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Treating diseases, not patients.

Highly trained medical specialists now possess a vast array of sophisticated technical apparatus with which to fight diseases. These tools, coupled with a growing emphasis on cost accounting and a medical paradigm emphasizing facts and depicting the human body as a machine, depersonalize health care by militating against a holistic approach to treating patients. Medical training and patient education must combine to ensure a new humanistic approach to the practice of medicine built on technical skills, but buttressed by comparison, commitment, humility, and those other attributes that will encourage physicians to treat people and not just diseases.

Holistic Health↗

Nursing theory-based practice in the home and community: the crux of professional nursing education.

Nursing has been viewed as a service for people wherever they may be--a service, grounded in scientific knowledge, that transcends setting. Yet nursing education has been overwhelmed by hospital institutions for the past 50 years, its attention diverted to medical entities and institutional trends, with fragmentation and depersonalization of general health care as well as nursing care as the result. Nursing theory-based practice is not feasible in institutions where medical orders overshadow all other disciplines. Community-based experiences in which nursing students learn about people and their health in the context of home and community offer the best promise for students to learn the complex human dynamics of real life and develop the holistic perspective required for independent nursing practice. The time has passed for nursing education to focus on the fraction of the population in hospitals while slighting knowledge about health as it is lived every day. Priority content for all nursing students should be a portable nursing theorybase that can be taken anywhere, focusing on health promotion, healthy environments, and quality of life.

Community Health Nursing↗

Antioxidant enzymes, occupational stress and burnout in workers of a prehospitalary emergency service.

BACKGROUND: Reactive oxygen species (ROS) play an important role in many diseases and aging. Scavenging enzymes represent one of several natural defence mechanisms against ROS-induced damage. Superoxide dismutase (SOD) and catalase are enzymes that are involved in antioxidant defence. Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment. OBJECTIVES: To determine the activity of two antioxidant enzymes, SOD and catalase, and their variation according to demographic and occupational variables in workers of a prehospitalary emergency service, and to analyse the relationship between antioxidant enzyme activities and burnout 111 healthy workers of a prehospitalary emergency service were surveyed. METHODS: SOD activity was analysed by the Minami and Yoshikawa method. Catalase activity was measured by the method of Aebi. To measure burnout, the Maslach Burnout Inventory was used. RESULTS: No significant variations with respect to sex were detected in SOD and catalase activities and levels of burnout. Significant differences in SOD activity between the control group and workers of a prehospitalary emergency service (P<0.001) were found. SOD activity was higher in workers on night and evening shifts (P<0.001). These workers also obtained higher scores in burnout subscales, but without statistical significance.

Adult↗

Exacerbation of mania secondary to right temporal lobe astrocytoma in a bipolar patient previously stabilized on valproate.

OBJECTIVES: To investigate breakthrough mania secondary to a right temporal lobe neoplasm in a bipolar patient previously stabilized on sodium divalproex. BACKGROUND: Right hemispheric brain tumors involving the orbitofrontal or basotemporal cortex are a rare cause of secondary mania. In such cases, early neurologic signs may be difficult to distinguish from bipolar symptoms. Breakthrough mania secondary to brain neoplasm in a bipolar patient stabilized on medication is an extremely rare phenomena which has not been previously reported. METHOD: The clinical course of a bipolar subject stabilized on valproate who developed mania secondary to a right temporal lobe astrocytoma is described. Serial brain magnetic resonance imaging (MRI), baseline electroencephalogram (EEG), and neuropsychiatric evaluations were used to examine the relationship between the patient's brain mass and behavioral disturbances. RESULTS: Symptoms were those that accompanied prior episodes of mania. In addition, signs of temporal lobe dysfunction were evident including periods of detachment, déjà vu experiences, and olfactory hallucinations. In the context of mania, depersonalization was initially attributed to bipolar symptoms. Only several months later, when olfactory hallucinations and alterations in consciousness became evident, was a temporal lobe lesion suspected. Neuropsychiatric abnormalities responded to a combination of surgical intervention, radiation therapy, and topiramate, however the tumor was advanced and invasive at diagnosis resulting in a poor prognosis. CONCLUSIONS: This case suggests that clinicians examining unexplained cases of breakthrough mania should be vigilant for early signs of temporal lobe dysfunction, which could aid in detecting treatable lesions.

Anticonvulsants↗

Effect of duty hour standards on burnout among orthopaedic surgery residents.

