Advance Care Planning and Goals-of-Care Decisions Among Veterans With Malignancy.

BACKGROUND: There is a limited knowledge base about factors affecting advance directives and code status decisions among veterans with malignancy. In addition, few studies have focused on the benefit of palliative care (PC) in goals-of-care discussions among veterans with cancer. OBJECTIVES: This study examined advance care planning and goals-of-care decisions among veterans with malignancy. METHODS: Demographic and clinical data were obtained using retrospective chart analysis. Patient characteristics were analyzed using univariate descriptive statistics. To compare patients with and without a do-not-resuscitate (DNR) decision, chi-square test was performed. FINDINGS: More than half of the patients in the study were referred to PC within one year of their cancer diagnosis. Most had documented metastatic disease at the time of their PC referral. Veterans with prostate cancer were more likely to elect full code status. In this study, White veterans were more likely to choose a DNR order than African American veterans.

The effects of written emotional disclosure and coping skills training in rheumatoid arthritis: a randomized clinical trial.

OBJECTIVE: Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing. METHOD: We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups. RESULTS: Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months. CONCLUSIONS: The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.

An Emotional Exposure-Based Treatment of Traumatic Stress for People with Chronic Pain: Preliminary Results for Fibromyalgia Syndrome.

Emotional trauma occurs in many patients with chronic pain, particularly fibromyalgia syndrome (FMS). Current cognitive-behavioral treatments for chronic pain have limited effects, perhaps because the trauma is not addressed, whereas emotional exposure-based treatments improve post-traumatic stress, but have not been tested on chronic pain. We present a novel, brief treatment protocol for people with chronic pain and unresolved trauma (Multi-Stimulus, Multi-Technique Emotional Exposure Therapy), which involves detecting avoidance of a range of emotion-related stimuli, implementing exposure techniques tailored to the patient's avoidances, and negotiating the process and therapeutic alliance. This treatment was pilot tested on 10 women with intractable FMS and trauma histories. Three months post-treatment, the sample showed moderate to large effects on stress symptoms, FMS impact, and emotional distress; and small to moderate improvements on pain and disability. Two patients showed substantial improvement, four made moderate gains, two showed modest improvement, and two did not benefit. This pilot study suggests that emotional exposure treatment for unresolved trauma may benefit some patients with FMS. Controlled testing of the treatment for FMS and other chronic pain populations is indicated.

The assessment of alexithymia in medical settings: implications for understanding and treating health problems.

The construct of alexithymia encompasses the characteristics of difficulty identifying feelings, difficulty describing feelings, externally oriented thinking, and a limited imaginal capacity. These characteristics are thought to reflect deficits in the cognitive processing and regulation of emotions and to contribute to the onset or maintenance of several medical and psychiatric disorders. In this article, we review recent methods for assessing alexithymia and examine how assessing alexithymia can inform clinical practice. Alexithymia is associated with heightened physiological arousal, the tendency to notice and report physical symptoms, and unhealthy compulsive behaviors. Alexithymic patients may respond poorly to psychological treatments, although perhaps not to cognitive-behavioral techniques, and it is unclear whether alexithymia can be improved through treatment. Interpretive problems regarding alexithymia include its overlap with other traits, whether it is secondary to illness or trauma, the possibility of subtypes, and low correlations among multiple measures. Nonetheless, we encourage the assessment of alexithymia in applied settings.

Trait and social processes in the link between social support and affect: an experimental, laboratory investigation.

This study investigated the extent to which the link between perceived social support and affect reflected support recipients' trait perceived support as well as three distinct social processes: the objective supportiveness of providers, the unique relationships among recipients and providers that were stable over occasions, as well as the unique relationships that varied across occasions. Ten recipients interacted with each of the same four providers on five separate occasions, for a total of 200 interactions. Recipients and independent observers rated recipient affect and provider support. Greater perceived support was related to greater positive affect for recipients' trait perceived support, as well as for relationships that were stable over occasions and relationships that varied across occasions. No social support effects were found for negative affect. Perceived similarity was a consistent predictor of recipients' support perceptions. Implications for social support models and interventions were discussed.

Extra-individual sources of social support as described by adults with mild intellectual disabilities.

The extra-individual social support responses provided by adults with intellectual disabilities on a social support survey were examined. Felton and Berry (1992) argued that extra-individual social support, support from larger than individual entities, is a valid source of social support for older adults. We hypothesized that extra-individual support would also be relevant to adults with intellectual disabilities. Results showed that 43% of participants with intellectual disabilities listed extra-individual support sources in their social networks or as providers of one of several support functions. The most popular forms of extra-individual support were those from "staff" and "work." Findings are discussed in terms of implications for social support measurement for persons with intellectual disabilities.