Illness apprehension, depression, anxiety, and quality of life in liver transplant candidates: implications for psychosocial interventions.

BACKGROUND: End-stage liver disease is associated with diminished quality of life (QOL). Numerous physical and psychosocial problems that affect QOL are common in those undergoing evaluation for liver transplantation. OBJECTIVE: Identifying which of these challenges are most closely associated with QOL would be helpful in developing priority targets for evidence-based interventions specific to those undergoing transplant evaluation. METHOD: A total of 108 adults undergoing psychologic assessment for liver transplant completed clinical interview, neuropsychologic testing, and self-report inventories of depression, anxiety, cognitive appraisal characteristics, support resources, and QOL. RESULTS: Multiple regression analyses revealed that while emotional symptoms (anxiety and depression) were primarily associated with mental QOL, illness apprehension was the only variable uniquely associated with physical QOL after accounting for severity of liver disease, cognitive status, emotional symptoms, and support resources. CONCLUSION: Findings suggest that psychosocial interventions prioritizing reduction of illness-related fear and symptoms of anxiety/depression would likely have the greatest effect on QOL in persons with end-stage liver disease awaiting transplantation.

Post-traumatic stress disorder and post-traumatic stress symptoms following critical illness in medical intensive care unit patients: assessing the magnitude of the problem.

INTRODUCTION: Post-traumatic stress disorder (PTSD) is a potentially serious psychiatric disorder that has traditionally been associated with traumatic stressors such as participation in combat, violent assault, and survival of natural disasters. Recently, investigators have reported that the experience of critical illness can also lead to PTSD, although details of the association between critical illness and PTSD remain unclear. METHODS: We conducted keyword searches of MEDLINE and Psych Info and investigations of secondary references for all articles pertaining to PTSD in medical intensive care unit (ICU) survivors. RESULTS: From 78 screened papers, 16 studies (representing 15 cohorts) and approximately 920 medical ICU patients met inclusion criteria. A total of 10 investigations used brief PTSD screening tools exclusively as opposed to more comprehensive diagnostic methods. Reported PTSD prevalence rates varied from 5% to 63%, with the three highest prevalence estimates occurring in studies with fewer than 30 patients. Loss to follow-up rates ranged from 10% to 70%, with average loss to follow-up rates exceeding 30%. CONCLUSION: Exact PTSD prevalence rates cannot be determined due to methodological limitations such as selection bias, loss to follow-up, and the wide use of screening (as opposed to diagnostic) instruments. In general, the high prevalence rates reported in the literature are likely to be overestimates due to the limitations of the investigations conducted to date. Although PTSD may be a serious problem in some survivors of critical illness, data on the whole population are inconclusive. Because the magnitude of the problem posed by PTSD in survivors of critical illness is unknown, there remains a pressing need for larger and more methodologically rigorous investigations of PTSD in ICU survivors.

Divergent thinking in Alzheimer's and frontotemporal dementia.

Twenty-three patients with mild dementia of the Alzheimer's type (DAT) or frontotemporal type (DFT) and age- and education-matched control subjects were administered tests of complex fluency involving divergent thinking and tests of letter, category, and figural fluency. The tests of complex fluency discriminated the dementia patients from control subjects more strongly than did the other fluency tests. The results suggest that divergent thinking as assessed by complex fluency tests is a cognitive domain that is impaired early in the course of dementia. The sensitivity of complex fluency tests compared to that of letter, category, and figural fluency tests may be related to greater demands for conceptualization in relating stimulus attributes to function and greater demands for flexible thinking during self-directed search processes.

Patterns of normal personality structure among chronic pain patients.

