Poststroke fatigue: the patient perspective.

PURPOSE: Fatigue is reported as a prevalent symptom post stroke. The purpose of this study is to explore the patent perspective of this symptom, how it is experienced, and its subjective impact on the patient. METHOD: The qualitative procedure of interpretative phenomenological analysis (IPA) was used to analyze the narratives of 10 subjects with previous stroke, who each undertook a single, semi-structured interview. RESULTS: Fatigue was a salient symptom for all the patients. Six main themes were identified. Tiredness/sleep was recognized in all the narratives, and themes of restriction, frustration, and determination/coping reflected varying degrees of physical, cognitive, and psychological dimensions to fatigue. Depression/motivation was also identified, reflecting low mood and helplessness. The remaining theme support indicated a social dimension, with patients recognizing the need for professional and familial support. Further subthemes were identified, and the thematic descriptions of the physical and psychosocial aspects indicated the complexity of fatigue and unique patient profiles. A holistic overview of each narrative furthered an understanding of the dynamic interrelationships between these aspects and their impact on the patient. There were prevalent patterns, but these were different for each patient. CONCLUSION: A better understanding of the varied dimensions or themes elaborated for poststroke fatigue, and their interrelationships, should help in mitigating its impact. The analysis cautions against giving any simplistic and unitary advice to patients about dealing with fatigue.

A randomized group intervention trial to enhance mood and self-efficacy in people with multiple sclerosis.

OBJECTIVES: To document mood, self-efficacy, and resiliency in people with multiple sclerosis (MS) following a brief group psychological intervention, and to examine whether benefits were greater than those derived from provision of education or group social interaction. DESIGN: A randomized controlled intervention trial assessing outcomes at five time points over a 1-year follow-up. METHODS: Participants with MS were assigned to one of three groups: one receiving brief group psychological intervention (PG) comprising three 90 minute cognitive behavioural sessions supported by an Information Booklet dealing with mental and emotional issues relating to MS; a group provided only with educational material - the information booklet group (IBG); and a group who not only received the booklet but also participated in non-structured social discussion (SDG) sessions similar in length and number to PG participants. Outcomes were documented using questionnaires. RESULTS: Outcomes were assessed using area under the curve (AUC) analysis: a summary measure that considers individual changes serially over time to provide a more meaningful picture than the one based on single time points. Ninety participants were followed up over the 12-month post-intervention, and their data are included in the analysis. Analyses indicated benefits in all outcome dimensions for the psychotherapeutic (PG) and social discussion groups (SDG) relative to the IBG group, but no differences between PG and SDG. CONCLUSION: The study indicates benefits from psychosocial intervention compared with bibliotherapy, with some additional benefit from psychological intervention compared with a social discussion group. Results suggest that much of the benefit may derive from non-specific therapeutic components. Without psychosocial intervention, the psychological status of people with MS worsened over time.

Worries and concerns of patients with multiple sclerosis: development of an assessment scale.

This study examined the nature of worry in adult patients with multiple sclerosis (MS) in the UK. A measure of worry in MS was developed and the relationship between worry and standard scale measures of anxiety and depression was examined. Thirty-nine patients with MS and 40 controls completed the new worry scale (WQMS) that was psychometrically evaluated, together with the Penn State Worry Questionnaire (PSWQ), the Hospital Anxiety and Depression Scale (HAD) and a previously developed scale to assess self-efficacy in MS (SESMS). The scores for both anxiety (t = 2.34; P < 0.05) and depression (t = 5.52; P <0.01) were higher in MS patients than controls, as was the new scale for worry--the WQMS. A factor analysis (explaining 65.73% of the variance) suggests that the worries of patients may be dichotomized into those concerned with the physical effects of the disease and those relating to the impact on social interaction, family relationships and daily activity in the home and/or work. Worry in patients with MS was associated with a decreased sense of being able to produce positive activities or effect positive outcomes (low self-efficacy). The questionnaire provides a framework for investigation in clinic of specific concerns and level of worry they engender.

Development and validation of a self-efficacy measure for people with multiple sclerosis: the Multiple Sclerosis Self-efficacy Scale.

