Depression in disabling illness: severity and patterns of self-reported symptoms in three groups.

The nature of association between depression and disabling illness, whether as an organic symptom or emotional consequence, has been the source of interest and controversy. Depression in three groups of medically ill, disabled patients (Parkinson's disease, right hemisphere stroke, and amputation) was studied. Mean depression severity and frequency of depression were equal for all groups. Severity of neurologic symptomatology was not consistently related to depression. Type of prosthesis, but not amputation type, was related to depression for amputees. Patterns of depression on discriminant analysis did differentiate the groups. A depression symptom conglomerate suggesting guilt and body image change with fatigue characterized the Parkinson patients most and the amputees least. A second depression conglomerate suggesting indecisiveness and thoughts of death or self-harm characterized amputees most and stroke patients least. Depression as an emotional response may not be a singular, specific feature of disabling illness in general, given uniformity of prevalence and severity, but differential etiology in specific instances should be considered.

Depression and denial in psychotherapy of persons with disabilities.

Disability may challenge some basic assumptions about the world, and some psychological aspects of self may be profoundly violated, particularly when onset is sudden and functional changes seem catastrophic. The losses incurred in disability, broadly defined, whether minimal or major, physical, psychologic, symbolic, or all of the above, may lead to some predictable human emotional responses, although individual patients' responses do vary. Factors including prior life history, concurrent life stressors, social and financial resources, intrapsychic functions, psychodynamic issues, and personal/subcultural issues may influence the experience of disability. Depression, as a natural concomitant to loss, may present in clinical form or in bereavement and grief patterns, and warrants full consideration (both diagnostically and therapeutically). In treating the patient with a disabling loss, the dynamic nature of denial must also be considered. The often visible inability or disability may stand in sharp contrast to that which is denied. The risk/benefit ratio of denial is a consideration when the psychotherapist weighs the need to maintain denial defensively versus the advisability of confronting the denial in an attempt to soften its brittleness. Countertransference reactions are also of prime importance and may differ from more typical reactions by virtue of the enormity of the patient's losses and their tendency to evoke the psychotherapist's own sense of vulnerability, mortality, and humanity.

Symbolization in psychotherapy with patients who are disabled.

Symbols created during the process of psychotherapy serve psychological functions of giving form and substance to previously murky experiences, making what is private something shared, and forging meaningful linkages among thoughts, emotions, and perceptions. Symbols can also enable therapist and patient together to gain insight into transference themes, transformations in identity, and feelings about life changes, as well as serve as guides to articulating treatment goals. Clinical vignettes are used to illustrate the process.

Psychotherapy with the neuropsychologically impaired adult.

Despite opinions to the contrary, psychotherapy can be conducted with probably all but severely brain-impaired patients, albeit with some modification. The challenge is for the clinician to tailor his/her training to meet the needs of brain-impaired patients. There are certain real limitations, however, of neuropsychologically impaired patients that make psychotherapeutic attempts difficult. Assessment of patients' awareness of their losses, and of the implications of these losses is basic to an understanding of the emotional reactions observed. Screening and/or evaluation of certain neuropsychological functions is vital, as these functions have direct impact upon treatment efficacy. Traditionally, brain impairment has been thought to exacerbate premorbid or underlying character traits. An explanation is proposed for this traditional view of "exacerbation of premorbid style," in terms of decreased problem-solving skills, greater rigidity, and inherent increased strain of brain impairment. Neuropsychological deficits may interact with premorbid character types to produce some (predictable) behavioral alterations. Adjustments are required to accommodate to the deficits of brain-impaired patients, while retaining the richness of subjective experience in the clinical interaction. In treating neuropsychologically impaired persons, a model of equilibrium is thus suggested to balance patients' deficits with the therapist's interactions.

The effect of semantic relations on the memory deficit associated with Parkinson's disease.

Analysis of a series of verbal memory experiments reveals a systematic performance deficit in subjects with Parkinson's disease, relative to matched normal and right-hemisphere stroke controls, in both recall and recognition tasks. Parkinson patients benefit less from semantic recall cues; they find semantically mediated synonym detections particularly difficult; and they show reduced benefits from the introduction of semantically novel material in a recall task. Their recall is as well organized semantically as that of normal controls, but reduced in amount. Recognition deficits arise principally from increases in false positive responses.