Fifty-nine chronic pain patients satisfying one of four previously identified pain group classifications were evaluated using the NEO Personality Inventory (NEO-PI), a standardized measure of normal adult personality structure. Minnesota Multiphasic Personality Inventory (MMPI) pain subgroups differed with respect to level of NEO-PI Neuroticism. In particular, emotionally overwhelmed pain patients as defined by multiple MMPI scale elevations had higher NEO-PI Neuroticism scores. Post hoc analyses revealed higher levels of depression, anxiety, vulnerability, and hostility in emotionally overwhelmed subjects. None of the remaining groups differed from each other on NEO-PI Neuroticism. Additionally, none of the other NEO-PI domains discriminated pain subgroups. NEO-PI profiles for pain patients (except for Neuroticism in emotionally overwhelmed patients) yielded t scores in the average range, suggesting that chronic pain patients present with a relatively normal underlying personality structure.

An emotional component analysis of chronic pain.

The present study sought to determine the relative contribution of frustration, fear, anger and anxiety, to the unpleasantness and depression pain patients experience. Sixty-nine women and 74 men, with an average age of 47 years, were included. Patients underwent psychological evaluation which included use of the Minnesota Multiphasic Personality Inventory (MMPI), Beck Depression Inventory (BDI), and 7 visual analog scales (VAS) measuring degree of emotional unpleasantness, pain intensity, anxiety, frustration, fear, anger and depression. Test-retest reliability coefficients were significant for the negative feeling VAS yielding an average reliability coefficient of 0.82. Analyses relating the negative feeling state VAS to pain unpleasantness and depression indices from the MMPI (scale 2) and BDI (sum score) yielded significant canonical correlations. Multiple regression was used to clarify the relationships between negative feeling VAS, pain-related unpleasantness, and indices of depression. After statistically controlling for intensity of pain, anxiety and frustration predicted unpleasantness. Regression analyses indicate that anger is an important concomitant of the depression that pain patients experience. The results suggest that anger and frustration are critical concomitants of the pain experience. Treatment techniques specifically targeting anger and frustration in these patients may prove efficacious.

A canonical correlation analysis of the influence of neuroticism and extraversion on chronic pain, suffering, and pain behavior.

The relationship between neuroticism and extraversion on the 4 major stages of pain processing, that of pain sensation intensity, pain unpleasantness, suffering, and pain behavior, were studied in 205 chronic pain patients (88 male and 117 female). Patients underwent psychological evaluation which included the Pain Experience visual analogue scales (VAS) (Price et al. 1983), NEO Personality Inventory (NEO-PI) (Costa and McCrae 1985), and the Psychosocial Pain Inventory (PPI) (Getto and Heaton 1980). Canonical correlation was used to control for pain sensation intensity in evaluating affective dimensions of pain and to control for neuroticism in assessing effects of extraversion on different stages and dimensions of pain. Neither neuroticism nor extraversion were related to pain sensation intensity. Only neuroticism was associated with pain unpleasantness. Personality factors had their greatest impact on stages 3 (suffering) and 4 (illness behavior) of pain processing. The results of multiple regression analyses indicated that life-long vulnerability to anxiety and depression is paramount in understanding the relationship between personality and suffering in chronic pain. These findings provide support for the idea that personality traits influence the ways in which people cognitively process the meanings that chronic pain holds for their life, and hence the extent to which they suffer.

Correlations for scores on the 180-item version of the MMPI-2 and the Neuroticism scale of the NEO-Personality Inventory.

64 normal adult controls (53 men, 11 women; M age 45.2 yr.) in a study of an estuary-associated syndrome were administered the MMPI-2-180 and the Neuroticism scale from the NEO-Personality Inventory. Pearson product-moment correlations between MMPI-2 scales and the Neuroticism scale were similar to those reviously reported using the full-length MMPI. Correlations between MMPI-2 scales, D, Pt, Sc, and Si, and NEO-PI Neuroticism (range .44 to .52) suggest that many psychiatric conditions are associated with psychological distress of the type individuals high in trait neuroticism are prone to experience.

The Relationship between Marital Status and Psychological Resilience in Chronic Pain.

