross-sectional survey of 85 family members or close friends who were present at an assisted suicide was conducted in December 2007. Full or partial Post-Traumatic Distress Disorder (PTSD; Impact of Event Scale–Revised), depression and anxiety symptoms (Brief Symptom Inventory) and complicated grief (Inventory of Complicated Grief) were assessed at 14 to 24 months post-loss.ResultsOf the 85 participants, 13% met the criteria for full PTSD (cut-off ≥ 35), 6.5% met the criteria for subthreshold PTSD (cut-off ≥ 25), and 4.9% met the criteria for complicated grief. The prevalence of depression was 16%; the prevalence of anxiety was 6%.ConclusionA higher prevalence of PTSD and depression was found in the present sample than has been reported for the Swiss population in general. However, the prevalence of complicated grief in the sample was comparable to that reported for the general Swiss population. Therefore, although there seemed to be no complications in the grief process, about 20% of respondents experienced full or subthreshold PTSD related to the loss of a close person through assisted suicide.     

The impact of killing and injuring others on mental health symptoms among police officers

This study examined the relationship between killing or seriously injuring someone in the line of duty and mental health symptoms in a sample of police officers (N = 400) who were first assessed during academy training and at five additional time points over three years. We found that nearly 10% of police officers reported having to kill or seriously injure someone in the line of duty in the first three years of police service. After controlling for demographics and exposure to life threat, killing or seriously injuring someone in the line of duty was significantly associated with PTSD symptoms (p < .01) and marginally associated with depression symptoms (p = .06). These results highlight the potential mental health impact of killing or seriously injuring someone in the line of duty. Greater attention to mental health services following these types of exposures can serve as a preventative measure for police officers who have been negatively impacted.     

Screening for trauma‐related symptoms via a smartphone app: The validity of Smart Assessment on your Mobile in referred police officers

To facilitate easily accessible screening for trauma‐related symptoms, a web‐based application called Smart Assessment on your Mobile (SAM) was developed. In this study, we examined whether SAM was able to accurately identify posttraumatic stress disorder (PTSD) and depression in adults. Eighty‐nine referred police officers completed SAM, containing the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (DSM)‐5 (PCL‐5) and the Depression Anxiety and Stress Scale (DASS‐21), on their own device prior to a diagnostic interview where the Clinician‐Administered PTSD Scale for DSM‐5 (CAPS‐5) and Structured Clinical Interview for DSM‐IV (SCID‐I/P) were administered. Results showed a substantial agreement between SAM and the diagnostic interview in the assessment of PTSD and depression. An optimal trade‐off between sensitivity (89%) and specificity (68%) levels was found at a cut‐off score of 31 on the PTSD Checklist for DSM‐5 (area under the curve = 0.845, 95% CI [0.765, 0.925], diagnostic odds ratio = 15.97). This is one of the first studies to support the validity and reliability of a mobile screener following trauma. SAM may facilitate screening for trauma‐related symptoms on a large scale and could be a first step in a stepped‐care model for trauma survivors to help identify individuals who need further diagnostics and care.     

Characteristics of DSM-IV Attention Deficit Hyperactivity Disorder Combined and Predominantly Inattentive Subtypes in a Turkish Clinical Sample

Consecutively referred subjects (N = 537) to an outpatient clinic were evaluated to compare the Attention Deficit Hyperactivity Disorder Combined (ADHD-C) and predominantly inattentive (ADHD-PI) subtypes using parent and teacher ratings and neuropsychological variables. Statistical significance was at P < 0.002 adjusted for multiple comparisons. ADHD-PI subjects were older, more likely to be female, higher socioeconomic status, had lower Child Behavior Checklist and Teacher Report Form Aggression, Delinquency and Social Problems scores, and higher Withdrawal and Competence scores, compared to ADHD-C subjects. Comorbid conduct problems were more common among ADHD-C subjects. There were no differences in terms of anxiety/depression, and neuropsychological measures. The study is unique in that it provides data on a broad range of measures from a middle income developing country with important confirmation of similar pattern of differences and similarities between ADHD-C and ADHD-PI subtypes previously reported in North American and Western European samples.     

Avoidance behaviour of patients with posttraumatic stress disorder. Initial development of a questionnaire, psychometric properties and treatment sensitivity

In this study, the development of the Posttraumatic Avoidance Behaviour Questionnaire (PABQ) is described and validated in 437 participants; PTSD patients (N = 75), clinical controls (patients with panic disorder with agoraphobia; PDA) (N = 50), and non-clinical traumatized controls (N = 312). Item reduction and exploratory factor analyses yielded 25 items reflecting seven factors. Internal consistency, test-retest reliability, convergent and discriminative validity of the PABQ proved adequate. In a second study, the PABQ showed to be sensitive to change due to exposure treatment outcome (N = 26).     

Trauma type as a conditional risk factor for posttraumatic stress disorder in a referred clinic sample of adolescents

IntroductionTraumatic experiences that are varied in type and severity may lead to the development of Posttraumatic Stress Disorder (PTSD). Some trauma types present a higher conditional risk for PTSD owing to their nature and impact on growth and functioning. Few studies have investigated the conditional risk of PTSD in clinic referred adolescents in low- and middle-income countries. The aim of the study was to determine the conditional risk for PTSD based on various trauma types (car accidents, other serious accidents, fires, witnessing a natural disaster, witnessing a violent crime, being confronted with traumatic news, witnessing domestic violence, physical abuse and sexual abuse) and to stratify risk by gender.MethodAdolescents exposed to at least one Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) qualifying trauma were referred to a research clinic in Cape Town, South Africa (n = 216). PTSD status was assessed using a clinician administered interview. Conditional risk was determined using backwards stepwise multiple logistic regression analysis for 1) the whole sample, 2) females only and 3) males only. Gender differences in exposure to trauma types were determined using chi-square tests and cross-tabulation.ResultsThe prevalence of PTSD was 48.1% in the whole sample. Age (β = .16, p = .048, OR 1.17), fire exposure (β = 2.32, p = .036, OR 10.12) and sexual abuse (β = .93, p = .001, OR 2.54) were significant predictors of PTSD in the whole sample with the model explaining 12.4% of the variance in PTSD status. Age (β = .22, p = .041, OR 1.24) and sexual abuse (β = .87, p = .018, OR 2.39) were significant predictors of PTSD in female participants and explained 9.8% of the variance in PTSD status. Being a victim of a violent crime (β = .78 p = .100, OR 2.19) was the only remaining predictor of PTSD in male participants and showed a trend towards significance. The model explained 7% of the variance in PTSD status.ConclusionsThe findings underscore the importance of timely identification of trauma, particularly, sexual abuse and violence. Longitudinal tracking of adolescents exposed to different trauma types may identify those in need of treatment and enhance our understanding of the lasting impact of trauma.