Ethical dilemmas in the care of cancer patients near the end of life.

By definition, an ethical dilemma involves the need to choose from among two or more morally acceptable options or between equally unacceptable courses of action, when one choice prevents selection of the other. Advances in medicine, increasing economic stress, rise of patient self-determination and differing values between healthcare workers and patients are among the many factors contributing to the frequency and complexity of ethical issues in healthcare. In the cancer patient near the end of life, common ethical dilemmas include those dealing with artificial nutrition and hydration, truth-telling and disagreements over management plans. It would stand the clinician in good stead to be aware of these issues and have an approach toward dealing with such problems. In addition, organisations have a responsibility to ensure that systems are in place to minimise its occurrence and ensure that staff are supported through the process of resolving dilemmas and conflicts that may arise.

Experimental modification of P50 suppression.

White and Yee (1997) found that normal suppression of the P50 component of the event-related potential was disrupted during a paired-click paradigm when nonpsychiatric subjects performed mental arithmetic (MA) problems aloud, concurrently with the presentation of auditory stimuli. In fact, the degree of disruption reflected in the P50 suppression ratio fell within the range that is typically observed in schizophrenia patients. The present study was conducted to clarify the processes that might underlie the apparent disruption of P50 suppression during performance of an oral MA task. Participants completed a series of tasks designed to examine the impact of competing cognitive activity, competing auditory stimulation, muscle activity, and acute psychological stress on P50 amplitude and P50 suppression. Results suggested that psychological stress and heightened facial muscle activity may exert modulatory effects on P50 suppression.

P50 suppression in recent-onset schizophrenia: clinical correlates and risperidone effects.

Chronic schizophrenic patients often do not suppress the auditory P50 component of the event-related potential to the second of 2 clicks, presented 500 ms apart, suggesting a loss of normal inhibition. This study attempted to replicate the P50 suppression deficit in patients with recent-onset schizophrenia and to examine whether P50 is related to clinical symptoms or is affected by an atypical antipsychotic medication. Data from 22 recent-onset schizophrenia patients and 11 normal controls revealed that disruption in P50 suppression is present during the early stages of illness. In addition, impaired P50 suppression covaried with clinical ratings of anxiety, depression, and anergia; results also suggested that the P50 inhibitory deficit may be related to the degree of patients' attentional impairment. Finally, risperidone, compared with a typical antipsychotic medication, improved inhibition of P50 to the second click. These results support P50 suppression as a measure of disordered neurocognition in schizophrenia.

A longitudinal analysis of eye tracking dysfunction and attention in recent-onset schizophrenia.

The effect of an attentional manipulation on eye tracking dysfunction (ETD) in the early stages of schizophrenia was examined in 34 recent-onset schizophrenic patients and 24 demographically matched normal subjects over a 1-year period. An attentional enhancement manipulation improved eye tracking performance of recent-onset schizophrenic patients more than that of normal subjects. Eye tracking level also was moderately stable for both groups over the course of 1 year. The possible role of attentional allocation in ETD highlights the need for further examination of the interface between attentional and eye tracking measures of vulnerability to schizophrenia.

Effects of attentional and stressor manipulations on the P50 gating response.

The decline in amplitude of the P50 component of the event-related potential to the second of paired clicks has been suggested as a measure of preattentional gating. Two experiments were conducted to assess the effects of attention and a psychological stressor on P50. Experiment 1 included two choice reaction time tasks designed to direct attention selectively to the first or second click in each pair. Results suggest that the N100 component was responsive to attentional manipulations, whereas P50 was not affected. Experiment 2 examined the impact of a brief psychological stressor on the P50 response. Parallel mental arithmetic tasks were administered silently and orally. Self-report and measures of autonomic activity were used to assess the level of stress occurring during the performance of the mental arithmetic tasks. Results indicate that P50 suppression was sensitive to the acute stressor, the oral mental arithmetic task. Implications of these findings for studies of P50 suppression in schizophrenia are discussed.

Event-related potential correlates of linguistic information processing in schizophrenics.

