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PubMed1993

Ethical issues in emergency care.

The ethical framework established for most health care decision making should apply to elderly patients in the ED, i.e., the authority to decide should rest either with the competent patient or, in case of incapacity, with the patient's surrogate. Whenever possible, ethical dilemmas in the ED should be prevented from occurring through the judicious use of advance directives crafted in the doctor's office. DNR orders should be based upon the wishes of a competent patient or upon a surrogate's estimation of the patient's values and best interests. Because advanced age is a predictor of poor outcome for most hospitalized elderly patients, physicians should educate themselves about the actual benefits and burdens of CPR in this population and share this information with patients and surrogates. In case physicians determine that CPR would be futile in a strict sense, they have no ethical or legal obligation to administer it, even if requested to do so; however, they have an ethical obligation to inform the patient or family of the reasons for the decision and should offer the family the option of dispute mediation in case of disagreement. If the patient arrives in the ED capable of making decisions but lacking an advance directive, it is the responsibility of physicians and nurses to educate the patient concerning the respective merits and drawbacks of the living will and health care proxy. Except for those elderly patients who lack family or friends or who do not wish to burden others with such decisions, the health care proxy, supplemented perhaps to some extent by oral or written specific directives, appears to be the best approach. Attention to these important problems bearing on the substance and procedures for life and death decision making in the ED should not obscure the manifest injustice of the context in which these decisions are often made. At many inner-city hospitals serving a largely poor and elderly clientele, the ED has become nothing short of a torture chamber for many critically ill elderly persons. An ethical framework for decision making, no matter how urgently needed, will not address the unnecessary pain and confusion of frail elderly patients subjected to an impersonal, overcrowded, and depersonalizing environment.

Advance Directives↗
PubMed1993

Effects of social support and undermining on African American workers' perceptions of coworker and supervisor relationships and psychological well-being.

Although social undermining is a commonly experienced stressor in human services workplaces, it has received little study in contemporary models of social work stress and burnout. Furthermore, African Americans currently make up nearly 25 percent of self-identified social workers in the United States, yet most literature on personnel relationships in human services does not reference this group. Data collected from a national sample of 288 African American members of the National Association of Social Workers were used to investigate the impact of undermining among coworker and supervisor-supervisee relationships. Multiple regression analyses revealed substantial increases in irritability, depression, anxiety, and depersonalization among social workers when social undermining was included in a set of predictor variables (age, gender, and social support). The presence of social support, however, did not diminish the impact of undermining. The authors discuss several practice and training implications of these findings.

Adult↗
PubMed1993

Trauma and dissociation.

The stress associated with experiencing or witnessing physical trauma can cause abrupt and marked alterations in mental state, including anxiety and transient dissociative symptoms. Intense manifestations of this pattern of response to trauma are described in a new diagnostic category proposed for DSM-IV: acute stress disorder. Severe dissociative symptoms may predict subsequent posttraumatic stress disorder. Persons who experience a series of traumatic events may be especially vulnerable to a variety of dissociative states, including amnesia, fugue, depersonalization, and multiple personality disorder. Treatment for these symptoms emphasizes strengthening supportive interpersonal relationships and developing insight that reduces psychological pain by integrating the trauma into a meaningful, less self-blaming perspective.

Adaptation, Psychological↗
PubMed1993

Burnout in gerontological social work.

Although burnout in various fields of social work has been explored in some depth, there is a dearth of research on the gerontological social worker's experience with burnout. This article reports a national survey of burnout among 1,196 social workers who work with elderly people and who belong to either the National Association of Social Workers or the Gerontological Society of America. The extent to which these social workers experience the three components of burnout (emotional exhaustion, depersonalization, and personal accomplishment) is reported. The significant client, organizational, and personal factors associated with burnout among gerontological social workers are identified, and implications for social work practice are discussed.

Adult↗
PubMed1995

Computers in the examining room: the patient's perspective.

