[Psychedelics in the field of chronic pain. A path to explore?] / Psychédéliques dans le domaine de la douleur chronique. Une piste à explorer?

Psychedelics are emerging as a therapeutic innovation in psychiatry and their use in chronic pain is worth exploring. In fact, they can modulate the serotonergic system, affecting central pain sensitization mechanisms. Ketamine, used for chronic analgesia, can lead to pain reduction, but additional studies are needed to assess its longterm effectiveness. "Classic" psychedelics are recently attracting renewed interest for their potential effects on chronic pain. Despite limited studies, evidence suggests analgesic benefits, an effect on inflammation, and potential impacts on certain functional disorders. These results pave the way for further research in this ever-evolving field.

Les psychédéliques émergent comme une innovation thérapeutique en psychiatrie et leur utilisation dans la douleur chronique mérite d'être explorée. En effet, ils peuvent moduler le système sérotoninergique, influençant les mécanismes de sensibilisation centrale à la douleur. La kétamine, utilisée en antalgie chronique, peut aboutir à une réduction de la douleur, mais des études supplémentaires sont nécessaires pour évaluer son efficacité à long terme. Les psychédéliques «classiques¼ suscitent un regain d'intérêt récent pour leurs effets potentiels sur la douleur chronique. Malgré des études limitées, des indices suggèrent des bénéfices analgésiques, une influence sur l'inflammation et des impacts potentiels sur certains troubles fonctionnels. Ces résultats ouvrent la voie à de nouvelles recherches dans ce domaine en constante évolution.

Successful MRI-Guided Focused Ultrasound Thalamotomy after Ipsilateral Gamma Knife Radiosurgery for Essential Tremor: A Case Report with Video.

We report the case of a 67-year-old left-handed female patient with disabling medically refractory essential tremor who underwent successful right-sided magnetic resonance-guided focused ultrasound (MRgFUS) of the ventral intermediate nucleus after ipsilateral gamma knife radiosurgery (GKRS) thalamotomy performed 3 years earlier. The GKRS had a partial effect on her postural tremor without side effects, but there was no reduction of her kinetic tremor or improvement in her quality of life (QoL). The patient subsequently underwent a MRgFUS thalamotomy, which induced an immediate and marked reduction in both the postural and kinetic tremor components, with minor complications (left upper lip hypesthesia, dysmetria in her left hand, and slight gait ataxia). The MRgFUS-induced lesion was centered more medially than the GKRS-induced lesion and extended more posteriorly and inferiorly. The MRgFUS-induced lesion interrupted remaining fibers of the dentatorubrothalamic tract (DRTT). The functional improvement 1-year post-MRgFUS was significant due to a marked reduction of the patient's kinetic tremor. The QoL score (Quality of Life in Essential Tremor) improved by 88% and her Clinical Rating Scale for Tremor left hand score by 62%. The side effects persisted but were minor, with no impact on her QoL. The explanation for the superior efficacy of MRgFUS compared to GKRS in our patient could be due to either a poor response to the GKRS or to a better localization of the MRgFUS lesion with a more extensive interruption of DRTT fibers. In conclusion, MRgFUS can be a valuable therapeutic option after unsatisfactory GKRS, especially because MRgFUS has immediate clinical effectiveness, allowing intra-procedural test lesions and possible readjustment of the target if necessary.

[Mindfulness-Oriented Recovery Enhancement (MORE): integrative treatment for chronic pain]. / Mindfulness-Oriented Recovery Enhancement (MORE) : traitement intégratif pour la douleur chronique.

Chronic pain requires an integrative approach. The prescription of opioids is increasing in Europe, including Switzerland, for the -treatment of chronic pain, despite their modest effectiveness. Mindfulness-based interventions have demonstrated their effectiveness in the management of chronic pain. The MORE program (Mindfulness-Oriented Recovery Enhancement) is an integrative therapy that uses mindfulness practices to help patients develop new positive beliefs and regain meaning, motivation and pleasure. The MORE program has been proven effective in reducing opioids and increasing well-being in patients suffering from chronic pain and thus constitutes a promising therapeutic approach.

