Catastrophic Reactions Research Articles

Psychiatric Aspects of Neurologic Diseases: Practical Approaches to Patient Care

Back to table of contents Previous article Next article Book ForumFull AccessPsychiatric Aspects of Neurologic Diseases: Practical Approaches to Patient CareTHOMAS M. WISE M.D.,THOMAS M. WISE M.D.Search for more papers by this author,Published Online:1 Oct 2009https://doi.org/10.1176/appi.ajp.2009.09030401AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This excellent clinical resource opens with the statement that psychiatry and neurology had their origins together and were linked by a “fascination with behavior in the broadest meaning.” Today these two disciplines overlap: many patients with neurologic diseases suffer from cognitive deficits, abnormal mood states, and difficult behaviors that are fundamental to their disease states or reaction to the illness, and psychiatrists are increasingly asked to help manage such patients. This book from the psychiatry faculty at Johns Hopkins should be in the library of both psychiatrists and neurologists.The first section, “Psychiatric Assessments and Syndromes,” reviews the psychiatric examination and describes various psychiatric symptoms and syndromes. Demoralization, a common yet often misunderstood reaction to adversity, is increasingly recognized as a unique category in itself and is comprehensively described. This is a section that should be used by medical students during their psychiatric clerkships and by psychiatrists preparing for their general psychiatric boards.The second section, “Psychiatric Aspects of Neurologic Diseases,” reviews elements of mind, mood, and behavior of a variety of neurologic disorders including stroke, traumatic brain injury, headaches and chronic pain, multiple sclerosis, and other disorders commonly seen by physicians. Each chapter is outstanding and outlines both the common psychiatric disorders that co-occur with a neurologic disorder and helpful treatment interventions. The chapter on pain reviews headaches but also chronic pain and provides excellent tables for analgesics. The chapter on traumatic brain injury reviews common problems in this syndrome, such as apathy, irritability, behavioral disorders, and depression, with an excellent table on various medications for each symptom complex. The caregivers of individuals with neurologic diseases are not forgotten and are briefly discussed within each chapter. The chapter on Tourette’s syndrome includes important information about children and adolescents who are often diagnosed with this troubling syndrome. Chapters on other disorders, whether common, such as Parkinson’s, epilepsy, and stroke, or less common, such as Huntington’s, allow the reader to easily obtain necessary information on presentation, course, and treatment.The final section, on psychiatric treatments, covers in detail contemporary psychotropic medications and their uses and side effects. The chapter on the use of stimulants and dopamine augmenters is particularly helpful. Neuroleptics, anxiolytics, and mood stabilizers are included in this section.Chapters on psychotherapy and other nonpharmacological interventions, which include the rationale for structured day treatment centers and psychoeducation, complete the volume. A glossary at the end of the book is useful. For example, “catastrophic reaction” is defined and a clinical example is provided. The book is issued in paperback and can fit into a lab coat pocket. All the chapters are carefully edited and presented in a clear and consistent writing style with judicious use of tables. Whatever the reader’s level of training, this book offers an up-to-date means of mastering a body of knowledge that is mandatory for any competent psychiatrist or neurologist.Falls Church, Va.The author reports having served on the speakers bureaus for Eli Lilly and Pfizer.Book review accepted for publication June 2009 (doi: 10.1176/appi.ajp.2009.09030401). FiguresReferencesCited byDetailsCited byNone Volume 166Issue 10 October, 2009Pages 1194-1194THE AMERICAN JOURNAL OF PSYCHIATRY October 2009 Volume 166 Number 10 Metrics PDF download History Published online 1 October 2009 Published in print 1 October 2009

Patterns of Antecedents of Catastrophic Reactions in Nursing Home Residents With Dementia in the United States