We examined the relationship between marital status and a 2-stage model of pain-related effect, consisting of pain unpleasantness and suffering. We studied 1914 chronic pain patients using multivariate analysis of covariance (MANCOVA) to clarify whether marital status was a determinant factor in the emotional or ideational suffering associated with chronic pain after controlling for pain sensation intensity, age, and ethnicity. Marital status was unrelated to immediate unpleasantness (P = 0.08). We found a strong association with emotional suffering (P < 0.0001) but not with negative illness beliefs (P = 0.44). Interestingly, widowed subjects experienced significantly less frustration, fear, and anger than all other groups (married, divorced, separated, or single). A final MANCOVA including sex as a covariate revealed that the emotional response to pain was the same for both widow and widower. Only those individuals whose spouse died experienced less emotional turmoil in the face of a condition threatening their lifestyle. These data suggest that after experiencing the death of a spouse, an individual may derive some "emotional inoculation" against future lifestyle threat.

Executive function, intellectual decline and daily living skills.

Understanding the cognitive changes associated with compromised daily living skills in elderly individuals is important for making appropriate recommendations about the capacity for independent functioning. To this end, we retrospectively examined data from 92 elderly individuals presenting with cognitive decline who were administered measures of executive functioning, general intelligence, and daily living skills. Multiple regression analyses were used to examine the relationship between executive functioning and daily living skills, while controlling for age, depression, and either IQ decline or current IQ. Executive functioning accounted for additional variance in a broad range of daily living skills after controlling for IQ decline. When FSIQ was used in the regression model rather than IQ decline, executive functioning was no longer uniquely associated with daily living skills. Executive functions appear to be important for daily living skills until a critical threshold of low intellectual functioning is reached, reflecting the combined influence of premorbid ability and the extent of intellectual decline. Our results suggest that understanding the relative contribution of different cognitive domains to functional decline in elderly individuals should take into account general intellectual functioning and estimated decline, and that the initiation and/or persistence of self-directed cognitive processes may be important for adaptive daily functioning. These findings have implications for making more evidence-based recommendations about the capacity for independent living.

General intellectual decline and daily living skills.

A total of 64 elderly individuals presenting with cognitive decline were administered a test of general intelligence and a measure of adaptive knowledge and daily living skills. Premorbid ability was estimated using a demographic formula and a reading test. After controlling for age and depression, general intellectual ability accounted for a large amount of the variance in a broad range of adaptive knowledge and behavioral skills, reflecting the influence of premorbid ability and especially estimated decline. Different patterns of adaptive knowledge and skills were identified as a function of measured IQ and of estimated decline in IQ. Results suggest a threshold of intellectual decline for deterioration in daily living skills. Studies purporting to demonstrate that impairments in particular neuropsychological domains predict specific functional deficits need to control for general intellectual ability and/or the extent of intellectual decline.

Official position of the American Academy of Clinical Neuropsychology on serial neuropsychological assessments: the utility and challenges of repeat test administrations in clinical and forensic contexts.

Serial assessments are now common in neuropsychological practice, and have a recognized value in numerous clinical and forensic settings. These assessments can aid in differential diagnosis, tracking neuropsychological strengths and weaknesses over time, and managing various neurologic and psychiatric conditions. This document provides a discussion of the benefits and challenges of serial neuropsychological testing in the context of clinical and forensic assessments. Recommendations regarding the use of repeated testing in neuropsychological practice are provided.

The prediction of change: normative neuropsychological trajectories.

While the application of normative standards is vital to the practice of clinical neuropsychology, data regarding normative change remains scarce despite the frequency of serial assessments. Based on 285 normal individuals, we provide co-normed baseline data with demographic adjustments and test-retest standardized regression based (SRB) models for three time points for several measures. These models delineate normal, expected change across time, and yield standardized z-scores that are comparable across tests. Using a new approach, performance on any previous trial was accounted for in the subsequent models of change, yielding serial normative formulas that model change trajectories rather than simple change from point to point. These equations provide indices of deviation from expected baseline and change for use in clinical or research settings.