La douleur chronique nécessite une approche intégrative. La prescription des opiacés augmente de plus en plus en Europe, y compris en Suisse, pour le traitement de la douleur chronique, malgré leur efficacité modeste. Les interventions basées sur la méditation de pleine conscience ont démontré leur efficacité quant à la prise en charge de la douleur chronique. Le programme MORE (Mindfulness-Oriented Recovery Enhancement) est une thérapie intégrative qui utilise des pratiques de pleine conscience afin d'aider les patients à développer des nouvelles croyances positives et de retrouver le sens, la motivation et le plaisir. Ce programme a été prouvé ­efficace quant à la réduction des opiacés et l'augmentation du bien-être chez les patients souffrant de douleurs chroniques. Il constitue ainsi une approche thérapeutique prometteuse.

[When the discontinuation of psychotropic drugs is necessary: clinical manifestations and therapeutic approach]. / Quand la discontinuation des psychotropes s'impose : manifestations cliniques et approche thérapeutique.

The reduction or suspension of psychotropic treatment may be necessary for various medical reasons. This can have serious consequences for patients, including clinical manifestations, both physical and psychological. These manifestations, which are often unpleasant, can compromise care during hospitalization and undermine the therapeutic alliance. Their early detection, readjustment of treatment, when necessary, as well as regular communication with the patient and among specialists are important tips to take into account from caregivers.

La diminution ou mise en suspens d'un traitement psychotrope peut être imposée par des raisons médicales diverses. Cela peut avoir d'importantes conséquences pour les patients, notamment des manifestations cliniques, tant physiques que psychologiques. Elles sont souvent désagréables, peuvent compromettre l'adhésion aux soins lors d'une hospitalisation et mettre à mal le lien thérapeutique. Leur détection précoce, le réajustement du traitement quand nécessaire, ainsi que la communication régulière avec le patient et entre spécialistes sont des éléments importants à prendre en compte lors de ces prises en charge.

[Contain psychomotor agitation in somatic units : implementation of a protocol at the HUG]. / Contenir l'agitation psychomotrice dans les unités somatiques : mise en place d'un protocole aux HUG.

Psychomotor agitation in somatic units is a medical and psychiatric emergency requiring rapid intervention by the team in charge of the patient and the liaison psychiatrist. Verbal de-escalation is attempted throughout the treatment. Securing the surroundings is needed to protect both the patient and the team. The etiology of the agitation, somatic and/or psychiatric, should be investigated to allow the administration of an adequate treatment. Antipsychotics and benzodiazepines are often recommended. Physical restraint measures can be applied as a last resort if necessary. The continuation of care is decided jointly between the team in charge and the liaison psychiatrist. An intervention protocol has been drawn up by the HUG liaison psychiatry team.

L'agitation psychomotrice dans les unités somatiques est une urgence médicale et psychiatrique qui nécessite une intervention rapide de l'équipe en charge et du psychiatre de liaison auprès du patient. Une désescalade verbale est tentée tout au long de la prise en charge. La sécurisation de l'environnement pour protéger le patient et l'équipe est primordiale. L'étiologie de l'agitation, somatique et/ou psychiatrique, doit être recherchée, ce qui permet l'administration d'un traitement adéquat. Les antipsychotiques et les benzodiazépines sont souvent préconisés. Des mesures de contention physique peuvent être appliquées en dernière intention si besoin. La poursuite des soins se décide en commun entre l'équipe en charge et le psychiatre de liaison. Un protocole d'intervention a été élaboré par l'équipe de la psychiatrie de liaison des HUG.

[Personalized approach in chronic pain psychotherapy]. / Approche personnalisée dans la psychothérapie des douleurs chroniques.

Chronic pain is a complex phenomenon that includes three dimensions : biological, socio-cultural and psychological. The psychological aspect plays an amplifying role in the perception of pain and therefore, adjuvant psychotherapies are an important tool in the multidimensional management of chronic pain. In this article, we present the main psychotherapeutic approaches and techniques applied in the field of chronic pain which act on the cognitive-emotional, traumatic, as well as on the sensory level. The personalization of psychotherapeutic treatment, as well as the involvement of patients in its choice, should allow psychotherapeutic approaches to achieve their goal in terms of improving the quality of life of patients.

