Perspectives of Patients and Providers in Using Shared Decision Making in Psychiatry

Community Mental Health Journal - There is increased interest over the last decade in the use of Shared Decision Making with individuals with serious mental illness to improve engagement in...     

Abnormal Corticospinal Excitability in Patients with Disorders of Consciousness

BackgroundTranscranial magnetic stimulation (TMS) has been frequently used to explore changes in the human motor cortex in different conditions, while the extent of motor cortex reorganization in patients in vegetative state (VS) (now known as unresponsive wakefulness syndrome, UWS) and minimally conscious (MCS) states due to severe brain damage remains largely unknown.Objective/hypothesisIt was hypothesized that cortical motor excitability would be decreased and would correlate to the level of consciousness in patients with disorders of consciousness.MethodsCorticospinal excitability was assessed in 47 patients (24 VS/UWS and 23 MCS) and 14 healthy controls. The test parameters included maximal peak-to-peak M-wave (M_max), F-wave persistence, peripheral and central motor conduction times, sensory (SEP) and motor evoked (MEP) potential latencies and amplitudes, resting motor threshold (RMT), stimulus/response curves, and short latency afferent inhibition (SAI). TMS measurements were correlated to the level of consciousness (assessed using the Coma Recovery Scale-Revised).ResultsOn average, the patient group had lower M_max, lower MEP and SEP amplitudes, higher RMTs, narrower stimulus/response curves, and reduced SAI compared to the healthy controls (P < 0.05). The SAI alterations were correlated to the level of consciousness (P < 0.05).ConclusionsThe findings demonstrated the impairment of the cortical inhibitory circuits in patients with disorders of consciousness. Moreover, the significant relationship was found between cortical inhibition and clinical consciousness dysfunction.     

Disorders of Consciousness: An Embedded Ethnographic Approach to Uncovering the Specific Influence of Functional Neurodiagnostics of Consciousness in Surrogate Decision Making

A recent qualitative study published in Neuroethics by Schembs and colleagues explores how functional neurodiagnostics of consciousness inform surrogate decision making in cases of disorders of consciousness. In this commentary, we argue that the chosen methodology significantly limits the scope of the potential conclusions and suggest an embedded ethnographic approach of co-presence as an alternative.

     

White Matter Deficits Underlying the Impaired Consciousness Level in Patients with Disorders of Consciousness

In this study, we aimed to (1) identify white matter (WM) deficits underlying the consciousness level in patients with disorders of consciousness (DOCs) using diffusion tensor imaging (DTI), and (2) evaluate the relationship between DTI metrics and clinical measures of the consciousness level in DOC patients. With a cohort of 8 comatose, 8 unresponsive wakefulness syndrome/vegetative state, and 14 minimally conscious state patients and 25 patient controls, we performed group comparisons of the DTI metrics in 48 core WM regions of interest (ROIs), and examined the clinical relevance using correlation analysis. We identified multiple abnormal WM ROIs in DOC patients compared with normal controls, and the DTI metrics in these ROIs were significantly correlated with clinical measures of the consciousness level. Therefore, our findings suggested that multiple WM tracts are involved in the impaired consciousness levels in DOC patients and demonstrated the clinical relevance of DTI for DOC patients.     

Brain Network Studies in Chronic Disorders of Consciousness: Advances and Perspectives

Neuroimaging has opened new opportunities to study the neural correlates of consciousness, and provided additional information concerning diagnosis, prognosis, and therapeutic interventions in patients with disorders of consciousness. Here, we aim to review neuroimaging studies in chronic disorders of consciousness from the viewpoint of the brain network, focusing on positron emission tomography, functional MRI, functional near-infrared spectroscopy,electrophysiology, and diffusion MRI. To accelerate basic research on disorders of consciousness and provide a panoramic view of unconsciousness, we propose that it is urgent to integrate different techniques at various spatiotemporal scales, and to merge fragmented findings into a uniform‘‘Brainnetome'(Brain-net-ome) research framework.     

Spatial Properties of Mismatch Negativity in Patients with Disorders of Consciousness

In recent decades, event-related potentials have been used for the clinical electrophysiological assessment of patients with disorders of consciousness (DOCs). In this paper, an oddball paradigm with two types of frequency-deviant stimulus (standard stimuli were pure tones of 1000 Hz; small deviant stimuli were pure tones of 1050 Hz; large deviant stimuli were pure tones of 1200 Hz) was applied to elicit mismatch negativity (MMN) in 30 patients with DOCs diagnosed using the JFK Coma Recovery Scale-Revised (CRS-R). The results showed that the peak amplitudes of MMN elicited by both large and small deviant stimuli were significantly different from baseline. In terms of the spatial properties of MMN, a significant interaction effect between conditions (small and large deviant stimuli) and electrode nodes was centered at the frontocentral area. Furthermore, correlation coefficients were calculated between MMN amplitudes and CRS-R scores for each electrode among all participants to generate topographic maps. Meanwhile, a significant negative correlation between the MMN amplitudes elicited by large deviant stimuli and the CRS-R scores was also found at the frontocentral area. In consequence, our results combine the above spatial properties of MMN in patients with DOCs, and provide a more precise location (frontocentral area) at which to evaluate the correlation between clinical electrophysiological assessment and the level of consciousness.     

