Search

ObjectivesTo determine, for doctors looking after older medical inpatients: (1) how difficult they find discussions about ‘do not attempt cardiopulmonary resuscitation’ (DNACPR); (2) whether difficulty is associated with doctors’ personal and professional characteristics; (3) how frequently DNACPR discussions are made more difficult by practical issues and by doctors’ uncertainties.MethodsSurvey of hospital doctors working on the acute medical wards of a UK NHS teaching hospital.Results171/200 (86%) of eligible doctors participated. 165 had experience of DNACPR discussions with older inpatients and/or their families and were included in our analysis. ‘Difficulty’ (defined as finding discussions ‘fairly difficult’ or ‘difficult’) was experienced by 52/165 (32%) for discussions with patients and 60/165 (36%) for discussions with families. Doctors with specific training in DNACPR discussions were less likely to have difficulty in discussions with patients. Older, more experienced doctors were less likely to have difficulty in discussions with families. Lack of time and place, and uncertainty about prognosis were the most frequently reported causes of difficulty.ConclusionsMany doctors have difficulty in DNACPR discussions. Training needs to include managing discussions with families, as well as with patients, and doctors need time and space to deliver this important part of their job.

The editorial by Whitty and colleagues about the challenge of multimorbidity is both timely and important.1 We must heed their call to arms and recognise the increasing challenge …

Functional neurological symptoms (FNS) are commonly encountered but have engendered remarkably little academic interest. 'UK-Functional Neurological Symptoms (UK-FNS)' was an informal inaugural meeting of UK based clinicians in March 2011 with a variety of research and clinical interests in the field. This narrative review reflects the content of the meeting, and our opinion of key findings in the field since the turn of the millennium.

Objectives Emotional distress, including depression, is an important issue for cancer patients and their families. Guidelines recommend the use of antidepressant drugs (ADs) for the management of depression in cancer. This study explores the views of oncology professionals about the inclusion of ADs in treatment plans. Design Semi-structured interview study. Data were analysed using framework analysis. Setting A specialist cancer centre and six district general hospitals across the Yorkshire Cancer Network. Participants 18 randomly selected professionals from lung, breast, urology and colorectal cancer teams: oncologists (n=8), surgeons (n=3), clinical nurse specialists (n=2) and ward nurses (n=5). Results Three main themes emerged relating to professionals9 attitudes, knowledge and behaviour. Positive attitudes were primarily expressed by nurses. However, negative views were expressed about the potential for over-reliance on ADs, and their use constituting ‘giving in’. Doctors reported a lack of confidence in the use of and knowledge about ADs with an associated reluctance to prescribe. The general practitioner (GP) was regarded as the most appropriate professional to prescribe ADs. Conclusions Cancer professionals highlighted a need for training in the appropriate use of ADs. Further, this research suggests that negative attitudes towards antidepressants may be a factor in their exclusion from treatment plans. The GP is seen to have a key prescribing role for AD therapy; however, it is unclear whether the GPs is asked to do this. This research raises questions about the adequacy of ADs in cancer care and to what extent the GP is able to meet this need.

What is fatigue? It is a sensation that we all feel at times and which has a variety of synonyms such as tiredness, exhaustion, and weariness.1 In this article we are concerned with a general feeling of fatigue or exhaustion and not with fatigue specific to a part of the body; this is sometimes called central as opposed to peripheral fatigue.2 Although one may interpret a complaint of “fatigue” as meaning whatever the patient wants it to mean, it is useful to apply more precision by exploring exactly what the patient means by the term. For example, to differentiate the core concept of fatigue as a lack of ability to initiate or sustain activities because of a feeling of lack of energy, from other meanings such as the “lack of interest and motivation” that is typical of depression, and the “tendency to fall asleep” that is typical of sleep disorders. When is fatigue abnormal? Fatigue as a symptom must be differentiated from normal tiredness. Given that the severity of fatigue is continuously distributed in the population (fig 1), we need to draw some kind of cutoff to define fatigue of clinically important severity, in the same way that we do for blood pressure and depression. One approach is to define this as fatigue that has persisted for a period of time (say a month or more) and that is of sufficient severity to interfere with the patient’s activities or to be otherwise severely troublesome. A patient with fatigue of this severity and duration may then be referred to as “a case” of clinically significant fatigue. Figure 1 The distribution of the complaint of fatigue in the population. Reproduced with permission from Pawlikowska T, Chalder T, Hirsch SR, et al . Population based study of fatigue and psychological distress. BMJ 1994 … [OpenUrl][1][Abstract/FREE Full Text][2] [1]: {openurl}?query=rft.jtitle%253DBMJ%26rft.stitle%253DBMJ%26rft.issn%253D0007-1447%26rft.aulast%253DPawlikowska%26rft.auinit1%253DT%26rft.volume%253D308%26rft.issue%253D6931%26rft.spage%253D763%26rft.epage%253D766%26rft.atitle%253DPopulation%2Bbased%2Bstudy%2Bof%2Bfatigue%2Band%2Bpsychological%2Bdistress%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fbmj.308.6931.763%26rft_id%253Dinfo%253Apmid%252F7908238%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=bmj&resid=308/6931/763&atom=%2Fpractneurol%2F6%2F2%2F72.atom