We surveyed orthopaedic surgery residents and faculty from two university training programs to quantify quality of life measures including burnout, general health, and relationship issues. Residents exhibited high levels of burnout and emotional exhaustion but only average levels of personal achievement, while faculty showed lower levels of burnout and emotional exhaustion with above average scores for personal achievement. Resident burnout was positively correlated with number of hours worked while faculty hours worked was inversely related to burnout. The survey was readministered two years after implementing the Accreditation Council on Graduate Medical Education guidelines on residency duty hours. At this time resident scores for personal accomplishment had improved, while scores for emotional exhaustion showed a strong trend towards decreasing, and depersonalization scores also showed a possible trend towards decreasing. Resident duty hour limitation was associated with improvement in objective measures of burnout.

Adult↗

Clinical holistic medicine: mental disorders in a holistic perspective.

From a holistic perspective, psychiatric diseases are caused by the patient's unwillingness to assume responsibility for his life, existence, and personal relations. The loss of responsibility arises from the repression of the fundamental existential dimensions of the patients. Repression of love and purpose causes depersonalization (i.e., a lack of responsibility for being yourself and for the contact with others, loss of direction and purpose in life). Repression of strength in mind and emotions leads to derealization (the breakdown of the reality testing, often with mental delusions and hallucinations). The repression of joy and gender leads to devitalization (emotional emptiness, loss of joy, personal energy, sexuality, and pleasure in life). The losses of existential dimensions are invariably connected to traumas with life-denying decisions. Healing the wounds of the soul by holding and processing will lead to the recovery of the person's character, purpose of life, and existential responsibility. It can be very difficult to help a psychotic patient. The physician must first love his patient unconditionally and then fully understand the patient in order to meet and support the patient to initiate the holistic process of healing. It takes motivation and willingness to suffer on behalf of the patients in order to heal, as the existential and emotional pain of the traumas resulting in insanity is often overwhelming. We believe that most psychiatric diseases can be alleviated or cured by the loving and caring physician who masters the holistic toolbox. Further research is needed to document the effect of holistic medicine in psychiatry.

Adult↗

Koro following cannabis smoking: two case reports.

Koro in the background of drug abuse is quite rare. The present report of Koro during the first experience with cannabis is the only account of its kind in the world Koro literature to date. The nature and extent of this genital depersonalization is discussed.

Adult↗

Establishing rigour in qualitative research: the decision trail.

The aim of this paper is to show the way in which the decision trail of a qualitative research process can be maintained. It is argued that the trustworthiness (rigour) of a study may be established if the reader is able to audit the events, influences and actions of the researcher. The actual study containing the recording of this decision trail aimed to express the concerns of older patients who were admitted to the acute care sector. The study took place in two care of the elderly wards in a 1000-bed National Health Service hospital in the UK, in 1991. Eventually, 14 patients were interviewed, each on several occasions, and their concerns are expressed in themes, namely: routine geriatric style of care, depersonalization, care deprivation and geriatric segregation. I describe the preparations that were undertaken before patient interviews could commence. The literature recording the process of the interviewer's experience as data in qualitative research is scarce. I show the researcher's participation in making the data as part of an existential phenomenological research process. Existential phenomenology relies on recording influences while generating data such as significant literature, media reports, my value position and journal data.

Aged↗

Nurse educators' workplace empowerment, burnout, and job satisfaction: testing Kanter's theory.

BACKGROUND: Empowerment has become an increasingly important factor in determining college nurse educator burnout, work satisfaction and performance in current restructured college nursing programmes in Canada. AIM: This paper reports a study to test a theoretical model specifying relationships among structural empowerment, burnout and work satisfaction. METHOD: A descriptive correlational survey design was used to test the model in a sample of 89 Canadian full-time college nurse educators employed in Canadian community colleges. The instruments used were the Conditions of Work Effectiveness Questionnaire, Job Activities Scale, Organizational Relationship Scale, Maslach Burnout Inventory Educator Survey and Global Job Satisfaction Questionnaire. RESULTS: College nurse educators reported moderate levels of empowerment in their workplaces as well as moderate levels of burnout and job satisfaction. Empowerment was significantly related to all burnout dimensions, most strongly to emotional exhaustion (r = -0.50) and depersonalization (r = -0.41). Emotional exhaustion was strongly negatively related to access to resources (r = -0.481, P = 0.0001) and support (r = -0.439, P = 0.0001). Multiple regression analysis revealed that 60% of the variance in perceptions of job satisfaction was explained by high levels of empowerment and low levels of emotional exhaustion [R(2) = 0.596, F (1, 86) = 25.01, P = 0.0001]. While both were significant predictors of perceived job satisfaction, empowerment was the stronger of the two (beta = 0.49). CONCLUSIONS: The results provide support for Kanter's organizational empowerment theory in the Canadian college nurse educator population. Higher levels of empowerment were associated with lower levels of burnout and greater work satisfaction. These findings have important implications for nurse education administrators.