CompuHx* is an Interactive Health Appraisal System (IHAPS) used in the examining room at Kaiser-Permanente's San Diego Department of Preventive Medicine to record patient information, assist in diagnosis, and provide a legible summary of findings. The purpose of the present project was to examine the impact of computer use in the examining room on patient satisfaction with the Health Appraisal experience. Survey results showed no significant differences in patient satisfaction between patients whose examiners used CompuHx and those whose examiners did not. These findings indicate that, in the eyes of the patients surveyed, clinician use of a computer in the examining room did not depersonalize their relationship with the clinician, nor did it enhance satisfaction with the thoroughness of the exam or confidence in the examiner's findings.

Attitude to Computers↗
PubMedDate not supplied

Staff nurses' perceptions of job empowerment and level of burnout: a test of Kanter's theory of structural power in organizations.

Kanter's structural theory of organizational behavior was used as framework to explore the relationship between perceptions of power and opportunity and level of burnout in a sample of 87 hospital staff nurses. Data were collected using a modified version of the Conditions for Work Effectiveness Questionnaire (Chandler, 1986) and the Human Services Survey (Maslach & Jackson, 1986). Consistent with Kanter's theory, perceived access to power and opportunity was significantly related to the three aspects of burnout: level of emotional exhaustion and depersonalization (r = -.3419, p = .004; r = -.2931, p = .02), and personal accomplishments (r = .3630, p = .002). The results of this study are useful for nurse administrators positioned to create organizational structures than empower staff nurses and subsequently decrease burnout.

Adult↗
PubMedDate not supplied

[Delusion and sleep deprivation].

In this article, the authors report two observations of short delusion that occurred after taking Guronsan--a psychostimulant commercialized in France--for a few days, with the intention of maintaining a total deprivation of sleep for three days in both cases. The ensuing clinical picture included a state of depersonalization, a loss of the sense of reality, illusions and even visual hallucinations as well as a delirious feeling of persecution. These disorders altered with the state of vigilance and the patients remembered them clearly. The authors discussed the etiopathogenic role of this psychotrope, as its components--acid ascorbic, glucuronamide and caffein--are not mentioned in literature as causing factors of a psychotic state. Then they compared this psychotrope with other molecules: amphetamines in particular may start a delirium of persecution, but normally they just reveal an underlying psychotic structure, which doesn't seem to be the case here, where the two young adults were only found a little immature. Chloroquine has sometimes been incriminated for disorders similar to those mentioned above, with a difference lying in a greater stability in the duration of these disorders that would persist several days after the end of the treatment. The clinical picture of the two cases was more labile and sedation was complete as soon as the absorption of the psychotrope was interrupted and sleep was restored at the same time. That is why the authors emphasize the importance of the deprivation of sleep as a causing factor of those delusion disorders which have particularly been observed in the case of solitary navigators. The psychiatrist dealing with emergencies shouldn't overlook this clinical and etiological possibility, all the less so as the treatment is simple and the resort to neuroleptics unnecessary.

Adult↗
PubMed1996

[Symptom complex, prevalence of trauma and body image of psychiatric patients with self-injury behavior].

Within the group of in-patients the patients exhibiting self-injurious behavior (SIB) have a significantly more disturbed body image--as assessed by the Holtzman Inkblot Technique (HIT)--than the patients who do not have this symptomatology. The more disturbed the body image, the higher the frequency of SIB. The method of self-injury most frequently reported is cutting the skin of the extremities, followed by burning the skin with cigarettes or open flames. This behavior serves the purpose of alleviating diffuse internal tension, of directing aggression inward, i.e. toward the self, and of terminating depersonalization states. During the act of self-mutilation, the perception of pain is lessened appreciably or inactivated. 48 percent of the female patients in this group suffered sexual abuse during childhood.

Adolescent↗
PubMedDate not supplied

[Factors causing stress in patients in intensive care units].