The purpose of this study was to describe the patterns of antecedents of catastrophic reactions (CRs) in nursing home residents with dementia in the United States. A total of 229 catastrophic reaction events were the sample for this study. Ten antecedent variables were selected and analyzed using cluster analysis to address the patterns of antecedents of CRs in dementia. Data were obtained from field observation and a structured recording form over a 6-week period covering all 7 days of the week and all three shifts (i.e., 21 shifts in total) in two nursing homes in the United States. This study showed that there were two distinct patterns of antecedent conditions at the time of, or immediately prior to, CRs in dementia: (a) a cluster of antecedents that consists of components of the physical environment including public location, olfactory stimulation, use of media, sundowning hours, and being in a dementia unit ("Stimulation in Early Evening"); and (b) a cluster of antecedents that is composed of mixed components of the physical and social environment including olfactory stimulation, activities of daily living (ADL)-related care activities, demands of tasks, and being in a dementia unit ("Stress due to Care, Tasks, and Odors"). The findings suggest that elders who are exposed to overstimulation in sundowning hours or experience stress from care activities and task performance beyond their baseline competency are likely to be at risk of presenting with CRs. Health care providers need to be aware that a CR is a multi-factorial phenomenon in which multiple contextual antecedents are involved and that creation of a therapeutic physical and social milieu is an important nursing goal in preventing the occurrence of CRs in nursing home residents with dementia. [Asian Nursing Research 2009;3(3):99-110].

Catastrophic Reactions of a Child with an Autism Spectrum Disorder: A Social Phenomenon

AbstractThis investigation presents analysis of the catastrophic reactions of a child with pervasive developmental disorder—not otherwise specified (PDDNOS). Upon analysis, these catastrophic reactions are effectively described as social phenomena. That is, although maladaptive coping patterns in children with autism spectrum disorders often lead to catastrophic reactions including tantrums, self-injury, and aggression, these behaviors are often oriented to social interactions. The authors discuss three themes that permeate such social interaction: collaboration, negotiation, and control. By recognizing these themes, in this participant, the data suggest that it is possible that at least some catastrophic reactions by children are not totally irrational, but rather social in nature. Clinical implications include the consideration of the importance of family centered intervention for children with developmental disorders. Clinicians are encouraged to identify patterns of interaction with the child's social...

Patients with painful bladder syndrome have altered response to thermal stimuli and catastrophic reaction to painful experiences

To compare cutaneous sensory thresholds, habituation to somatic stimuli, and tendency towards catastrophic reaction to painful stimuli in patients with Painful Bladder Syndrome (PBS) to controls without PBS. Thermal and vibratory sensory thresholds were established in 11 PBS patients and 10 controls at C5, T1, T12, and S3 dermatomes. Supra-threshold thermal stimuli were then applied at T12 and S3 for 60 sec while patients periodically rated the intensity of stimuli using a visual analog scale. A Pain Catastrophizing Scale (PCS) questionnaire was also completed by all participants before testing. PBS patients were less sensitive to warm stimuli in the T12 dermatome than asymptomatic controls (thresholds 36.6 +/- 1.10 degrees C vs. 35.3 +/- 1.0 degrees C, P < 0.02) but otherwise had similar thermal and vibratory thresholds. Habituation to supra-threshold stimuli at T12 and S3 dermatomes was more common in controls than PBS subjects (7 (70%) vs. 2 (18%), P < 0.03 and 9 (90%) vs. 3 (27%), P < 0.008, respectively). The PCS score correlated with the duration of PBS symptoms and with thresholds to warm stimuli at T12 dermatome (rho = 0.65, P < 0.03 and rho = 0.5, P < 0.021, respectively). Our data suggests that habituation to stimuli may be impaired and that a catastrophic reaction to perceived stimuli may be involved in the sensory experience of PBS patients and facilitate chronic pain. Neurourol. Urodyn. 28:400-404, 2009. (c) 2009 Wiley-Liss, Inc.