Burnout, Professional↗

Listening to the voices of older patients: an existential-phenomenological approach to quality assurance.

The motivation behind this study was a desire to gain access to the experiences of elderly people receiving nursing care in hospital. Previous experience with quantitative approaches to quality assurance had led to dissatisfaction with their neglect of the patient perspective or reliance on patient satisfaction questionnaires. An existential-phenomenological approach was used in an attempt to reconstruct patients' experiences as reported in their own words. Themes which emerged from the data and are reported here focus on 'routine geriatric care', 'care deprivation', 'depersonalization', and 'geriatric segregation'. The findings are discussed against the background of literature about nursing care of elderly people. It is suggested that in the setting studied, limitations posed by past management deficiencies, under-staffing and poor physical environment contributed to the situation reported. Trained nurses felt they worked hard to give the best care they could but, with a high ratio of untrained staff and lack of continuing education, they were aware that their levels of achievement were far from ideal. The study demonstrates that, with an appropriate methodology, it is possible to gain access to how patients' experience their care and in this sense the attempt to 'listen to the voices of patients' was successful and gives pointers to developing more patient-sensitive quality-assurance processes.

Aged↗

A tentative classification of "neuroses" based on behavioristic consideration of the pathogenetic mechanisms.

Pathogenetic mechanisms of "neuroses" were reconsidered based on a behavioristic framework which includes not only the traditional stimulus-response learning theory but also the concept of conflict proposed by Lewin. Most of the subtypes of "neuroses"--with the exception of panic disorder--were divided into two categories: conditioned fear-related disorders and conflict-related disorders. Phobias have been suggested to be caused by an escape or avoidance behavior motivated by an unconditioned or conditioned fear and obsessive compulsive disorder by an avoidance behavior motivated by a conditioned fear, while such disorders as posttraumatic disorder or hypochondriasis (nosophobia) were considered to be direct manifestations of conditioned fear. Generalized anxiety and depersonalization disorders were suggested to be caused by conflicts, but these conflicts seemed to persist even after the appearance of the symptoms. In contrast, appearances of conversion, somatization, somatoform pain, psychogenic fugue, or psychogenic amnesia were suggested to result in a temporary attenuation of the causative conflicts.

Anxiety Disorders↗

Factor structure of the Maslach Burnout Inventory among Finnish nursing staff.

The purpose of the study was to investigate the factor structure of the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) among Finnish nursing staff. Although the factorial validity of the MBI-HSS has been studied across different countries, the factor structure has never been investigated among Finnish nursing staff. The data were gathered by postal questionnaires from nursing staff working in health-care organizations around Finland. The sample consisted of 627 nurses and nurse managers. The factor structure was studied by using exploratory and confirmatory factor analysis. The fit of the hypothesized three-factor model to the data was superior to the alternative one-factor and two-factor models. The three-factor structure (emotional exhaustion, depersonalization, reduced personal accomplishment) showed the best fit, while the internal consistencies of the subscales were satisfactory. The MBI-HSS is a highly suitable instrument for measuring burnout among nursing staff and it is very applicable to Finnish health-care research.

Adult↗

A longitudinal study comparing the prenatal care of Puerto Rican and white women.

This study examined the effect of ethnicity on health-seeking attitudes and behavior, including patient compliance, use of the clinic, knowledge of childbirth, and the relationship between the patient and primary health care provider. Anthropologic techniques of observations and interviews were conducted longitudinally with 27 Puerto Rican women and 26 white women who received perinatal care at a tertiary-level hospital throughout the antepartum, intrapartum, and postpartum periods. Approximately 500 standardized and open-ended interviews and 150 observations of clinical interactions with resident physicians and nurse-midwives compared reproductive knowledge, beliefs, and practices. Results of this three-year study indicated that both groups of women were similar in age, years of education, and percentage receiving financial assistance. Puerto Rican women identified strongly as a separate ethnic group; all spoke Spanish and most were bilingual. Office visits and explanations from primary care providers were more important to women in both groups than information obtained from families, friends, or folk beliefs. Knowledge of pregnancy care procedures and childbirth, although limited, was no different between the groups. Long waits, depersonalized service, and a lack of continuity of care adversely affected patient and physician satisfaction and diminished effective doctor-patient interactions. This study suggests that differences in ethnic background do not necessarily adversely affect the delivery of reproductive health care. Indigent white and Puerto Rican women wanted the same thing: quality perinatal care and education.

Adolescent↗

Periictal Capgras syndrome after clustered ictal fear: depth-electroencephalogram study.