The aim of this study is to develop and validate a brief measure of self-efficacy specifically for use with people with multiple sclerosis (MS). Self-efficacy is the subjective belief that one can overcome challenges that one is faced with. In order to incorporate the subjective experiences of individuals with MS, a 'patient-focused' methodology has been adopted. Open-ended interviews were used to generate potential scale items. Items were piloted on an initial sample of individuals with MS and reduced to 14 items on the basis of their perceived relevance to this patient group. The final 14-item scale was then used with a further 142 individuals in order to assess its psychometric properties. The scale demonstrated high internal consistency (Cronbach's alpha = 0.81) and test-retest reliability (r = 0.81, P < 0.001) and acceptable validity. Issues concerning the assessment of validity are discussed in terms of the scale's relevancy to individuals with MS and the theoretical issues around the construct of self-efficacy. The scale has shown sensitivity to detect change following a brief therapeutic intervention, with an effect size of 0.502. This MS Self-efficacy Scale could, therefore, be a useful tool in the assessment of psychological adjustment and quality-of-life of individuals with MS.

Predicting blood pressure reactivity and heart rate variability from mood state following coronary artery bypass surgery.

STUDY OBJECTIVES: Coronary Artery Bypass Graft (CABG) surgery is a common and successful procedure for revascularisation. However, the experience can induce emotional reactions prior to and following surgery. This study aimed to document changes in blood pressure (BP) reactivity and heart rate variability (HRV) following CABG surgery, and to determine the impact of mood state, particularly anxiety and depression upon cardiovascular functioning. METHOD: Twenty-two patients preparing to receive elective, first time CABG surgery were recruited from The Cardiothoracic Centre, Liverpool, UK and psychologically assessed using the Hospital Anxiety and Depression Scale (HAD), Global Mood Scale (GMS) and the Dispositional Resilience Scale (DRI). BP and heart rate responses were also measured during four conditions: baseline response; laboratory session; ambulatory monitoring; and self-initialised recordings during the ambulatory period. In addition, HRV was measured for 12 h in conjunction with the ambulatory monitoring period. All measures were assessed 1 week prior to surgery and 2 months following surgery. RESULTS: A significant decrease in negative mood and an increase in positive mood were reported following surgery. Forty percent of patients were clinically anxious and depressed prior to surgery although this was reduced to 27% after surgery. Depression was the strongest independent predictor of pre-operative BP and HRV whilst anxiety was most significantly related to follow-up BP reactivity. DBP was most strongly predicted by mood state. CONCLUSIONS: These results suggest that patients with higher levels of anxiety and depression are at risk of reduced HRV and increased BP reactivity in response to mental stressors. The study also strongly suggests that current patient services should be expanded to acknowledge the role of psychological factors within clinical prognosis after CABG surgery.

Quality of life issues in motor neurone disease: the development and validation of a coping strategies questionnaire, the MND Coping Scale.

A person's ability to cope with having motor neurone disease may be an important factor in determining their quality of life. We have developed a scale to measure coping strategies in people with MND. A disease-specific and patient-focused approach was employed. Open-ended interviews were used to generate initial items. Coping with the condition was an important consideration for all subjects. The final scale was administered to a sample of 44 people with MND. A factor analysis of the results demonstrated subscales comprised of distinct styles of coping. Reliability and validity were demonstrated within individual subscales. Significant correlations were shown between coping styles and psychological well being, disease duration and disability. Although still at a preliminary stage of development, the MND Coping Scale is proposed as a useful tool for further longitudinal study of coping in MND, with the potential to discover cause effect relationships between coping and psychological outcome.

Quality of life assessment in MND: development of a social withdrawal scale.

A scale to measure 'social withdrawal,' was developed specifically for use with MND patients. Scale design was based upon patient-focused interviews which were used to explore patients' concerns. The impact the condition had upon their social interactions with others was salient for all patients and affected their overall quality of life. Using issues raised by patients, a 23-item scale was generated to specifically and quantitatively measure social withdrawal and this scale was psychometrically evaluated. The scale was administered to a sample of 23 patients at varied stages of progression of MND, and to a control group of patients with arthritis with similar levels of physical disability. For MND patients withdrawal from the community was found to be closely related to severity of physical symptoms and depression. Specific patients were identified who are particularly susceptible to withdrawal and depression. Comparison of the pattern of withdrawal in the MND and arthritis patient groups suggested that there may be differences between the factors governing social withdrawal in different patient populations.