La douleur chronique est un phénomène complexe qui inclut trois dimensions : biologique, socioculturelle et psychologique. L'aspect psychologique joue un rôle amplificateur dans la perception douloureuse et de ce fait, les psychothérapies adjuvantes constituent un outil important quant à la prise en charge multidimensionnelle de la douleur chronique. Dans cet article, nous présentons les approches et techniques psychothérapeutiques principales appliquées dans le domaine de la douleur chronique qui agissent tant sur le plan cognitivo-émotionnel et traumatique que sur le plan sensoriel. La personnalisation du traitement psychothérapeutique ainsi que l'implication des patients dans son choix devraient permettre aux approches psychothérapeutiques d'atteindre leur objectif en termes d'amélioration de la qualité de vie des patients.

[To pretend or to really suffer ? Questions from caregivers about the factitious disorder]. / Faire semblant ou souffrir vraiment ? Questions des soignants face au trouble factice.

The diagnosis of factitious disorder can only emerge when caregivers are in difficulty in caring for their patient. This disorder is a real challenge for healthcare teams throughout the treatment, from its discovery to its treatment. Secrecy and self-inflicted injuries are components that we can be uncomfortable with as caregivers. The factitious problem requires well-coordinated care between the various specialists and often questions our practices. In this article we deal with the questions frequently asked by the care teams to the liaison psychiatrists that we are, by working on the identification of the problem in the clinic, the therapeutic issues and the attitude to adopt.

Le diagnostic de trouble factice ne peut émerger que lorsque les soignants sont en difficulté dans la prise en soins de leur patient. Ce trouble est un véritable défi pour les équipes soignantes tout au long de la prise en charge, de sa découverte à sa prise en soins. Mise en échec, secret et lésions auto-infligées sont autant de composantes avec lesquelles nous pouvons être mal à l'aise comme soignants. La problématique factice demande une prise en charge bien coordonnée entre les divers spécialistes et, souvent, questionne nos pratiques. Dans cet article, nous traitons des questions fréquemment posées par les équipes de soins aux psychiatres de liaison que nous sommes, en s'occupant de l'identification du problème en clinique, des enjeux thérapeutiques et de l'attitude à tenir.

[Psychological health and cardiovascular disease : interdependency and therapeutic opportunities]. / Corpus sanum in mente sana : stratégies de promotion de la santé psychique en cas de pathologie cardiovas.

Despite progress in primary and secondary prevention, pharmacological and device-based therapies, cardiovascular disease remains a leading cause of morbidity and mortality worldwide. The specifics of cardiac disorders being in the spotlight, less attention has been given to psychological health and its interdependent relation to cardiovascular disease. Psychological health issues can contribute to increase cardiovascular disease risk, and cardiovascular disease itself can promote development of mental health issues. Psychological health in patients with cardiovascular disease represents an underexplored opportunity for intervention, an endeavour that could be designed as behavioural cardiology, which would be synergistic with efforts aimed at primary and secondary prevention.

Malgré les progrès réalisés en prévention primaire et secondaire ainsi qu'en termes de traitements pharmacologiques et de dispositifs médicaux, les pathologies cardiovasculaires restent la cause principale de morbidité et de mortalité à travers le monde. L'attention médicale portant particulièrement sur les pathologies cardiaques elles-mêmes, la santé mentale du patient peut être l'objet d'une attention insuffisante. Les souffrances psychiques contribuent à une augmentation du risque de pathologie cardiovasculaire et, réciproquement, une pathologie cardiovasculaire rend vulnérable et peut favoriser l'apparition d'un trouble psychique. La prise en charge globale du sujet cardiopathe, en particulier de son vécu intrapsychique, représente une opportunité d'intervention largement sous-exploitée. Cette discipline, nommons-la cardiologie comportementale, pourrait être menée en parallèle des mesures de prévention primaire et secondaire.

[Demoralization and meaning in life in suicidal ideation†: a role for patients suffering from chronic pain?] / Démoralisation et sens dans la vie dans l'idéation suicidaire†: un role chez les patients douloureux chroniques†?

Chronic pain is strongly related to the emotional state of the individual and may be associated with suicidal ideation. The concepts of demoralization and meaning in life may have a role in suicidal ideation as a factor of crisis and resilience, respectively. Demoralization, and especially one of its elements, hopelessness, predisposes to suicidal behavior and is often associated with chronic pain conditions. In addition, the meaning that a patient with chronic pain attributes to his or her existence may also influence suicidal behavior. Follow-ups focused on demoralization and meaning in life may be a promising psychotherapeutic approach for patients suffering from chronic pain.