PURPOSE: To describe periictal Capgras syndrome as a result of rapid, successive bouts of ictal fear. METHODS: This periictal psychotic state was documented by depth EEG recordings. RESULTS: Episodes of paroxysmal fear, experienced as a vivid sensation of someone being nearby, corresponded with unilateral left limbic ictal discharge. CONCLUSIONS: Depersonalization, regardless of organic or functional origin, is an important contributor to the genesis of Capgras syndrome.

Adult↗

A long-term follow-up study of schizophrenia: psychiatric course of illness and prognosis.

A systematic psychiatric follow-up study of 502 schizophrenics was carried out using the same well-defined criteria to evaluate the patients throughout the investigation. After an average course of disease of 22.4 years, 22.1% of the patients showed complete psychopathological remission, 43.2% had non-characteristic types of remission and 34.7% suffered from characteristic schizophrenic deficiency syndromes. At the time of the last follow-up investigation, 86.7% of the patients were living at home, while 13.3% were permanently hospitalized. Of the entire sample, 55.9% were found to be "socially recovered". Higher education, psychoreactive provocation, depressive traits, perception of delusions, catatonic agitation, non-characteristic thought disorders and symptoms of depersonalization at the onset of the illness tended to carry with them a favorable prognosis. On the other hand, low intelligence, abnormal primary personality, premorbid disturbances in social behavior, broken homes, prolonged prodromal stages, pneumoence-phalographically measurable atrophic or dysplastic changes in the brain ventricles as well as somatic and auditory hallucinations and predominance of hebephrenic symptoms at the onset of the illness tended to lead to an unfavorable prognosis. The principle of the basic reversibility of typical schizophrenic symptoms and the extensive irreversibility of the non-characteristic defect is important for the psychopathological and social long-term prognosis.

Adolescent↗

Agoraphobics and social phobics: differences in background factors, syndrome profiles and therapeutic response.

Seventy-three agoraphobic and 31 social phobic women, all rated unsuitable for insight-oriented psychotherapy, were compared regarding family and personal history, intelligence, personality and factors pertaining to the disorder. The same patients, with 11 men included in the social phobic group, were also compared regarding response to four randomly assigned types of treatment given over a 3 month period, with a 9 months' follow-up. The following differences were revealed: 1) Social phobias were associated with a higher social class of the parental home, higher education, higher scores on verbal intelligence, and a higher social class of the patient. 2) Social phobics scored higher on the personality factor, aggressive non-conformance, otherwise there were no differences in the personality factor. 3) Agoraphobias were associated with mother working outside home during the patient's childhood, neurotic symptoms in childhood, and current economic difficulties. Agoraphobics more often gave experience of death as a cause of the disorder. 4) Social phobias started at an earlier age. 5) Target phobia and the global rating were of equal severity in the two syndromes, but the agoraphobics had higher ratings on free anxiety and depersonalization. 6) Social phobics responded better to prolonged exposure in vivo, while agoraphobics responded better to supportive therapy of dynamic type, or to a simple basal therapy. Social phobics more often wanted the therapists to give advice and guidance.

Adult↗

Female habitual self-mutilators.

Data are presented on 240 female habitual self-mutilators. The typical subject is a 28-year-old Caucasian who first deliberately harmed herself at age 14. Skin cutting is her usual practice, but she has used other methods such as skin burning and self-hitting, and she has injured herself on at least 50 occasions. Her decision to self-mutilate is impulsive and results in temporary relief from symptoms such as racing thoughts, depersonalization, and marked anxiety. She now has or has had an eating disorder, and may be concerned about her drinking. She has been a heavy utilizer of medical and mental health services, although treatment generally has been unsatisfactory. In desperation over her inability to control her self-mutilative behavior this typical subject has attempted suicide by a drug overdose.

Adolescent↗

Factors affecting illicit and licit drug use among adolescents and young adults in Greece.

A cross-sectional survey on psychosocial issues, drug use, alcohol and health was carried out in Greece, with a nationwide probability sample of 2448 respondents aged 12-17 and 18-24. Factors potentially associated with illicit and unprescribed licit drug use were tested by logistic regression analysis. Several predictors were revealed. Sex and age were related to a higher lifetime use of illicit drugs, the male young adults reported a higher lifetime use of illicit drugs than the females. Positive attitudes toward hashish use, systematic smoking and use of drugs by close friends were more closely related to illicit than to unprescribed licit drug use. In addition "low self-esteem, family members using tobacco and alcohol" and "problematic drinking" were found only to predict illicit drug use. Other variables, "family members using drugs with or without a doctor's prescription", "being dissatisfied with social life" and "suffering from anxiety, depression and depersonalization symptoms" were found to be significantly associated with licit but unprescribed drug use.

Adolescent↗