Alluvial and coastal hazards caused by long-range effects of Plinian eruptions: the case of the Lattari Mts. after the ad 79 eruption of Vesuvius

Abstract The Lattari Mountains (a limestone ridge about 20 km south of Vesuvius) received 1–2.5 m of fallout from the famous Plinian eruption of ad 79. As demonstrated by many residual outcrops of thick volcanoclastic debris-flow and alluvial deposits (referred to here as the Durece unit), the pyroclastic fall was soon followed by rapid erosion and landsliding that produced (1) decametre-scale aggradation of some narrow valley floors; (2) reactivation of alluvial fans; and (3) growth of new fan-deltas (extending as far as 500 m) at the coast. This response was primarily due to the steep topography of the area and the high erodability of the pyroclastic materials (light and cohesionless pumice fragments). Several geo-archaeological data indicate that the accelerated sedimentation had a duration of the order of decades and was followed by rapid dissection of the Durece unit deposits and fast dismantling by wave action of the newly created fan-deltas. This case highlights the need to consider the possibly catastrophic reaction of fluvial and coastal systems to large explosive eruptions, even in non-volcanic terrains at some distance from the volcano.

New Thinking on Flame Retardants

No one wants their bed, couch, chair, computer, or TV to catch on fire. “If an ordinary upholstered chair in your home gets ignited, it can essentially take your whole house down,” says Richard Gann, a senior research scientist at the U.S. National Institute of Standards and Technology’s (NIST) Building and Fire Research Laboratory. The most flammable part of a mattress or couch is its plastic polyurethane foam cushioning, he explains. Once a fire gets through a chair or mattress’s fabric covering and into this cushioning, it can start a catastrophic reaction that quickly leads to “flashover,” in which nearly everything combustible inside a room ignites simultaneously. Until very recently, brominated flame retardants, especially polybrominated diphenyl ethers (PBDEs), were one of the main materials used to reduce the speed with which the plastic components of consumer goods including beds, couches, chairs, and electronics could be consumed by fire. However, growing evidence shows that PBDE compounds are escaping from the products they protect and making their way into the products’ users. Moreover, the chemicals may disrupt human thyroid hormone functioning and cause other health effects, prompting many nations to ban or suspend their use in new consumer goods. [For more information on the health effects of PBDEs, see “Unwelcome Guest: PBDEs in Indoor Dust, p. A202 this issue.] Although bromine- and chlorine-containing flame retardants are still used in some products, the need for new alternatives is being driven by a confluence of policy, standards, and pressure from environmental groups. Europe banned the use of two formulations, PBDE pentaBDE and octaBDE, in 2004, the same year they were withdrawn from the North American market. A third compound, decaBDE, was banned 1 April 2008 by the European Court of Justice. Stateside, Maine has banned the use of decaBDE, the only PBDE still on the market in North America, in mattresses and residential upholstered furniture produced and sold in that state, and will extend the ban to electronics in 2010. Washington prohibits the use of decaBDE in mattresses and sets a process for a future ban in furniture and electronics if the state can identify a safer and feasible alternative that meets fire safety standards. Asian countries and other U.S. states have similar legislation in the works. “Instead of adding new fire retardant chemicals that ultimately may be shown to cause health problems, we should be asking whether we need to use these chemicals or if there are other ways to achieve equivalent fire safety,” contends Arlene Blum, a biophysical chemist and visiting scholar at the University of California, Berkeley. “So many of the chemicals we have banned in the past were flame retardants—think about asbestos, polychlorinated biphenyls, polybrominated biphenyls, tris(2,3-dibromopropyl) phosphate, PBDEs—[and] they all ended up in the environment and in people,” she points out. “We need to think carefully about adding these sorts of chemicals to consumer products before there is adequate health information.”

Reaction to a Dementia Diagnosis in Individuals with Alzheimer's Disease and Mild Cognitive Impairment

To examine short-term changes in depression and anxiety after receiving a dementia diagnosis. Pre/post survey design. Alzheimer's Disease Research Center. Ninety individuals and their companions. Fifteen-item Geriatric Depression Scale and 20-item "state" version of the State-Trait Anxiety Inventory. Sixty-nine percent of the individuals were diagnosed with dementia; two-thirds of those were in the earliest symptomatic stages of dementia that, in other settings, is considered to represent mild cognitive impairment. No significant changes in depression were noted in individuals or their companions, regardless of diagnostic outcome or dementia severity. Anxiety decreased substantially after diagnostic feedback in most groups. Disclosure of a dementia diagnosis does not prompt a catastrophic emotional reaction in most people, even those who are only mildly impaired, and may provide some relief once an explanation for symptoms is known and a treatment plan is developed.

