Arnstein Finset

Coping strategies in patients with acquired brain injury: relationships between coping, apathy, depression and lesion location

Coping strategies in individuals suffering severe traumatic brain injury (TBI), cerebrovascular accidents (CVA), or hypoxic brain injury (HBI) were investigated in relation to apathy, depression, and lesion location. Seventy patients (27 with TBI, 30 with CVA, and 13 with HBI) filled in a coping questionnaire (COPE) and were evaluated with respect to apathy and depression. A comparison sample of 71 students also filled in COPE. Patients coping strategies were similar to the comparison group, but patients tended to display less differentiated coping styles. A factor analysis indicated two dimensions of coping in the patient sample; approach oriented and avoidance oriented coping. Approach and avoidance coping sum scores, based on subscales from the two factors, were positively correlated in the patient sample, but not in the comparison group. Lack of active approach oriented coping was associated with apathy, whereas avoidant coping was associated with depression. Coping styles were not related to lesion location. Apathy was related to subcortical and right hemisphere lesions. In bivariate analyses, depression was unrelated to lesion location, but, in a MANCOVA, avoidant coping, apathy and lesion location (left hemisphere lesions) contributed to the variance in positive depressive symptoms. The consistent relationships between coping strategies and neuropsychiatric symptoms were interpreted as two dimensions of adaptational behaviour: an active vs. passive dimension and a depression?distress-avoidance dimension.

Apathy and depressed mood in acquired brain damage: relationship to lesion localization and psychophysiological reactivity

BACKGROUND Apathy is a frequent neurobehavioural sequel in patients with acquired brain damage and it may seriously affect outcome of rehabilitation. METHODS Patients with traumatic brain injury, cerebrovascular insults and hypoxic brain injury, categorized into four lesion localization groups: left hemisphere damage (LHD); right hemisphere damage (RHD); bilateral hemispheric damage (BHD); and subcortical damage (SCD) were assessed with the Apathy Evaluation Scale (AES) and Montgomery and Asberg Depression Rating Scale (MADRS). Heart rate and electrodermal activity were recorded in an experimental situation that exposed the patients to mental stressors in order to measure psychophysiological reactivity. RESULTS Significant differences in level of apathy were found between diagnostic groups as well as between localization subgroups. SCD and RHD patients displayed most apathy. Factor analysis of MADRS revealed a three-factor solution; depressed mood, somatic symptoms and negative symptoms. Apathy was significantly correlated with negative symptoms in all localization subgroups, except among the BHD patients. Apathy was not correlated with depressed mood or somatic symptoms. Moreover, apathy was significantly correlated with heart rate reactivity, but not with electrodermal reactivity. CONCLUSION Apathy is common, its severity depending on diagnosis and localization of lesion. Apathy and depression in brain damaged patients share common features, but may be differentiated. The significant relationship between apathy and heart rate may provide a psychophysiological correlation of the disengagement, lack of interest and absence of emotional responsivity typically seen in apathy. The results have implications for the theoretical understanding of apathy and related negative symptoms, and for rehabilitation practice.

Long-term prevalence of impairments and disabilities after multiple trauma.

The prevalence of impairments and disabilities in activities of daily living (ADL), nonwork activities, and work were registered in a consecutive series (n = 69) of subjects with severe injuries. At follow-up 3 years after trauma, residual impairments prevailed in 80%. Only a few (6%) were ADL-dependent. Seventy-six percent had lost at least one nonwork activity, while vocational disability caused by the trauma occurred in 19%. Cognitive impairment was significantly associated with vocational disability, while physical impairment and pain were significantly associated with nonwork disability. Other parameters that influenced vocational disability negatively were age and blue-collar employment status. Although overall changes in social network quantity and quality were small, significantly more subjects with cognitive impairment or vocational disability experienced a decline in the quality and quantity of their social network after trauma. Furthermore, 25% of the subjects reported an increase in feelings of loneliness after trauma. We recommend the design of individualized, multidisciplinary rehabilitation plans before discharge from departments of surgery.