Intensive care units have been considered stress generating areas. Knowing the causes why this happens will allow us to take specific measures to prevent or minimize it. This study has been performed with the aim to identify stress raising factors, as they are perceived by intensive care patients. The study has been performed in 49 patients most of whom were being attended in postoperatory control. The valuation of the degree of stress was performed using the "Scale of Environmental Stressors in Intensive Care" by Ballard in 1981, modified and adapted to our environment, with a result of 43 items distributed in six groups; Immobilization, Isolation, Deprivation of sleep, Time-spacial disorientation, Sensorial deprivation and overestimulation, and depersonalization and loss of autocontrol. The level of stress perceived by patients was low. The factors considered as most stressing were those related to physical aspects; presence of tubes in nose and mouth, impossibility to sleep and presence of noise, whereas those less stressing referred to Nursing attention. We conclude that patients perceive ICU as a little stressing place in spite of the excessive noise, remark the presence of invasive tubes and the difficulty to sleep as the most stressing factors, and in the same way, express a high degree of satisfaction about the attention received.

Humans↗
PubMed1996

[Windmill principle versus clockwork principle--tradition and interaction in academic lectures. A. N. S. A. Radiologica].

In reply to depersonalization of teaching, students hiding behind anonymity and their decreasing effective presence in campus life, academic teaching has to become practice-oriented, attractive and at least more effective. The traditional teacher-based lecture competes with student-centered and issue-related academic events like problem-based learning, thus, concerning student-teacher interaction. The model of a clockwork represents the components of a traditional lecture. The model of a windmill is suitable for explaining synergistic effects in scope and experience during an interaction concerned lecture. An example of student-teacher interaction and students' activation even in a preclinical course of lectures on anatomy and radiology is given. A high response and acceptance of the lecture is assured by structure-and process-oriented features.

Anatomy↗
PubMed1997

The identification and management of self-mutilating patients in primary care.

Self-mutilation has been described as a complex group of behaviors resulting in the deliberate destruction of body tissue without conscious suicidal intent. Clinical reports suggest that many adults who engage in self-destructive behavior have childhood histories of trauma and disrupted parental care. Painless cutting after a period of depersonalization, followed by relaxation and repersonalization after bleeding, is the typical pattern reported. Complications include social rejection and condemnation as a response both to the behavior or the resulting disfigurement. The most serious complication of self-mutilation is death as a direct result of damage inflicted on the body or from a drug overdose. Primary care providers are in an excellent position to identify and intervene in self-injurious behavior. Establishing a trusting relationship appears to be the most critical component of assessing and treating the client who self-mutilates. Psychotherapy and psychotropic medications, though not specific to self-mutilation, remain the most compelling treatment options.

Adolescent↗
PubMed1977

Micropsia and testicular retractions.

Five episodes of micropsia, which were precipitated by oedipal masturbatory fantasies, are described in the analysis of an adult male. Traumatic visual events and testicular retractions during the oedipal and latency years predisposed the ego functions concerned with visual perception to later involvement in conflict. The micropsia itself is seen as defending against castration anxiety by means of a series of unconscious fantasies of denial. These fantasies cause a regression to an earlier mode of visual perception (and to micropsia) characteristic of latency. The defensive modifications of the functions of the ego itself seen in micropsia are closely allied to those seen in the dèjá vu experience and in depersonalization.

Adult↗
PubMed1997

[A 76-year-old man with loss of vision and dementia].