The Immunogenic Potential of Generic Version of Low-Molecular-Weight Heparins May Not be the Same as the Branded Products

translate into their safety and efficacy profiles in a given clinical indication. Therefore, the United States Food and Drug Administration (FDA) and other regulatory bodies consider each of the commercially available LMWHs as a distinct drug and require clinical validation for the approval of each of these in specific indications. The introduction of generic versions of the branded LMWHs has challenged the regulatory bodies to develop specific guidelines for their approval. The current guidelines for generic drug approval are not adequate because of the complex nature of the LMWHs due to biologic origins and chemical modifications of a polycomponent mixture of glycosaminoglycans. Although the incidence of HIT is rare with the use of LMWHs and heparinomimetics such as fondaparinux and idraparinux when used for prophylactic and therapeutic indications, these agents are capable of generating antibodies to heparin-PF4 complex, which are measurable by using immunologic methods. The relative prevalence of these antibodies is method-dependent owing to different capturing probes. Moreover, the relative proportion of antibody subtypes (immunoglobulin G, A, and M) differ from product to product. Up to 20% of the patients treated with LMWHs generate these antibodies. The pathophysiologic role of these antibodies remains unknown at this time. However, this immunogenic response is comparable to autoimmune responses observed in the case of the antiphospholipid syndrome. Additional data are needed to identify the role of these antibodies in various pathologic states and their impact on clinical outcomes. The FDA has been visionary in identifying the immunogenicity of LMWHs as an important criterion to differentiate and demonstrate the bioequivalence Heparin-induced thrombocytopenia (HIT) is a catastrophic adverse reaction associated with the use of heparins and related products. Although the incidence of HIT with low-molecularweight heparins (LMWHs) is much lower than with unfractionated heparin (UFH), these agents are capable of triggering immunogenic responses in 10% to 20% of the patients treated for different indications. The generation of these antibodies depends on the dosage, duration of treatment, patient population, and underlying comorbidities. Differences in the immunogenic responses among different branded LMWHs have been noted. These differences are due to the structural composition of the LMWH and the interactions with endogenous platelet factor 4 (PF4) and other proteins. Low-molecular-weight heparins have been differentiated on the basis of several biophysical, biochemical, and pharmacologic properties. These differences

Angst und Panik als „Katastrophenreaktion” des Organismus - Die Aktualität Kurt Goldsteins (1878-1965) für die moderne Psychosomatik im Spannungsfeld von Neurobiologie, Tiefenpsychologie und Psychotraumatologie