A prospective study of changes in negative mood states of women undergoing surgical hysterectomy: the relationship to cognitive predisposition and familial support.

Levels of anxiety and depression were documented by questionnaire response from a sample of 89 women who were to undergo surgical hysterectomy 3 weeks later. Fifty-four per cent (n = 48) of the sample reported anxiety and 26% (n = 23) reported depression at clinical levels during the preoperative period, with an additional number (n = 16 anxiety; n = 19 depression) at borderline status. Despite an overall significant postoperative reduction of negative mood states, clinical levels of anxiety were found in a substantial minority of women both 2 (24%) and 6 months (31%) after surgery. Levels of depression at these times were respectively 13% and 11% of the sample which provided postoperative information. These data confirm previous reports of high levels of negative mood states in patients referred for surgical hysterectomy. However, analyses of individual profiles of change confirm that there was a beneficial outcome for the large majority of the women, with 83% of those with clinical levels of anxiety showing improved status. Regression analyses indicated that postoperative outcomes with respect to negative affect could be predicted from preoperative status, and the data provide some support for the hypothesis that for a minority of women, negative mood states co-presented with gynecological symptoms may not be attenuated by surgery. Both dispositional resilience and familial cohesiveness were entered as significant variables in regression models examining postoperative status, although they provided only a limited increase to the postoperative variance prediction from measure of preoperative levels of affect. Preoperative mood status was found to be inversely related to an intrapersonal dimension of 'dispositional resilience' and to 'family cohesiveness'. It is suggested that measurement of preoperative mood status to family cohesiveness and dispositional resilience may provide useful adjunctive measures in attempts to identify women at risk of reporting an unsatisfactory surgical outcome.

Circling behaviour induced by apomorphine after lesions of the habenula.

Apomorphine, 2 mg/kg (s.c.) produced significant contralateral turning in rats with unilateral radiofrequency lesions of the habenula nucleus over a test period of 60 min when tested at post-surgery days 3, 7, and 14. Levels of contralateral circling were not significantly increased when the animals were tested on days 21 and 28, although a contralateral bias was still observed. Rotation induced by apomorphine was completely blocked by the administration of haloperidol (0.3 mg/kg i.p.), and there was no behavioural asymmetry in lesioned animals following administration of saline or a high dose of haloperidol (2 mg/kg i.p.). These results indicate that unilateral habenula lesions lead to imbalance of dopaminergic activity, which is expressed as contralateral circling when the animal is challenged with apomorphine.

Dissociation of behavioral changes in rats resulting from lesions of the habenula versus fasciculus retroflexus and their possible anatomical substrates.

Lesions in either the habenula or its primary efferent pathway, the fasciculus retroflexus (FR), impaired avoidance responding. However, lesions of only the FR provided a persistent elevation of locomotor activity. Immunocytochemical study of the interpeduncular nucleus (IPN) through injection of retrograde tracers into the IPN and the overlying ventral tegmental area indicated that habenular lesions spared both rostral habenula and forebrain projections to the caudal midbrain, but these projections were axotomized by FR lesions. Rostral sparing of the habenula resulted in normal peptidergic staining in the IPN, and normal cholinergic innervation was absent. Performance of individual rats in behavioral tests was consistent with variations in anatomical sparing. Such considerations may account for previous discrepancies in functional effects of habenular lesions.

A water-maze discrimination learning deficit in the rat following lesion of the habenula.

Although the habenula occupies a potentially important link between forebrain and midbrain, lesion of the complex produces little effect in most standard behavioral paradigms. More recently, it has been shown that such lesions may impair the ability to initiate or switch responses appropriate to environmental contingencies but only under demanding conditions. Although such deficits have been described as response failures, they could equally well be attributed to restricted attentional mechanisms. The present study was designed to further substantiate a role for the habenula in acquisition of adaptive behavior under demanding conditions and to examine the possible contribution of attentional failure. The initial response preference to 'escape' onto platforms situated in two chambers at the distal end of a water tank was established for groups of lesioned and sham-operated rats. Rats were subsequently trained in discrete trials to escape by choosing the side of the nonpreferred chamber. During training the choice of escape chamber was cued by distracting black or white visual stimuli displayed on the tank sides and above the entrances to the chamber. These were moved over trials so as to be nonpredictive of the appropriate escape position. Lesioned animals were significantly impaired in the acquisition of this positional discrimination. Analysis of response times suggested that both lesion and control animals were attending to the irrelevant visual cue. The results confirm a behavioral inflexibility following lesion of the habenula and suggest that this deficit cannot be explained simply in terms of a failure to attend to environmental cues. The lesion deficit also could not be attributed to a response perseveration.

