Goal-setting and attainment in prolonged disorders of consciousness - development of a structured approach.

Aims: To develop a structured goal-set for use in programs for the assessment and management of prolonged disorders of consciousness (PDOC).Methods: A retrospective analysis of goals from a consecutive cohort of patients (n = 162) admitted to a specialist in-patient PDOC program in the UK from 2007 to 2018. Overall goal attainment was examined with Goal Attainment Scaling (GAS) using the GAS-Light method. Rates of individual goal-setting and achievement were examined for both standardized objectives (n = 2959) and personalized goals (n = 661). Goal statements from the personalized goals were independently reviewed and mapped to the domains of the existing structured objective set to identify any missing goal areas.Results: Mean outcome GAS T-scores were 47.2 (95% CI: 46.7, 47.6) and 47.7 (95% CI: 46.7, 48.8), respectively, for the standardized and personally set goals. These were closely correlated (r = 0.482, p < .001) with no significant difference between them. Analysis of goal achievement within each domain identified goals that were/were not likely to be achieved. An initial structured set of 20 standardized objectives in 12 domains was expanded and re-organized to produce a final-structured goal-set of 36 objectives in 18 domains.Conclusions: Developed through real-life clinical practice, this first published structured goal-set for PDOC programs now requires testing in other services/settings.

Dietary gluten and learning to attend to redundant stimuli in rats.

The purpose of the present study was to assess the effect of a high-gluten diet against a gluten-free diet on learning stimulus-response relationships in rats. In the first phase of training rats learned to associate a stimulus light with responding on a particular response lever. In the second phase, the same rats were exposed to new, but redundant stimuli to guide responding (a tone and houselight). Probe trials, involving only new stimuli, revealed that rats fed a gluten-free diet displayed a "blocking" effect. That is, gluten-free rats did not learn to associate these new stimuli with particular responses. In contrast, high-gluten rats very quickly learned to use these redundant stimuli to guide responding. Subsequent phases of training demonstrated, however, that this group difference could be removed. The present findings are discussed in the context of the possible links between dietary gluten and schizophrenia.

Spared retrograde memory with anterograde amnesia and widespread cognitive deficits.

A case is described of a young male who suffered head injuries in a motor accident and subsequently displayed a severe anterograde amnesia in the presence of a relatively intact retrograde memory. He also demonstrated marked impairment of general intellectual ability, naming, perceptual skills and executive functioning. This case demonstrates a striking dissociation between anterograde and retrograde memory. Moreover the retention of retrograde memory in the face of such severe and global cognitive impairment accentuates the dissociation or isolability of retrograde memory. It is further argued that while frontal impairment occurred in this case it lacks any of the hallmarks of frontal amnesia. The case is further evidence for the fractionation of amnesic syndromes.

Use of hormonal contraceptives in an institutional setting: reasons for use, consent and safety in women with psychiatric and intellectual disabilities.

AIM: To describe the use of hormonal contraceptives in institutionalised women with psychiatric and/or intellectual disabilities. METHODS: Women who had been disability or mental health service inpatients for six months or more and were prescribed hormonal contraceptives were included. Data were collected from their clinical files and from structured interviews of the women and of their primary care givers. RESULTS: Forty two women were prescribed contraceptives, of whom 23 were intellectually disabled and 28 had mental illnesses. Most women had no children; four had had one child and two, two children. Thirteen were not sexually active. Depot medroxyprogesterone acetate (Depo Provera) was prescribed for 69%, combined oral contraceptive agents for 14% and progestin-only oral contraceptives for 17%. Contraceptives were initially prescribed by hospital staff for all but 1 woman, and were administered without consent for over half the group, including 11 women for whom this administration was not legally authorized. Less than half the group had blood pressure measured within the previous 12 months and only a third had a cervical smear within the previous 3 years. Of the women who were sexually active, less than half knew how to protect themselves from sexually transmitted diseases and less than 10% regularly used condoms. CONCLUSIONS: Improvements in reproductive health care for these women are needed, in particular attention to education and client participation in decisions about contraceptive treatment. It is suggested that gynaecological and family planning services be provided separately from psychiatric services.