Bei Angst und Panik handelt es sich um ein psychophysisches Gesamtgeschehen, bei dem einmal mehr psychische, einmal mehr körperliche, vegetative Symptomatik im Vordergrund steht. Insbesondere bei Komorbidität mit chronischen Schmerzen sollte bei Schmerzkrisen oder depressiven Dekompensationen an catastrophic reactions gedacht werden. Der menschliche Organismus ist mit der konkreten existenziellen Situation untrennbar verknüpft, seinen Handlungsmöglichkeiten und Selbstaktualisierungen. Bei 10-20 % aller chronischen Schmerzpatienten mit Angstzuständen und schweren Depressionen mit Anpassungsstörungen (vor allem von Frauen) finden sich erhebliche psychophysische Traumatisierungen in der frühen Lebensgeschichte wie sexueller Missbrauch, Psychoterror und Gewalt oder in der späteren wie zum Beispiel Mobbing. Der Zusammenbruch gerade angesichts alltäglicher Belastungen ist im Sinne eines neurobiologischen und neuropsychologischen Geschehens als Katastrophereaktion einzuordnen. Damit ist ein Hinweis auf Verlust der Fähigkeiten zum „Kategorialen” gegeben mit der Folge konkretistischer Fixierung. Die Somatisierung ist ein Phänomen einer solchen existenziellen Einengung auf Konkretistisches. Das hat Konsequenzen für die Therapie, die den Patienten langsam an die Bewältigung erfüllbarer Aufgaben heranführen muss und ihn für komplexere Weltbezüge, wie Arbeitssituation, Konflikte durchzuhalten, neue Beziehungen aufzunehmen, vorzubereiten hat. Wie in der psychotraumatologischen Behandlung sind der Umgang mit einem neurobiologisch zu verstehenden Geschehen, wie zum Beispiel der Intrusion, und das sich zurechtfinden in hermeneutisch und ideografisch zu erschließenden Phänomenen der Existenz mit psychodynamischem Geschehen, untrennbar miteinander verknüpft. In dieser Lernphase können auch auf dem Boden einer tragfähigen Arzt-Patient-Beziehung Psychopharmaka hilfreich sein. Damit erlernt der Patient, sein eigener Arzt zu werden und Dekompensationen, wie der Katastrophenreaktion, vorzubeugen. Die Katastrophenreaktion geht einher mit vegetativer Krise, Affektdurchbrüchen, Panik und Angstüberflutung. - Das Organismische Verstehen bietet die Chance, phänomenologisch vielfältige Krankheitsbilder vom hirnorganisch begründbaren Leiden, über PTBS, Somatisierungsstörungen bis hin zu vordergründig „rein psychischen” eine anthropologische Basis für Handlungssicherheit und grundlegende therapeutische Prinzipien zu geben. Die von Kurt Goldstein in der Behandlung von Hirnverletzten beider Weltkriege in vorbildlicher interdisziplinärer Zusammenarbeit von Neurologen, Biologen und Psychologen erarbeiteten Konzepte zum Organismischen beinhalten nicht nur ein für Klinik und Forschung wegweisendes erweitertes Verständnis von Biologie, sondern auch kritisches Potenzial für eine auf psychogene Konzepte eingeengte Psychosomatik, mit wichtigen Perspektiven für die Beziehung zur Psychiatrie.

The Big One: A Review of Richard Posner's Catastrophe: Risk and Response

Richard Posner's Catastrophe: Risk and Response (Oxford University Press, 2004) examines four risks whose worst cases could end advanced human civilization or worse: asteroid impacts, a catastrophic chain reaction initiated in high-energy particle accelerators, global climate change, and bioterrorism. He argues that these all warrant more thought and response than they are receiving, and that they can usefully be assessed using a simple analytic framework based on cost–benefit analysis. This essay reviews knowledge of these risks and critically examines Posner's claims for a consistent analytic approach. While the conclusions that each risk merits more thought and effort appear persuasive, these rely on ad hoc arguments specific to each risk. The general analytic claims do not hold up well, as Posner develops his proposed framework thinly and applies it unevenly. Applying such a framework consistently to catastrophic risks would require engaging some fundamental problems that Posner does not address. The book's major contributions are to identify and describe these risks, highlight the inadequate attention they are receiving, and advance a persuasive argument for their more serious examination.

Holistic neuropsychological rehabilitation in Finland: The INSURE program—a transcultural outgrowth of perspectives from Israel to Europe via the USA

Given the interaction of cognitive, behavioural, psychological, and physical factors resulting from traumatic brain injury (TBI), a comprehensive, multidisciplinary, and neuropsychologically oriented rehabilitation could prove to be particularly promising and efficacious in the neuropsychological rehabilitation of post‐acute brain‐injured individuals. Kurt Goldstein, an eminent pioneer in the development of holistic rehabilitation, stated that brain‐injured patients need environments that help them to avoid catastrophic reactions. In his view, the tasks of rehabilitation are to create, for the brain‐injured individual, an environment that will minimize the chances for the occurrence of catastrophic responses. In this environment, the individual can engage optimally in various remedial activities, which will gradually culminate in the individual finding new meaning in life after rehabilitation. Yehuda Ben‐Yishay incorporated many of Goldstein's ideas and developed a milieu or holistic rehabilitation program in 1978 in New York. The emerging role of psychotherapy for patients and their family members was characteristic of the Neuropsychological Rehabilitation Program that Prigatano established in 1980 in Oklahoma. In Europe, Anne‐Lise Christensen, who was also influenced by the work of A. R. Luria, started a holistic program at Copenhagen University in 1985. Based on these pioneering programs, several similar programs were established in Europe. A Finnish program, INSURE, was established in 1993 in Helsinki. The INSURE program is a post‐acute, interdisciplinary, 6‐week rehabilitation program for selected groups of TBI patients. The core of the program is neuropsychological rehabilitation and psychotherapy with vocational interventions, and follow‐up support. In recent years, a holistic rehabilitation program was also established in Turku for children with acquired brain injury. The European Holistic Working Group was founded in 2001, and the authors will also discuss their personal experiences and future of holistic neurospychological rehabilitation in terms of ongoing research work, computer‐administered cognitive remediation, and quality of life assessment.