La douleur chronique est fortement liée à l'état émotionnel de l'individu et peut être associée à l'idéation suicidaire. Les concepts de démoralisation et de sens dans la vie peuvent avoir un rôle sur l'idéation suicidaire respectivement en tant que facteur de crise et de résilience. La démoralisation, et surtout l'un de ses éléments, le désespoir, prédispose au comportement suicidaire et est souvent associée à des états douloureux chroniques. En outre, le sens qu'un patient souffrant de douleurs chroniques peut attribuer à son existence peut également influencer le comportement suicidaire. Une prise en charge centrée sur la démoralisation et le sens dans la vie pourrait constituer une approche psychothérapeutique prometteuse pour les patients souffrant de douleurs chroniques.

What do older adults want from spine care?

Introduction: Older adults comprise a large portion of back pain (BP) sufferers but are under-represented in the literature. Patients over age 65 present with different clinical characteristics and psychosocial needs than younger patients. Therefore, recommended patient-centered outcomes for BP may not be relevant to older patients. Research question: What treatment outcomes are most important to adults over 65 years of age? Materials and methods: We queried older adults seeking treatment for BP using qualitative methods. Participants were asked about their goals and expectations of treatment in an audio-taped interview. Audiotapes were transcribed, coded and analyzed by the investigators. Using thematic analysis, main themes and constructs were extracted and interpreted by the investigators. From there we were able to generate hypotheses about what older patients want from spine treatment. Results: For all participants, age played a role in their treatment goals as a moderator or motivator. They were most concerned with returning to usual activities and preventing further physical limitations to maintain independence. Goals that reflect important outcomes such as increasing walking tolerance and improving balance were of particular importance. Confidence in the provider acted as a facilitator of goals. Discussion and conclusion: Unlike their younger cohorts, they did not emphasize work-related outcomes and pain relief. These findings can be tested in future quantitative studies and will help to develop protocols for outcomes assessment in older adults. This study is a first step towards understanding and improving the quality of care for older patients with back pain.

Demoralization and Suicidal Ideation in Chronic Pain Patients.

The literature has clearly stressed that patients suffering from chronic pain are at high risk of suicidal behavior (SB). Hence the need to improve the characterization of this behavior risk profile in these patients. Some findings indicate a possible relationship between demoralization and pain, with functional disability found to be correlated with demoralization. The primary objective of this study was to investigate the relationship between demoralization and suicidal ideation (SI) in patients with chronic pain. The secondary objective was to verify whether demoralization can occur independently of depression in these patients. Inclusion criteria were patients with chronic pain, with SI or not, matched for age and gender, aged > 18 years. Seventy patients with SI and 70 patients without SI were included. Between-group difference was statistically significant (F=1.064; t= 7.21, p<0.001, d=1.22), confirming the presence of numerous and intense depressive symptoms in the patients of the SI group. Regarding the Demoralization Scale (DS), the difference between the two groups was statistically highly significant (F=1.49; t=9.44; p<0.001, d=1.6). There was also a strong positive correlation between DS and Beck Depression Inventory (BDI-II) (R=0.749; p<0.001 for the study group and R=0.704; p<0.001 for the control group). Furthermore, there was a strong positive correlation between the DS and the Scale for Suicide Ideation (SSI) in the SI patients group, meaning that high demoralization is associated with higher suicidal ideation as well. Our findings did not allow us to distinguish between the notions of depression and demoralization, since the two constructs show almost the same strong positive correlation with suicidal thoughts, the two also being strongly correlated with each other.

Possible Contribution of Meaning in Life in Patients With Chronic Pain and Suicidal Ideation: Observational Study.