We report a 76-year-old man who developed blurred vision and dementia. He was apparently well until April 4, 1990 (70-year-old at that time) when he had a sudden onset of bilateral loss of vision. Corrected vision was 0.1 (right) and 0.09 (left). He was admitted to the ophthalmology service of our hospital on April 9, 1990, and neurological consultation was asked on April 11. Neurologic examination revealed alert and oriented man without dementia. Higher cerebral functions were intact. He had bilateral large visual field defects with loss of vision; he was only able to count the digit number with his right eye and to recognize hand movement with his left eye. Otherwise neurologic examination was unremarkable. General physical examination was also unremarkable; he had no hypertension. Cranial CT scan was normal on April 11; lumber spinal fluid contained 1 cell/microliter, 63 mg/dl of sugar, and 97 mg/dl of protein; myelin basic protein was detected, however, oligoclonal bands were absent. He was treated with methylprednisolone pulse therapy and oral steroid, however, no improvement was noted in his vision. He started to show gaze paresis to left, ideomotor apraxia, agnosia of the body, and dementia. Cranial CT scan on June 11 revealed a low density area in the deep left parietal white matter facing the trigonal area of the lateral ventricle. He was discharged on July 2, 1990. Hasegawa dementia scale was 2/32.5 upon discharge. In the subsequent course, he showed improvement in his mental capacity and Hasegawa dementia scale was 22.5/32.5 in 1991, however, no improvement was noted in his vision. In 1994, he started to show mental decline in that he became disoriented, and showed delusional ideation of self persecution and depersonalization with occasional confusional state. He also showed unsteady gait. Cranial MRI on February 13, 1996 revealed a T2-high signal intensity lesion on each side of the parietal deep white matter more on the left and another T2-high signal intensity lesion in the left pons as well as in the right thalamus. He complained of right hypochondrial pain and was admitted to another hospital on April 22, 1996. He was markedly confused and demented. He continued to show bilateral loss of vision, but no motor palsy was noted. Cranial CT scan on April 23, 1996 revealed diffuse cortical atrophy and ventricular dilatation in addition to the low density areas in both parietal deep white matter. He developed jaundice in the middle of May. Abdominal CT scan revealed multiple low-to iso-density areas in the liver and marked iso-to high-density swelling of the right kidney. The patient expired on June 9th, 1996. The patient was discussed in a neurological CPC and the chief discussant arrived at the conclusion that the patient had had a carcinomatous limbic encephalitis with optic neuropathy and a choleduct carcinoma. Other opinions entertained included acute disseminated encephalomyelitis with optic neuritis, and granulomatous angiitis of the central nervous system. Some participants thought the primary site of the carcinoma was the right kidney with metastasis to the liver. Post mortem examination revealed a mixed type carcinoma in the right kidney with liver metastases. Neuropathologic examination revealed an incomplete softening in the optic chiasm and the left optic nerve, and in the left parieto-occipital areas. (The right hemisphere was frozen for future biochemical assay.) One of the adjacent cortical arteries had an organized thrombus. Other arteries and arterioles also showed sclerotic changes. Some of the leptomeningeal arteries were positive for Congored staining as well as for beta-amyloid immunostaining. Many senile plaques were seen diffusely in the cerebral cortex and neurofibrillary tangles were seen in the CA1 area and the parahippocampal gylus. No cellular infiltrations or demyelinated foci were seen. The neuropathologic features were consistent with circulatory disturbance based on the amyloid angiopa

Aged↗
PubMed1997

Managing burnout in pediatric critical care: the human care commitment.

Burnout in social services professionals has been defined as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment. The pediatric critical care nurse is especially vulnerable to this phenomenon when exposed to prolonged, chronic suffering of a patient. The rewarding aspect of caring for the critically ill child who recovers from significant affliction is not experienced when caring for the "chronic child." This article reviews the dynamics of chronicity in pediatric critical care and explores protective strategies for burnout management. Several of Jean Watson's carative factors that define her human care philosophy provide the conceptual framework for the approaches outlined.

Burnout, Professional↗
PubMedDate not supplied

[Burnout and reaction to stress].

The recent flurry of attention to burnout syndrome still leaves numerous questions unanswered. One of them is the relationship between individual factors and the development of burnout. An understanding of the individual factors underlying burnout must include an assessment of the individual reactivity to stress. The occurrence, distribution and relationship with stress reactivity of the three dimensions of the burnout syndrome (emotional exhaustion, depersonalization and lowered feelings of personal accomplishment) were studied among a representative sample of the different professionals involved in the Primary Care Health System. Our results indicate that stress reactivity could be a variable that modulates the experienced psychopathology, suggesting a predisposition that increases the susceptibility to the development of burnout.