Event-related potentials (ERPs) were recorded from adult schizophrenics and age- and education-matched normal controls during performance of an idiom recognition task involving judgments of the meaningfulness of idiomatic, literal, and nonsense phrases. Schizophrenics produced more errors and had prolonged reaction times while attempting to correctly differentiate meaningful from meaningless phrases. An ERP correlate of that deficit was a larger than normal N400 to idioms and literals, with no difference in N400 amplitude to nonsense phrases. This result was interpreted as evidence that the influence of the linguistic context provided by the first word of two-word idiomatic and literal phrases is reduced in schizophrenia. Schizophrenics also showed reduced amplitude P300.

Ethnicity and gender in scales of psychosis proneness and mood disorders.

Data for Caucasian, African American, Asian American, and Latino college-student samples were compared for several popular self-report scales of psychopathology. Significant group differences were obtained for all scales, with the Caucasian sample consistently having the lowest means. Some gender effects and interactions with ethnic group were also observed. The authors discuss implications of these findings for use of these scales, including implications for use of Caucasian norms with other ethnic samples.

A dual-task analysis of resource allocation in dysthymia and anhedonia.

Research has shown dysthymic individuals to be hyporesponsive at various stages of information processing, yet it is not clear whether dysthymics are deficient in the amount of available attentional resources for information processing or, instead, in the allocation of those resources. To distinguish between these possibilities, the authors compared dysthymics to anhedonic and normal control Ss during the performance of memory tasks, under conditions of varying task priority and difficulty. Although there were no performance differences, dysthymics and anhedonics exhibited a consistently smaller P300 component of the event-related potential. Furthermore, P300 results indicated that dysthymics and anhedonics responded differently from controls to variations in task demands. Thus, although evidence was obtained for group differences in both resource capacity and resource allocation strategy, the overall pattern of results is interpreted as favoring the latter.

Early stimulus processing in dysthymia and anhedonia.

Previous event-related brain potential (ERP) research has found that dysthymic subjects differ from control subjects during later stages of information processing. An important issue that emerges from this literature is whether differences found in these ERP components, typically associated with cognitive processing, can be attributed to earlier differences in basic perceptual processing. This study was undertaken to determine whether early processing deficits are apparent in dysthymic persons. Responses of dysthymics (n = 23) were compared with those of anhedonic (n = 15) and normal control (n = 17) subjects. ERPs were recorded while subjects heard tones at 55, 65, 75, 85, and 95 dB. Overall, N1-P1 and N1-P2 components of the ERP increased in a strong linear fashion as stimulus intensity increased. Dysthymics did exhibit a smaller N1-P2 response than normal subjects, which suggests the presence of difficulties in initial perceptual processing.

Developmental Processes in Schizophrenic Disorders: longitudinal studies of vulnerability and stress.

The Developmental Processes in Schizophrenic Disorders project is a longitudinal study of schizophrenic patients who have recently had a first episode of psychosis. The project focuses on discriminating characteristics of schizophrenic patients that are "stable vulnerability indicators," "mediating vulnerability factors," and "episode indicators" by comparing normal subjects to schizophrenic patients assessed in clinically remitted and psychotic states. A parallel project goal is to identify predictors of relapse, social and work impairment, and illness course among potential psychobiological vulnerability factors and environmental potentiating factors. Hypothesized vulnerability factors and potential environmental stressors are examined first under standardized maintenance antipsychotic medication conditions for at least 1 year. Patients showing stable remission of psychosis after 1 year of maintenance antipsychotic medication are invited to enter drug crossover and withdrawal protocols to determine the need for continuous antipsychotic medication. Vulnerability and stress factors are again assessed. A summary of results to date is presented. Deficits in early components of processing visual arrays and in sustained discrimination of successive ambiguous perceptual inputs are relatively stable across psychotic and clinically remitted states in the schizophrenic patients. Performance on a vigilance task demanding active, working memory also remains abnormal during clinical remission but covaries significantly with psychotic state and is a candidate for a mediating vulnerability factor. Autonomic activation level does not appear to be an enduring vulnerability factor, but it predicts the extent of short-term symptomatic recovery and may mediate the impact of stressors. Under conditions of standardized, injectable antipsychotic medication, independent stressful life events and highly critical attitudes toward the patient in the social environment predict relapse risk. Prospective data suggest that signs and symptoms prodromal to psychotic relapse may be present in about 60 percent of patients.