Androgens and estrogens in relation to hot flushes during the menopausal transition

In this paper, the association of hormones to vasomotor complaints during the menopausal transition is discussed. Fifty-seven regularly menstruating women without history of hormone replacement therapy (HRT) were selected for a longitudinal, prospective study around the menopausal transition. The mean age at the start of the study was 51.3 (+/-2.0) years. At intervals of 12 months all women went through a semi-structured interview and filled in questionnaires. Venous blood samples were collected every 12-month for analyses of estradiol (E2), testosterone, androstendione, dehydroepiandrosterone-sulphate (DHEA-S), follicle stimulating hormone (FSH), thyrotropin (TSH), and luteinizing hormone (LH). Vasomotor complaints were tested using questions about hot flushes and bouts of sweating in terms of occurrence, frequency and degree of distress. Forty-six percent of the subjects reported hot flushes and bouts of sweating before menopause, increasing to 67% during the first year after menopause and 49% in the second year postmenopause. Low levels of estradiol and high levels of FSH were associated with vasomotor complaints before menopause. During menopause high levels of TSH were related to vasomotor complaints. The first year after menopause, women, who at this point achieved hot flushes, were characterised by high levels of E2, but declining and low levels of FSH, but increasing. Postmenopausal, high levels of testosterone and DHEA-S seemed to protect against vasomotor symptoms. Our most important finding was, that among women who achieved hot flushes at the first assessment postmenopause, the high androgen levels was a significant predictor of recovery from hot flushes at the last assessment, 1 year later.

Self-reported social networks and interpersonal support 2 years after severe traumatic brain injury

Fifty-four patients with traumatic brain injury (TBI) consecutively admitted to a rehabilitation hospital were examined 2 years post-injury. Social interaction and support, subjective complaints, and functional status were assessed. A large variability in social interaction and support patterns was found. Most patients had more interaction and received more support from family members than from friends and neighbours. Thirty-one patients (57.4%) reported that their social networks had markedly declined subsequent to injury. Relatively short duration of coma (< 1 week) and severe sequelae in terms of low functional status and poor emotional adjustment at follow-up, especially in terms of deficits in initiating behaviour, were found to be related to little interaction and support. The importance of both provider and patient initiative in order to establish and preserve a social support network is suggested, and clinical implications briefly discussed.

Emotional activation during therapeutic interaction in traumatic brain injury: effect of apathy, self-awareness and implications for rehabilitation

Apathy and reduced self-awareness are frequent occurring neurobehavioural sequelae following traumatic brain injury (TBI). Apathy, in terms of reduced goal directed activity and lowered motivation, and reduced self-awareness have a negative impact on the rehabilitation process. In this study, 30 patients suffering severe TBI were clinically rated for apathy and monitored for cardiovascular and electrodermal reactivity during baseline, neutral speech and therapeutic interaction. Applying a cut-off score criterion, two thirds of the TBI sample were classified as apathetic. The apathetic patients showed less psychophysiological reactivity from neutral speech to therapeutic interaction, compared to non-apathetic patients. They also reported less perceived emotional discomfort in the therapeutic situation measured with a visual analogue scale. Moreover, reduced self-awareness was associated with low autonomic reactivity. The results suggest that the reduced psychophysiological reactivity in apathetic patients may be a correlate to the lack of emotional responsivity, disengagement, lack of insight and concern about their own situation. Clinically, these results may have implications for psychotherapeutic intervention aimed at improving self-awareness. Recording psychophysiological responses during therapeutic interaction may serve as a method for monitoring emotional involvement during psychotherapy with TBI patients.

Physician communication in different phases of a consultation at an oncology outpatient clinic related to patient satisfaction

The aim of this study was to identify the relationship between content during the different phases of the consultation and overall patient satisfaction with regular follow-up consultations at a cancer outpatient clinic. Thirty-six consultations were analysed with Roter Interaction Analysis System (RIAS). In the statistical analysis, timed events of the RIAS categories were used. The regular follow-up consultations were rather short aiming at discussing medical and therapeutic aspects of the illness. There was a positive correlation between physician informal talk (IT) and patient satisfaction in the history-taking phase. Patients were found to be dissatisfied if the physician had focused on a great deal of psychosocial exchange (PE) during physical examination. Our study suggests that the physician should not initiate discussion of psychosocial topics during physical exam. This result should be studied further in other samples and designs.