Whose research is it anyway?

Taking part in research has had a bad press. No wonder, given catastrophic reactions to new drugs that were being tested in London and Baltimore, the use of dead children's organs without their parents' consent in Liverpool, and drug trials in India done with inadequate consent. These are extreme examples that do not reflect the careful and respectful approach of most researchers. But even the best researchers struggle to strike a proper balance between the overall public good of their work and the need to respect and protect the privacy of research participants. So this week's BMJ carries the first of …

Can childhood trauma predict response to topiramate in borderline personality disorder?

We report on a woman with borderline personality disorder and a history of childhood trauma that showed significant clinical response with low dosage of topiramate. We propose that topiramate changed some of the main features of this disorder, such as catastrophic reaction to real or imaginary abandonment or rejection, improving adaptive functioning. We hypothesize that topiramate might facilitate memory extinction, therefore decreasing emotional and behavioural reactivity.

Anger, hostility and aggression in the first days of acute stroke

In acute stroke patients, anger can disturb management and rehabilitation and creates a stressful situation for family, health-care providers and other patients. We aim to describe the presence of anger and its association with demographic, clinical, psychiatric, lesion variables and functional outcome in acute stroke patients. We screened anger prospectively in 202 consecutive acute stroke patients (< or =4 days) using eight items from three psychiatric scales (Catastrophic Reaction Scale, Mania Rating Scale and Comprehensive Psychopathological Rating Scale). Anger was present if the patient scored in at least one item. Anger was detected in 71 (35%) patients and 26 of these were severely angry (> or =4 points). There was no association between anger and the considered variables. Analysis of the items extracted two factors: (i) the emotional-cognitive and (ii) the behavioural components of anger. These components were independent of each other in 26 patients. In 38 patients we found a dissociation between clinical observation and patients' subjective expression. Anger was frequent in acute stroke patients. Anger was probably triggered by the brain lesion, which interfered with the emotional control. The lack of an association with clinical and imaging variables suggests a contribution of psychological/psychosocial dimensions.

Sensory Sensitivity, Attachment Experiences, and Rejection Responses Among Adults with Borderline and Avoidant Features

Both avoidant and borderline personality disorder (APD and BPD) are theoretically associated with temperamental vulnerabilities, adverse attachment experiences, and negative (pessimistic or catastrophic) reactions to the threat of perceived rejection; however, more work is needed to differentiate how these processes account for the etiology and maintenance of both disorders. In this study, 156 adults completed questionnaires measuring APD and BPD features, temperament (sensory-processing sensitivity), mood, and attachment experiences. A vignette task was devised to examine pessimistic cognitive-affective reactions in situations signaling potential rejection. Both APD and BPD were associated with temperamental sensitivity, but BPD was uniquely linked with a subscale measuring sensitivity to mental and emotive stimuli, whereas APD was uniquely linked with a subscale measuring the control and avoidance of aversive stimulation. Compared to APD, BPD was more strongly linked with negative moods (anxiety, anger, sadness) and insecure attachment to parents, whereas APD was more strongly linked (than BPD) to pessimistic cognitive-affective responses to rejection-related situations.