Intra-habenular injection of 6-hydroxydopamine produces impaired acquisition of DRL operant behavior.

The anatomical connections of the habenula complex indicate it provides a relay between limbic forebrain and midbrain. Somewhat paradoxically, consequences of nonspecific lesion of the habenula are ambiguous with little change in basic response evident within simple behavioral paradigms. However, the potential functional importance for this relay has more recently been indicated by the demonstration of deficits in the ability of lesioned animals to alter behavior appropriate to both internal and external stimuli in more demanding behavioral tasks. Doubts concerning the importance of the habenula remain because of the large number of descending fibers of passage through the habenula. To provide more substantive evidence, 6-hydroxydopamine was injected into the habenula of rats to provide more limited lesion of catecholaminergic terminals. Animals were subsequently trained on an operant DRL 20-s schedule for which deficits have been reported following nonspecific lesion of the habenula. Lesioned animals showed a tendency to overrespond and were significantly less efficient on the schedule with decreased number of reinforcements received relative to controls. While the neurotoxic lesion procedure used does not differentiate noradrenergic and dopaminergic damage, the importance of intact catecholaminergic systems within the habenula for effective DRL acquisition is consistent with the suggested importance of the habenula for feedback regulation of dopamine within the ventral tegmental area through ascending dopamine fibers to the habenula.

Increased immobility in an automated forced swimming test following lesion of the habenula in rats: absence of evidence for a contribution from motor impairment.

The effects of lesions of the habenula on responses during a forced swimming test (FST) were examined. Active behavior, documented by turns on a drum immersed in a water tank, were reduced in lesioned rats. Lesioned rats also demonstrated an inability to escape from the water by climbing onto the drum when it was locked in position at the end of the test. There was a tendency for lesioned rats to show more activity in open-field tests either after the FST or independent of such prior testing. Lesioned rats showed no motor or postural abnormalities and were able to maintain position for longer than controls during a rotating rod test. Collectively, the results are compatible with the suggestion that lesions of the habenula impair the ability to change motor strategies under stress but indicate such failures may not be ascribed to gross motor impairment.

An analysis of the relationship between hostility and training in the martial arts.

Contrasting views and data are available on the issue of whether combative sports facilitate or reduce aggression. In the present study levels of hostility were assessed in two groups of martial arts students using the Buss-Durkee Inventory. Levels of hostility on a variety of the sub-scales were compared with scores from similar samples of participants in a body contact, aggressive but non-combative sport (rugby football) and a competitive sport with no body contact or direct aggression (badminton). When the effects of age and length of training were controlled by use of partial correlation there was no evidence to support group differences in either the combined score from the varied sub-scales of the inventory or the more specific assaultive sub-scale. However, there was evidence to suggest a significant effect of length of training on hostility levels in martial artists. Beginners attracted to the martial arts were more hostile but the hostility declined with the duration of training. No difference was apparent in this respect for students participating in either jui jitsu or karate. It is suggested that such differential effects with respect to length of training may lead to the overall absence of the between-sport differences. The results provide tentative support for the notion that the discipline of the martial arts may reduce assaultive hostility rather than serve as a model for such behaviour, yet support the need for prospective longitudinal studies on intra-individual hostility.

Effort and stress influence the effect of lesion of the habenula complex in one-way active avoidance learning.