Implications of Recent Neuroscientific Findings in Patients with Disorders of Consciousness

A pressing issue in neuroscience is the high rate of misdiagnosis of disorders of consciousness. As new research on patients with disorders of consciousness has revealed surprising and previously unknown cognitive capacities, the need to develop better and more reliable methods of diagnosing these disorders becomes more urgent. So too the need to expand our ethical and social frameworks for thinking about these patients, to accommodate new concerns that will accompany new revelations. A recent study on trace conditioning and learning in vegetative and minimally conscious patients shows promise as a potential diagnostic and prognostic tool, both for differentiating between states of diminished consciousness, and for predicting patient outcomes, but it also generates fresh concerns about quality of life in patients previously thought to be completely unaware. Optimism about progress in diagnosing and treating disorders of consciousness must be tempered by the understanding that not all progress will necessarily be good for all patients. The prognosis for most patients remains bleak, and we must remain vigilant to acute questions and concerns about welfare and quality of life.     

Visual Fixation Assessment in Patients with Disorders of Consciousness Based on Brain-Computer Interface

Visual fixation is an item in the visual function subscale of the Coma Recovery Scale-Revised (CRS-R). Sometimes clinicians using the behavioral scales find it difficult to detect because of the motor impairment in patients with disorders of consciousness (DOCs). Brain-computer interface (BCI) can be used to improve clinical assessment because it directly detects the brain response to an external stimulus in the absence of behavioral expression. In this study, we designed a BCI system to assist the visual fixation assessment of DOC patients. The results from 15 patients indicated that three showed visual fixation in both CRS-R and BCI assessments and one did not show such behavior in the CRS-R assessment but achieved significant online accuracy in the BCI assessment. The results revealed that electroencephalography-based BCI can detect the brain response for visual fixation. Therefore, the proposed BCI may provide a promising method for assisting behavioral assessment using the CRS-R.     

A Novel Prognostic Approach to Predict Recovery in Patients with Chronic Disorders of Consciousness

正Severe brain injury can lead to acute or chronic disorders of consciousness (DOC), and the latter represents a more critical challenge in diagnosis and management. For most chronic unconsciousness survivors with preserved sleepwake cycles, including vegetative state (VS) and minimally     

Spinal Cord Stimulation Frequency Influences the Hemodynamic Response in Patients with Disorders of Consciousness

Spinal cord stimulation (SCS) is a promising technique for treating disorders of consciousness (DOCs). However, differences in the spatio-temporal responsiveness of the brain under varied SCS parameters remain unclear. In this pilot study, functional near-infrared spectroscopy was used to measure the hemodynamic responses of 10 DOC patients to different SCS frequencies (5 Hz, 10 Hz, 50 Hz, 70 Hz, and 100 Hz). In the prefrontal cortex, a key area in consciousness circuits, we found significantly increased hemodynamic responses at 70 Hz and 100 Hz, and significantly different hemodynamic responses between 50 Hz and 70 Hz/100 Hz. In addition, the functional connectivity between prefrontal and occipital areas was significantly improved with SCS at 70 Hz. These results demonstrated that SCS modulates the hemodynamic responses and long-range connectivity in a frequency-specific manner (with 70 Hz apparently better), perhaps by improving the cerebral blood volume and information transmission through the reticular formation-thalamus-cortex pathway.     

Order Effects within the Trail Making and Stroop Tests in Patients with Neurologic Disorders

Effects of order of presentation within the Trail Making and Stroop tests were investigated by comparing 50 consecutive patients receiving detailed neuropsychological assessment given the components of each test in standard order with 50 given them in reverse. Groups were well matched on a wide range of demographic and neuropsychological variables. The only significant group difference in mean scores for the test components and derived ratios and differences, a higher Trail Making Test Part B/Part A ratio in the ‘reverse’ group than in the ‘standard’ group, was most easily explained in terms of a slight effect of practice in visual scanning. Greater variance in the Stroop Test Part C score and its derivatives in the standard group may have been attributable to factors other than order of presentation. Performance of these tests in patients with neurological disorders is not crucially dependent upon accumulation of proactive interference from simpler to more complex parts; the latter can reasonably be used in isolation.     

Preferences for Participation in Decision Making Among Ethnically Diverse Patients with Anxiety and Depression

This study explored preferences for treatment decision making using the Control Preferences Scale and Problem Solving Decision Making Scale among a sample of ethnically diverse adults (N = 60) seeking treatment for anxiety and depression. Most participants expressed a desire for participation in shared decision making. Being Hispanic was significantly associated with a more passive role in decision making. Participants preferred more involvement in decision making versus problem solving tasks for both mental and general health vignettes, and more involvement in mental health versus general health decision-making. More research is needed to confirm tentative results on the influence of sociodemographic variables on preferences for role and participation in treatment decision making and the variation in these preferences. Treatment seeking individuals with anxiety and depression have identifiable preferences for participation in decision making. Asking about patient preferences and a better understanding of variability in preferences may improve patient-provider communication.     

Responses of Patients with Disorders of Consciousness to Habit Stimulation: A Quantitative EEG Study

Whether habit stimulation is effective in DOC patient arousal has not been reported. In this paper, we analyzed the responses of DOC patients to habit stimulation. Nineteen DOC patients with alcohol consumption or smoking habits were recruited and 64-channel EEG signals were acquired both at the resting state and at three stimulation states. Wavelet transformation and nonlinear dynamics were used to extract the features of EEG signals and four brain lobes were selected to investigate the degree of EEG response to habit stimulation. Results showed that the highest degree of EEG response was from the call-name stimulation, followed by habit and music stimulations. Significant differences in EEG wavelet energy and response coefficient were found both between habit and music stimulation, and between habit and call-name stimulation. These findings prove that habit stimulation induces relatively more intense EEG responses in DOC patients than music stimulation, suggesting that it may be a relevant additional method for eliciting patient arousal.