Burnout, Professional↗
PubMedDate not supplied

Delivering HIV/AIDS services: the professional care provider speaks out.

BACKGROUND: This study evaluates the stresses and satisfactions experienced by health care and social service providers working in HIV/AIDS service agencies in New York City. This study was part of the Ryan White Title I Evaluation in New York City. METHODS: This study is based on semi-structured interviews with 86 randomly sampled providers from a representative sample of 29 HIV/AIDS service agencies. Personal interviews were completed with a cross section of AIDS care providers. All staff interviewed were audiotaped to facilitate data analysis. Staff discussed their frustrations and their personal satisfaction at working in AIDS care. In addition, all staff completed the Maslach Burnout Inventory (MBI) to facilitate a structured comparison of their levels of burnout. RESULTS: Using the three subscales of the MBI, we found that interviewed AIDS care providers experienced lower than expected levels of burnout. Compared to national norms, health care and social service providers showed above-average levels of personal accomplishment, below-average levels of depersonalization, and average levels of emotional exhaustion. Interview transcripts were analyzed focusing on three broad themes: unique stressors of HIV/AIDS services, positive aspects of HIV/AIDS services, and effective provider supports. The study confirms that HIV/AIDS care providers feel a high level of personal commitment to working with HIV-positive clients. Personal commitment to HIV-positive clients may blunt some of the stresses associated with HIV/AIDS care.

Acquired Immunodeficiency Syndrome↗
PubMed1998

Panic disorder: a different perspective.

Panic disorder is a chronic and debilitating illness. In this article, we present an algorithm of the diagnosis and treatment of the illness. We place much importance upon the patient variables associated with the treatment decisions. We emphasize strong patient involvement in treatment as a way to become panic free and improve level of functioning. Panic disorder is defined in DSM-IV1 as "The presence of recurrent panic attacks followed by at least one month of persistent concern about having another panic attack, worry about the possible implications or consequences of the panic attack, or a significant behavioral change related to the attacks." A panic attack is defined as "a discrete period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached a peak within 10 minutes." 1) Palpitations, pounding heart or accelerated heart rate; 2) sweating; 3) trembling or shaking; 4) sensations of shortness of breath or smothering; 5) feeling of choking; 6) chest pain or discomfort; 7) nausea or abdominal distress; 8) feeling dizzy, unsteady, light-headed or faint; 9) derealization or depersonalization; 10) fear of losing control or going crazy; 11) fear of dying; 12) paresthesias; 13) chills or hot flashes. The following hypotheses have been used to conceptualize panic disorder from a psychiatrist's perspective.

Adult↗
PubMed1998

[Syndrome of juvenile asthenic deficiency].

A clinical and follow-up study of 155 young adults with a symptomcomplex of "juvenile asthenic deficiency"--"endogener juveniler asthenischer Versagensyndrome" (J.Glatzel, G.Huber, 1968) was carried out. It was found that protracted states in the youth with prevalence of educational disadaptation, weakening of initiative, psychophysical fatiguability should be attributed to atypical depressions, characterized by predominance of ideatoric disturbances with obliterated thymic and motor components. Depending on the specificities of ideatoric disturbances, 3 basic typological varieties of such depressions were recognized, i.e. depressions with prevalence of inhibition, disautomatization or distortion of cognitive processes, which statistically correlated reliably with definite nosological forms (affective disorders, schizophrenia). Depending on the nosologic belonging the studied states differed also in frequency of comorbid disturbances (obsessive-phobic, depersonalization, overvalued ideas), which occurred significantly rarer in the cases of affective disorders, than in schizophrenia. On the whole, follow-up study revealed relatively favourable prognosis of youth endogenous depressions with a clinical picture of "juvenile asthenic deficiency": in cases of affective disorders the course of disease was more frequently in the form of a single cyclothymic attack, while in cases of schizophrenia it took the form of protracted atypical pubertal attack.

Adaptation, Psychological↗