Previous studies which have examined the effects of lesions of the habenula on active avoidance learning have not provided unambiguous support for response deficits. Moreover, interpretation of early studies is confounded by large lesions which damaged adjacent structures. We report the effects of smaller circumscribed lesions of the habenula complex on a simple one-way active avoidance paradigm in three separate experiments in which the required operant was a step or jump onto an elevated platform. In the first study involving avoidance of shock of low intensity (0.5 mA) with an average long intertrial interval of 8 minutes, lesioned animals were not significantly different from sham operated controls. However, in following experiments in which stress levels were increased by raising the shock intensity and reducing the intertrial-interval, or in which the operant was made considerably more demanding by raising the height the animals had to jump to make an avoidance response, there were large lesion induced deficits in avoidance responding. The absence of significant differences between lesioned and sham operated controls in escape latencies suggested no lesion induced impairment of the response to the shock. It is suggested that the data not only support an effect of habenular lesions on active avoidance learning but also are consistent with a previous suggestion that the functional effects of lesion of the habenula on behaviour are effected through changes in dopaminergic function.

A failure to support cross-sensitization between effects of apomorphine and lesions of the habenula nucleus.

An interchangeability between the effects of stress and psychostimulants has been reported. The possible common physiological effects of lesions of the habenula, stress and psychostimulant administration of activation of ascending dopamine systems suggested examination of a cross-sensitization between lesions of the habenula and psychostimulant administration. Lesions of the habenula were found to increase baseline activity but there were no significant changes in response to apomorphine in either various categories of stereotypy or locomotor response. Lesioned rats and controls both demonstrated similar dose and time-related effects in various response measures. Although not significant, certain results suggested that changes tended to be in the direction opposite to that of the suggested sensitization. The results are contrasted with previous supporting data and discussed in terms of the potentially diverse manner in which habenular manipulation and psychostimulants may influence dopaminergic activity and subsequent behaviour.

Changes in motor activities induced by microinjections of the selective dopamine agonists LY 171555, quinpirole hydrochloride, and SK&F 38393 into the habenula nucleus.

The effects on behaviour of microinjections into the habenula complex of selective agonists for dopamine D-1 (SK&F 38393) and D-2 (LY 171555) receptors were documented in a holeboard, open-field test. The D-2 agonist reduced grooming responses, locomotor activity and rearing behaviour. In contrast, the D-1 agonist increased rearing and locomotor activity but was without effect on grooming responses. Neither drug produced significant effects on inspective hole exploration. The data extend findings of behavioural consequences of central D-1 receptor activation and provide direct evidence in support of the functional and behavioural importance of intrahabenular dopamine receptor sites. The findings are consistent with suggestions for feedback regulation of habenular efferents to midbrain dopaminergic neurons. Effects of both receptor agonists on some responses but not others indicates potential complex interactions between D-1 and D-2 receptors within the habenula.

Attenuated response to nomifensine in rats during a swim test following lesion of the habenula complex.

Male Lister rats with bilateral lesions of the habenula nuclei were observed during two consecutive phases of a swim test. During the first phase of the test, when escape was not possible, lesioned animals demonstrated fewer changes of behaviour. Lesioned animals failed to utilise an introduced external cue and escape route in the second part of the test. Control rats treated with the antidepressant nomifensine showed few changes of behaviour during the inescapable phase of the test but an enhanced ability to escape. Nomifensine produced no improvement of escape behaviour in lesioned animals, suggesting that this behavioural effect of nomifensine in controls is dependent on the habenula relay. The data also suggest that more than one response in swim tests can serve as an index of depression.

The effects of lesions of the habenula nucleus on lever press behaviour during a tandem operant schedule with contrasting response requirements.

The effect of bilateral lesions of the habenula nuclei in male Lister hooded rats was assessed in performance of a well learned complex tandem operant reinforcement schedule. The schedule requirement involved two successive and contrasting components in which 15 operant lever press responses followed by inhibition of the same response for a period of 15 s provided liquid-food reinforcement. Initially little disruption of performance was seen when each component of the schedule was differentially signalled with an external cue. However, relative to controls, lesioned animals showed an increasing disruption of performance when such cues were omitted. The deficit in performance of lesioned animals was not a simple failure to inhibit responding that could be predicted from an altered input from septal areas. It is suggested that these behavioural data are consistent with the anatomical evidence for the habenula as a functional relay for the integration of information from limbic structures and the striatum and that lesions of the habenula affect the ability of animals to maintain effective response strategies, particularly when these are under intrinsic control.