Dysfunctional beliefs in panic disorder: The Panic Belief Inventory

The Panic Belief Inventory (PBI) was developed to assess beliefs that increase the likelihood of catastrophic reactions to physical and emotional experiences in panic disorder. In the first stage of scale development, 197 panic disorder patients completed the PBI and standard self-report inventories of psychiatric symptomatology. An exploratory factor analysis yielded a 4-factor solution from which a 35-item instrument with 4 scales was constructed. The shortened measure and its scales had good internal consistency and convergent validity and moderate discriminant validity. Subsequently, 22 panic disorder patients who received cognitive therapy completed the PBI and other self-report inventories of dysfunctional cognitions at intake, 4 weeks, 8 weeks, termination, and several follow-up intervals. Results indicated that the PBI decreased significantly across treatment, with the largest decline occurring between intake and 4 weeks into treatment. The PBI correlated more strongly with dysfunctional cognitions associated with anxiety than dysfunctional cognitions associated with depression. These results provide preliminary evidence that the PBI has adequate psychometric characteristics, is useful to assess change in dysfunctional beliefs during treatment, and has the potential to advance cognitive theories of panic.

A prospective study of predictors of poststroke depression

To investigate the association between early depressive behavior after stroke onset and occurrence of poststroke depression (PSD) at 3- and 12-month follow-up evaluations. The study prospectively included 273 patients with first-ever single uncomplicated ischemic stroke. In the stroke unit, nurses scored crying, overt sadness, and apathy daily using an observational method to include patients with comprehension deficits. The Barthel Index was used to assess disability. Follow-up evaluation at months 3 and 12 included psychiatric assessment based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Crying (19.8%), overt sadness (50.5%), and apathy (47.6%) were observed. Of the patients observed crying, 4 showed pathologic crying, 19 emotionalism, and 12 catastrophic reactions. Crying and overt sadness, but not apathy, were associated with a subjective experience of depression (p < 0.05). Thirty of 52 (58%) patients observed crying, 12 of 19 (63%) patients with emotionalism, and 5 of 12 (41%) patients with catastrophic reactions developed PSD within the first year. Multiple logistic regression analysis showed that only severe functional disability (odds ratio [OR], 4.31; 95% CI, 2.41 to 7.69), crying behaviors (OR, 2.66; 95% CI, 1.35 to 5.27), and an age <68 years (OR, 2.32; 95% CI, 1.30 to 4.13) were (p < 0.05) predictors of late PSD development (13% of the variance). In the stroke unit, crying and overt sadness are more reliable indicators of depressed mood than apathy. In patients with first-ever stroke, crying behaviors soon after stroke, a younger age, and severe disability are predictors of poststroke depression occurrence within the first year after stroke onset.

Second-impact syndrome.

Sports-related injuries are among the more common causes of injury in adolescents that can result in concussion and its sequelae, postconcussion syndrome and second-impact syndrome (SIS). Students who experience multiple brain injuries within a short period of time (hours, days, or weeks) may suffer catastrophic or fatal reactions related to SIS. Adolescents are particularly susceptible to the dangers of SIS, and current return-to-play guidelines may be too lenient to protect a student from SIS. Any student with signs of a concussion should receive medical evaluation and not be allowed to return to play in the current game or practice. The role of the school nurse includes being knowledgeable about management of head injuries and return-to-play guidelines, providing follow-up for athletes who have concussions, and providing education on prevention and management of head injuries.

Attitudes of patients with mild dementia and their carers towards disclosure of the diagnosis.