Trait anxiety and reactions to patient-centered and doctor-centered styles of communication: an experimental study.

Objective: A patient-centered model of communication has often been advocated in preference to a doctor-centered model. The aim of the present study was to assess in an experimental setting how subjects’ general level of anxiety affects their reactions to these two communication styles as measured by emotional reactions and satisfaction immediately after consultation. Methods: Twenty students with low trait anxiety and 21 students with high trait anxiety each had a single consultation with a physician who performed the consultation using either a patient-centered or doctor-centered style of communication. Questionnaires about emotional state were completed by the students before and after the consultation, and a questionnaire about satisfaction was completed after the consultation. Results: Students with low trait anxiety were significantly more satisfied with a patient-centered than a doctor-centered style of communication. There were no significant differences in emotional response to the two styles of communication. Students with high trait anxiety reacted emotionally more positively to a doctor-centered communication style, with significant and nearly significant change scores for the emotions of tension/anxiety and vigor/activity, respectively. No significant difference was found between satisfaction scores. Conclusions: Data indicate that differences between subjects’ emotional traits may be of importance for a differentiated response to patient-centered and doctor-centered communication styles. Subjects’ trait anxiety seems to be a significant factor that should be taken into account when assessing the effects of different communication styles.

Learning to have less pain - is it possible? A one-year follow-up study of the effects of a personal construct group learning programme on patients with chronic musculoskeletal pain.

A randomised controlled study with the objective to explore the effects of a group learning programme based on a phenomenological epistemology and personal construct theory. Main outcome measures were: experienced pain, pain coping strategies, absenteeism, disability pension and health care consumption. One hundred and twenty-one patients with chronic musculoskeletal pain and high absenteeism were included in this study. The intervention group (n=77) consisted of nine smaller groups with 6-10 persons in each and were counselled by health personnel with special training. The control group consisted of 44 persons. The learning programme emphasised awareness, possible relations between bodily symptoms, emotions, mind and life situation, and change of focus from pain and disability to resources and potentials. One year after the end of the learning programme (T3), patients in the intervention group reported significant pain reduction, increased pain-coping abilities and a higher reduction of health care consumption than the control group (P<0.05). Absenteeism was not significantly reduced compared to the control group, but there were fewer persons receiving disability pension in the intervention group at T3 (38 versus 59%) (P<0.05). This group-learning programme should be considered an important adjunct to the therapy of patients with chronic muscular pain.

Communicating with alexithymic and non-alexithymic patients: An experimental study of the effect of psychosocial communication and empathy on patient satisfaction

Background: Previous studies have shown that alexithymia is associated with a wide range of somatic and psychiatric conditions. The aim of this study was to investigate experimentally how psychosocial communication and empathic response from the physician affects satisfaction in alexithymic and non-alexithymic patients. Method: Seven physicians and 65 female patients from a fibromyalgia patient association participated in the study. The Toronto Alexithymia Scale (TAS-20) was used to categorise patients as alexithymic or non-alexithymic. Patients also completed questionnaires regarding trait anxiety and satisfaction with their consultation. Physicians were instructed to differentiate their communication in terms of both psychosocial matters and empathic response. The content of the consultation was analysed using the Roter Interactional Analysis System. Results: Regression analyses revealed that alexithymic patients were significantly more satisfied when they received a greater empathic response from the physician. Non-alexithymic patients, however, were more satisfied when the consultation was of longer duration. Psychosocial communication did not have any statistically significant effect on satisfaction in either of the two subgroups. Conclusions: Verbalised empathic response from the physician may be crucial for the alexithymic patient’s post-consultation satisfaction and may thereby become the basis for a solid treatment alliance. The validity of this hypothesis should be tested in different clinical settings and with different patient populations. Future research on alexithymic patients’ response to psychosocial communication may benefit from determining to what extent this communication is concerned with general distress or more complex emotional phenomena.