BACKGROUND: Chronic pain is associated with an elevated risk of suicidal ideation (SI). OBJECTIVE: We aimed to examine if the presence or the search for Meaning in Life (MiL) are associated with less SI and explore whether MiL profiles emerge in our cohort. These profiles can be described as high presence-high search, high presence-low search, low presence-low search, and low presence-high search. METHODS: In this observational study, we recruited 70 patients who were referred to the Multidisciplinary Pain Center of the Geneva University Hospitals and who answered positively to question 9 on the Beck Depression Inventory, 2nd Edition, investigating SI. Patients who agreed to participate in the study were further investigated; they participated in a structured diagnostic interview to screen for psychiatric diagnoses. During this interview, they completed the Meaning in Life Questionnaire and the semistructured Scale for Suicide Ideation (SSI) to assess the characteristics and severity of SI. RESULTS: There was a statistically significant correlation between the presence of MiL subscale and the SSI. These 2 scales had a negative and statistically highly significant correlation (R=-.667; P<.001). The results also showed a negative and statistically highly significant correlation between the score of the search for MiL and the SSI (R=-.456; P<.001). The results thus pointed to the presence of MiL as a potential protective factor against the severity of SI, while the search for MiL is also a possible resiliency factor, although to a lesser extent. The profile low presence-low search grouped the vast majority (47%) of the patients; in these patients, the mean SSI score was 14.36 (SD 5.86), much higher compared with that of the other subgroups. CONCLUSIONS: This study's results point to MiL as a concept of interest regarding devising psychotherapeutic interventions for chronic pain patients in order to reduce the suicidal risk and more accurately determine patients' suffering.

Meaning in Life Among Patients With Chronic Pain and Suicidal Ideation: Mixed Methods Study.

BACKGROUND: Patients with chronic pain have elevated risk of suicidal ideation and behavior, including suicide attempts and completed suicides. In most studies, associations between chronic pain and suicidal ideation/suicidal behavior are robust even after adjusting for the effect of sociodemographics and psychiatric comorbidity. However, to refine the risk profile of these patients, further exploration of other possible risk and protective factors is necessary. OBJECTIVE: There is a common clinical observation that experiencing chronic pain often requires a revision of life goals and expectations, and hence, it impacts the existential domain including one's perception of the meaning in life (MiL). This study aimed to characterize the main domains that constitute the personal MiL, including the "presence of" and "search for" constructs, in a group of patients with chronic pain and suicidal ideation. METHODS: Seventy participants were enlisted by ongoing recruitment through a larger project anchored in daily clinical practice at the Multidisciplinary Pain Center of the Geneva University Hospitals. It was an observational mixed method study. Data were recorded through both validated quantitative questionnaires and qualitative open-ended questions. RESULTS: The total sample consisted of 70 patients. Responses to questionnaires showed a depressive episode in 68 (97%) patients and anxious disorders in 25 (36%) patients. With a score threshold for positive MiL of 24, the mean score for the "presence of" construct was 20.13 (SD 8.23), and 63% (44/70) of respondents had a score <24. The mean score for the "search for" construct was lower at 18.14 (SD 8.64), and 70% (49/70) of respondents had a score <24. The "presence of" and "search for" constructs were significantly positively correlated (R=0.402; P=.001). An open question addressed the "presence of" construct by inviting the respondents to cite domains they consider as providing meaning in their life at the present time. All patients responded to this question, citing one or more domains. The three main dimensions that emerged from content analysis of this qualitative section were as follows: the domain of relationships, the domain of personal activities, and pain and its consequences on MiL. CONCLUSIONS: The study results provide insights into patients with chronic pain and suicidal ideation, including the domains that provide them with meaning in their lives and the impact of pain on these domains with regard to suicidal ideation. The main clinical implications concern both prevention and supportive/psychotherapeutic interventions. They are based on a narrative approach aiming to explore with the patients the content of their suffering and the MiL domains that they could identify to mitigate it, in order to restructure/reinforce these domains and thus possibly reduce suicidal ideation. Specifically, a focus on maintaining the domains of interpersonal relationships and personal activities can allow patients to ultimately escape the biopsychosocial vicious cycle of chronic pain-induced deep moral suffering.

The Role of Demoralization and Meaning in Life (DEMIL) in Influencing Suicidal Ideation Among Patients Affected by Chronic Pain: Protocol of a Single-Center, Observational, Case-Control Study.