To determine the attitudes of patients with mild dementia and their carers towards the disclosure of diagnoses of cancer and dementia and whether there are differences between these groups. To determine whether any major adverse events occurred following disclosure of diagnosis of dementia. A prospective study followed by a retrospective case-note study after 1 year. Fifty patients with mild dementia and their carers were recruited from a memory clinic in Nottingham, UK, and an old-age psychiatrist, using a semistructured questionnaire, separately interviewed them. Questions related to whether patients and their carers wished to be told diagnoses of cancer and dementia; the reasons for this; whether they would want treatment and make use of predictive testing if available were included. At 1-year follow-up whether antidepressants had been prescribed and whether any catastrophic reaction had occurred following disclosure of diagnosis. An overwhelming majority of patients with mild dementia wished to be informed of their diagnosis (92%); even more (98%) of the same patient sample reported wanting disclosure of a hypothetical diagnosis of cancer. A higher proportion (98%) of carers would wish to be told if they were to develop either dementia or cancer. All patients and carers would like access to treatment for dementia. A total of 88% of patients and 86% of carers would make use of a predictive test of Alzheimer's disease. Before receiving a diagnosis of mild dementia, only 28% of patients had insight that they may have dementia. Only a quarter (26%) of carers did not want the doctor to disclose the diagnosis of dementia to the patient. After 1 year, 6% of the original sample had developed a depressive illness requiring antidepressant treatment and no major incidents had occurred following disclosure of diagnosis. There has been a growing debate on whether patients with dementia should be informed of their diagnosis. Until recently, little was known about the views of patients themselves. This study shows that the vast majority of patients with mild dementia wish to be fully informed. Despite increasing awareness, a quarter of carers still do not wish their relative to be informed, though wish to be informed if they themselves were to develop the illness. This is significantly lower, however, than previously reported, suggesting a shift in attitudes. This study adds support to the weight of evidence that disclosure of a diagnosis of dementia does not cause depression or any irreversible harm to the patient.

Sylvia Plath and the depression continuum

The use made by Dr Cooper (June 2003 JRSM1) of Sylvia Plath's case history to explore psychiatric nosology is interesting and his conclusion that she suffered from borderline personality disorder (BPD) is convincing. But there are further diagnostic issues to be considered. I have argued elsewhere2 that reliance on the DSM list of traits to diagnose BPD fails to highlight a central characteristic of these patients, namely a form of instability which reflects the alternating operation of one or other of a small range of patterns of interpersonal and intrapersonal functioning. This fragmented structure is initiated, in those genetically prone, by childhood exposure to psychologically unmanageable experiences. Subsequently, perceptions, experiences or thoughts of rejection or of threat can activate this dissociation. A relatively small range of constituent states is met with in borderline patients3 and these are most usefully described in terms of the relationship patterns determining interpersonal perceptions and behaviour and self attitudes and management. The 'overresponsiveness to daily experiences' and 'heightened reactivity to life's ups-and-downs' which Plath and other borderline people manifest are more accurately described by this 'multiple self states model' (MSSM). Four commonly encountered borderline states are evident in the case of Plath. The first is a state found in all borderline patients in which relationships are of the form 'abusing/abandoning to abused/abandoned'. Plath was over reactive to hints of rejection and could herself switch suddenly from closeness to abusing and rejecting others and harming herself. Second, striving can lead to real success, as with Plath, and praise can compensate for feeling unloved. But any hint of criticism or rejection can provoke catastrophic reactions, representing a switch from the 'striving–praising' to the 'abusing–abused' pattern, as evident in her self-harm and attempted suicide at Harvard. Third, intense relationships with idealized others can support phases of wellbeing and creativity but the actual or perceived shortcomings or betrayals of the other provoke switches into abusive patterns; this was manifest in her violently oscillating relationship with Hughes, well described in his Birthday Letters. Fourth, Plath's poetry can be seen to be preoccupied with 'borderline' themes (loss, violence and contradictory experiences of the self) but these do not necessarily generate poetry. The association of instability with creativity is probably linked with another borderline trait, the capacity for intense concentration. This represents a dissociation from current surroundings and preoccupations, even when these are difficult, as they were while she was writing Ariel. The distinction between bipolar disorders and borderline states may be less clear than Cooper suggests. Borderline states vary in the frequency with which they are mobilized and in their duration, and what provokes switches may not be apparent. The contrasting moods of bipolar patients are accompanied by changes in self-management and relationship patterns and their state switches may be reactive to life events. Borderline patients may be helped by mood stabilizing drugs and bipolar patients may be helped by psychotherapy.4 I would suggest that, in comparing the two conditions, the model of BPD needs to incorporate the structural understandings of the MSSM.