Comparative utility of Barona Formulae, Wtar demographic algorithms, and WRAT-3 reading for estimating premorbid ability in a diverse research sample.

Various Barona formulae, a WTAR algorithm based on demographic data, and WRAT-3 oral reading methods of estimating premorbid ability were compared in a diverse research sample of 119 subjects. These methods were correlated with one another and with a modified version of the Raven Standard Progressive Matrices. Descriptive data are provided to illustrate advantages and disadvantages of various methods of estimating premorbid ability when no formal intellectual testing is available. While predicting premorbid ability for individual subjects involves varying degrees of error, we found that the revised Barona formula was superior to the original formula for subjects at the upper end of ability level. When researchers have screened out learning disability and have subject samples with few individuals likely to be of superior premorbid intelligence, oral reading scores are a reasonable measure of premorbid ability. Otherwise, researchers are advised to use both demographic and oral reading methods to estimate premorbid ability.

Attention and the stages of pain processing.

OBJECTIVE: Explore the relationships between the four stages of pain processing and attention in chronic pain sufferers. DESIGN: A cross-sectional, retrospective study of 736 subjects participating in an outpatient university-based tertiary care pain treatment program. METHODS: Self-report measures of pain, pain-related unpleasantness, and suffering (Pain Experience Visual Analog Scales) in conjunction with a structured interview assessing illness behavior (adaptation of the Psychosocial Pain Inventory) and attention (Digit Span subtest of the Wechsler Adult Intelligence Scale-Revised) were employed. OUTCOME MEASURES: Separate step-wise multiple regression analyses were conducted using variables that measure each of the four stages of pain processing as predictors, with Digit Span being the criterion variable. RESULTS: Multiple regression analyses showed that, of the four pain stages, only suffering and pain behavior were related to attentional performance. Specifically, an individual's perception of lifestyle interference due to pain, level of depression, and the degree of solicitous responses from others each uniquely contributed to Digit Span performance. CONCLUSIONS: Treatment interventions specifically targeting suffering and pain behavior may prove efficacious in addressing the attentional problems in chronic pain.

Cognitive impairment in patients with chronic pain: the significance of stress.

This review article examines the role of emotional distress and other aspects of suffering in the cognitive impairment that often is apparent in patients with chronic pain. Research suggests that pain-related negative emotions and stress potentially impact cognitive functioning independent of the effects of pain intensity. The anterior cingulate cortex is likely an integral component of the neural system that mediates the impact of pain-related distress on cognitive functions, such as the allocation of attentional resources. A maladaptive physiologic stress response is another plausible cause of cognitive impairment in patients with chronic pain, but a direct role for dysregulation of the hypothalamic-pituitary-adrenocortical axis has not been systematically investigated.

Neuropsychologists diagnose traumatic brain injury.

The case of John versus Im (2002) stands for the proposition that clinical neuropsychologists are not qualified to diagnose traumatic brain injury. This ruling by the Supreme Court of Virginia prohibits neuropsychologists from testifying about these professional conclusions in the courtroom. However, in clinical practice neuropsychologists are often asked to disentangle the relative contribution of brain dysfunction and psychological factors to presenting symptomology. In the proposed submission, the authors provide an analysis of the neuropsychological testimony at issue in John versus Im using the admissibility standards for expert testimony that were established and refined by a trilogy of cases from the Supreme Court of the United States. The paper provides support for the notion that neuropsychological method has an established scientific base of knowledge, standards for clinical competence, and evidence of peer-reviewed acceptance by medical related disciplines. No other scientific discipline has employed a more rigorous methodology for assessing cognitive function and disentangling the relative contributions of brain dysfunction and psychological factors to presenting symptomology. By limiting the testimony of neuropsychologists as to cause of an individual's cognitive impairment, courts will exclude opinions based on scientific research and specialized knowledge that would assist in the trier of fact.

Pre-injury status and adaptation following traumatic brain injury.