BACKGROUND: Chronic pain is a significant risk factor for suicidal ideation (SI) and suicidal behavior (SB), including a 20%-40% prevalence rate of SI, a prevalence between 5% and 14% of suicide attempts, and a doubled risk of death by suicide in patients with chronic pain compared to controls. In most studies, associations between chronic pain and suicidality are robust, even after adjusting for the effect of sociodemographics and psychiatric comorbidity, and particularly for depressive conditions. A number of specific conditions that can modulate suicidality risk in patients with chronic pain have been investigated, but there is a need for their more specific characterization. Numerous recent studies have shown that demoralization and meaning in life (MiL) constructs affect suicidality as risk and protective factors, respectively. These constructs have been mainly investigated in patients with somatic illness and in community-dwelling individuals who may present with SI or SB independently of a psychiatric diagnosis of depression. However, a paucity of studies investigated them in suicidal patients affected by chronic pain. OBJECTIVE: The primary objective of this project is to investigate the relationship between demoralization and MiL on SI risk in patients with chronic pain. The secondary objectives are (1) to test whether demoralization can occur independently of depression in patients with chronic pain and SI, (2) to examine whether the expected association between demoralization and SI may be explained by a sole dimension of demoralization: hopelessness, (3) to examine whether the presence of MiL, but not the search for MiL, is associated with less SI, and (4) to explore whether previously described MiL profiles (ie, high presence-high search, high presence-low search, moderate presence-moderate search, low presence-low search, and low presence-high search) emerge in our cohort. METHODS: This project is a single-center, observational, case-control study-the Demoralization and Meaning in Life (DEMiL) study-conducted by the Division of Clinical Pharmacology and Toxicology, the Multidisciplinary Pain Centre, and the Service of Liaison Psychiatry and Crisis Intervention at the Geneva University Hospitals. Self- and hetero-administered questionnaires were conducted among patients and controls, matched by age and gender. The Ethics Committee of the Canton of Geneva approved the scientific utilization of collected data (project No. 2017-02138; decision dated January 25, 2018). Data have been analyzed with SPSS, version 23.0, software (IBM Corp). RESULTS: From March 1, 2018, to November 30, 2019, 70 patients and 70 controls were enrolled. Statistical analyses are still in progress and are expected to be finalized in November 2020. To date, we did not observe any unfavorable event for which a causal relationship with the collection of health-related personal data could be ruled out. Results of this study are expected to form the basis for possible prevention and psychotherapeutic interventions oriented toward demoralization and MiL constructs for suicidal patients with chronic pain. CONCLUSIONS: The interest in exploring demoralization and MiL in chronic pain patients with SI arises from the common clinical observation that experiencing chronic pain often requires a revision of one's life goals and expectations. Hence, the impact of chronic pain is not limited to patients' biopsychosocial functioning, but it affects the existential domain as well. The major clinical implications in suicidal patients with chronic pain consist in trying to (1) delineate a more precise and individualized suicide risk profile, (2) improve detection and prevention strategies by investigating SI also in individuals who do not present with a clinically diagnosed depression, and (3) enhance the panel of interventions by broadening supportive or psychotherapeutic actions, taking into consideration the existential condition of a person who suffers and strives to deal with his or her suffering. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24882.

Meaning in life and demoralization: a mental-health reading perspective of suicidality in the time of COVID-19.

Consequences on mental health have been reported in general population, vulnerable individuals, psychiatric patients, and healthcare professionals. It is urgently necessary to study mental health issues in order to set priorities for public health policies and implement effective interventions. Suicidality is one of the most extreme outcomes of a mental health crisis. It is currently too early to know what the effect of COVID-19 will be on suicidality. However, authoritative commentary papers alert that most of the factors precipitating suicide are, and probably will be for a long time, present at several individual existence levels. A number of prevention measures and research considerations have been drawn up. A point of the latter, recommended by the International COVID-10 Suicide Prevention Research Collaboration, states that "the COVID-19 suicide research response should be truly multidisciplinary. This will foster research that addresses the different aspects and layers of risk and resilience.It will also foster research that informs prevention efforts by taking a range of perspectives" (Niederkrotenthaler et al., 2020). In this light, we would like to propose a reading perspective of suicidality that takes into account Meaning in Life (MiL) and demoralization. Both of the constructs were studied in heterogeneous populations with extreme life situations having led to a fracture between a "before" and an "after", and play a role in affecting suicidality, respectively as resilience and risk factors. In clinical practice, during these unprecedent times, we wish that this more inclusive approach could: 1) contribute to prevention, by delineating more individualized suicidal risk profiles in persons conventionally non-considered at risk but here exposed to an extremely uncommon experience, 2) enrich supportive/psychotherapeutic interventions, by broadening the panel of means to some aspects constitutive of the existential condition of a person who is brutally confronted with something unexpected, incomprehensible and, in some ways, still unpredictable.