PIP: A study was made of all women who had been inpatients of the mental health or disability units of Porirua Hospital in New Zealand for at least 6 months who were prescribed oral or injectable hormonal contraceptives during January 1992. The aim was to describe the use of hormonal contraceptives in this population and assess the appropriateness and safety of this method as well as the patient consent process and patient satisfaction. Data were collected from medical records and from interviews with the patients (when possible) and their nurses. 42 women were prescribed contraceptives (60% of those under 50). 3 were married, 3 separated or divorced, and 36 never married. 32 were nulliparous, none had more than 2 children. 11 were Maoir, 1 Pacific Islander, and 29 New Zealand pakeha. 23 women were intellectually disabled, 28 had mental disorders, 9 had both. 29 of the women received Depo Provera, 7 progesterone-only oral contraceptives (OCs), and 6 combined OCs. 25 had been using their current contraceptive for more than 3 years. Treatment was prescribed by psychiatric staff in 16 cases, other staff in 25, and outside practitioners in 1. The reason for treatment was contraception in 32 women and menstruation prevention in 9. 27 women were smokers (21 heavy). 7, including 6 of the heavy smokers, had other contraindications to the use of estrogens. Of the 26 women interviewed, 12 complained of side effects, 8 of weight gain, 2 of depression, and 5 of other effects (the nurses identified only 2 of 42 women as suffering side effects). Of the 22 interviewees who were treated for contraception, 15 stated they were sexually active. The nurses thought that 29 of the 42 were or might be sexually active. Therefore, 13 women considered definitely not sexually active were prescribed contraceptives. Very few of the women used condoms, although 38% knew how to practice safe sex. 14 of the women interviewed stated they chose contraception. The nurses said 8 had given consent, the families of 2 gave consent, consent information was unknown for 10, and a unilateral staff decision was made for 22. 17 of the 28 women definitely treated without consent were mentally retarded. The women were given very little information about their contraceptive method and knew of very few other methods. These results indicate that contraceptives have been used to manage menstrual hygiene and address staff concerns. In some cases, their administration without consent was illegal. The patients received inadequate medical care and some of the prescriptions were inappropriate. Ethically correct ways in which to address the problem of contraception in this population exist through educationally-focused family planning services for both in- and out-patients.

Depression in multiple sclerosis: a review.

Several studies have reported high rates of depression in multiple sclerosis (MS) with a lifetime prevalence of approximately 50% and an annual prevalence of 20% not uncommon. Concern about the potential of new drug treatments to exacerbate or precipitate depression in MS has led to increased interest in the relation between MS and depression. This review on MS and depression identifies the following key issues: How common is depression in people with MS? Is depression in MS associated with lesions in specific regions of the central nervous system? Is there an increased risk of suicide in MS? Is there a higher than expected incidence of anxiety disorders in MS? Are fatigue and depressed mood related in MS? Is there a relation between depression and cognitive impairment in MS? Which psychosocial variables affect the development of depression in MS? Does treatment with interferon increase the risk of depression? How effective are treatments for MS patients with depression? Each of these issues is briefly reviewed with critical commentary, and some priorities for future research are suggested.

Preserved implicit learning on both the serial reaction time task and artificial grammar in patients with Parkinson's disease.

Thirteen nondemented patients with Parkinson's disease (PD) were compared with age-matched controls on two standard tests of implicit learning. A verbal version of the Serial Reaction Time (SRT) task was used to assess sequence learning and an artificial grammar (AG) task assessed perceptual learning. It was predicted that PD patients would show implicit learning on the AG task but not the SRT task, as motor sequence learning is thought to be reliant on the basal ganglia, which is damaged in PD. Patients with PD demonstrated implicit learning on both tasks. In light of these unexpected results the research on SRT learning in PD is reconsidered, and some possible explanations for the sometimes conflicting results of PD patient samples on the SRT task are considered. Four factors which merit further study in this regard are the degree to which the SRT task relies on overt motor responses, the effects of frontal lobe dysfunction upon implicit sequence learning, the effects of cerebellar degeneration, and the degree to which the illness itself has advanced.

Factor Analysis of the WAIS-R Using the Factor Replication Procedure, FACTOREP.

The factor structure of the WAIS-R has been the subject of much debate and recently researchers have examined multiple independent samples and compared the resulting factor structures using the coefficient of congruence. On the basis of this, one recent study concluded that the WAIS-R had three clear factors. In the present study this conclusion was questioned and it was claimed that the previous result was an artifact caused by the large general factor found in the WAIS-R. The present study aimed to clarify the situation by using identical data but the alternative factor comparison technique, FACTOREP, which was able to reduce the influence of both error variance and the general factor. On the basis of this comparison it was demonstrated that the WAIS-R has two strong factors but that there is little evidence for the existence of a third factor.