There are an estimated two million traumatic brain injuries (TBI) each year in the US. Behavioural and psychosocial sequelae are the most disabling consequences of TBI, but relatively little empirical data exist that identify factors underlying the variability in patient outcomes. There is an increasing appreciation that pre-injury coping liabilities are likely to contribute to persistent disability and that outcome reflects the combined effects of pre-morbid, injury-related, and post-injury factors. Despite this, most outcome studies focus on the effects of injury-related and post-injury variables. The present study evaluated outcome in 45 adults who suffered a moderate or severe TBI at least 2 years earlier. It was hypothesized that severity of pre-morbid psychiatric and substance abuse problems and less social support following brain injury would be associated with poorer post-injury adaptation as measured by employment status, independent living status, and neurobehavioural symptomatology. The authors found that pre-injury psychiatric and substance abuse histories predicted employment status and that pre-injury substance abuse predicted independent living status. Social support following TBI predicted significant other's assessment of the patients' neurobehavioural status. None of the independent variables were found to predict patient assessment of his or her own neurobehavioural functioning. These findings support the premise that pre-morbid coping liabilities are related to the degree of post-injury disability.

Six-month neuropsychological outcome of medical intensive care unit patients.

OBJECTIVE: To examine neuropsychological function, depression, and quality of life 6 months after discharge in patients who received mechanical ventilation in the intensive care unit. DESIGN: Prospective cohort study. SETTING: Tertiary care, medical and coronary intensive care unit of a university-based medical center. STUDY POPULATION: A total of 275 consecutive, mechanically ventilated patients from a medical intensive care unit were prospectively followed. At 6 months, 157 were alive, of whom 41 (26%) returned for extensive follow-up testing. MEASUREMENT AND MAIN RESULTS: Neuropsychological testing and assessment of depression and quality of life were performed at 6-month follow-up. Seven of 41 patients were excluded from further analysis due to preexisting cognitive impairment determined via surrogate interviews using the Modified Blessed Dementia Rating Scale and a review of medical records. On the basis of strict criteria derived from normative data, we found that 11 of 34 patients (32%) were neuropsychologically impaired. Impairment was generally diffuse but occurred primarily in areas of psychomotor speed, visual and working memory, verbal fluency, and visuo-construction. The rate of neuropsychological deficits in the study population was markedly higher than population norms for mild dementia. Scores on the Geriatric Depression Scale-Short Form were significantly more abnormal in the neuropsychologically impaired group than in the nonimpaired group at hospital discharge (p =.04) and at 6-month follow-up (p =.02), and clinically significant depression was found in 27% of impaired subjects at hospital discharge and in 36% at 6-month follow-up. No differences were observed between groups in quality of life as measured with the Short Form Health Survey-12 at discharge or 6-month follow-up. CONCLUSIONS: Prolonged neuropsychological impairment is common among survivors of the medical intensive care unit and occurs with greater than anticipated frequency when compared with relevant normative data. Future investigations are warranted to elucidate the nature of the association between critical illness, neuropsychological impairment, depression, and decreased quality of life.

The association between delirium and cognitive decline: a review of the empirical literature.

Delirium is a common neurobehavioral syndrome that occurs across health care settings which is associated with adverse outcomes, including death. There are limited data on long-term cognitive outcomes following delirium. This report reviews the literature regarding relationships between delirium and cognitive impairment. Psych Info and Medline searches and investigation of secondary references for all English language articles on delirium and subsequent cognitive impairment were carried out. Nine papers met inclusion criteria and documented cognitive impairment in patients following delirium. Four papers reported greater cognitive impairment among patients with delirium than matched controls. Four papers reported higher incidence of dementia in patients with a history of delirium. One study found 1 of 3 survivors of critical illness with delirium developed cognitive impairment. The evidence suggests a relationship between delirium and cognitive impairment, although significant questions remain regarding the nature of this association. Additional research on delirium-related effects on long-term cognitive outcome is needed.