In this article we offer an approach to management of functional symptoms based on our own experience and on the evidence from other specialities (because the evidence from neurology is so slim). We also tackle some of the most difficult questions in this area. What causes functional symptoms? Does treatment really work? What about malingering? We give two example cases adapted from real patients to illustrate our approach. Table 1 is not comprehensive but it summarises a large literature on the suggested causes of functional symptoms. This is a question that has been approached from many angles—biological, cognitive, psychoanalytic, psychological, social, and historical. The factors shown have been found to be more common in patients with functional symptoms than in patients with similar symptoms clearly associated with disease pathology. Tables like this can help you to make a formulation of the aetiology of the patient’s symptoms rather than just a diagnosis. An important feature of the table is the recognition of biological as well as psychological and social factors in the production and persistence of functional symptoms. View this table: Table 1 A scheme for thinking about the aetiology of functional symptoms in neurology Most of the factors in table 1 have also been associated with other types of functional somatic symptoms such as irritable bowel syndrome and chronic pain as well as with depression or anxiety. Consequently they should be regarded more as vulnerability factors for developing symptoms, than as specific explanations for why some patients develop certain symptoms such as unilateral paralysis and others have attacks that look like epilepsy. Recent functional imaging studies of patients with functional motor and sensory symptoms1 are beginning to offer biological clues (fig 1); they also challenge the idea that that such symptoms are “all in the mind”—they are in the brain too.2 Figure 1 A composite …

OBJECTIVES: To describe changes in personality after stroke and effects on carers. METHODS: A consecutive series of patients was recruited from hospital admissions with stroke. A novel questionnaire was administered to the patients' main carer at nine months after the stroke to determine their perception of the patients' pre-stroke and post-stroke personality. Personality change was identified by changes in these ratings, and associations between personality change and the following variables explored: emotional disorder in patients and carers (measured using the hospital anxiety and depression scale and a structured psychiatric interview), stroke classification (Oxford community stroke classification), residual disability (Barthel index and Nottingham extended activities of daily living scale), and lesion characteristics on computed tomography (CT). RESULTS: Carers of 35 patients with stroke took part. Reported changes in personality after stroke included: reduced patience and increased frustration (both p

BACKGROUND AND HISTORY It’s the middle of the clinic. Your next patient has a bulging set of case notes and struggles in to the room on two elbow crutches with a hand-written list of 15 somatic complaints. The worst symptom is progressive right leg weakness that has become so bad that any work has been impossible for six months. You have already noted some physical signs. The right leg is dragged like a sack of potatoes and when the patient climbs on the bed the leg is hauled on with both hands. On direct testing there is some ‘collapsing weakness’ even after you’ve cajoled and encouraged the patient. The reflexes are normal. How are you going to clinch the diagnosis of functional weakness? Can Hoover’s sign help you? Time to get some definitions straight. In this article we will use the term functional weakness to refer to medically unexplained weakness

OBJECTIVES: To determine the prevalence of anxiety and depressive disorders in patients referred to general neurology outpatient clinics, to compare disability and number of somatic symptoms in patients with and without emotional disorder, the relation to neurological disease, and assess the need for psychiatric treatment as perceived by patients and doctors. METHODS: A prospective cohort study set in a regional neurology service in Edinburgh, Scotland. The subjects were 300 newly referred consecutive outpatients who were assessed for DSM IV anxiety and depressive disorders (PRIME-MD, and HAD), health status, and disability (SF-36), and patients', GPs' and neurologists' ratings of the need for patient to receive psychiatric or psychological treatment. RESULTS: Of 300 new patients, 140 (47%) met criteria for one or more DSM IV anxiety or depressive diagnosis. Major depression was the most common (27%). A comparison of patients with and without emotional disorder showed that physical function, physical role functioning, bodily pain, and social functioning were worse in patients with emotional disorders (p

A major and increasing task for health services is the management of chronic illness. Although the details of chronic illness management will depend on the illness in question, many of the principles are common to all chronic conditions. ![][1] Treating chronic conditions must involve the family Whatever health services may offer, most of the day to day responsibilities for the care of chronic illness fall on patients and their families. Planners and organisers of medical care must therefore recognise that health care will be most effective if it is delivered in collaboration with patients and their families. To enable patients to play an active role in their care, health services must not only provide good medical treatment but also improve patients' knowledge and self management skills. This can be done by supplementing medical care with educational and cognitive behavioural interventions. Chronic disease treatment programmes have tended to underestimate the need for this aspect of care, and, consequently, many treatment programmes have been psychologically naive and, as a result, less effective than they could have been. #### Common elements of effective chronic illness management Services also need to be not merely reactive to patients' requests but proactive with planned follow up. Finally, to be most efficient, interventions are best organised in a stepped fashion—that is, the more complex and expensive interventions are given only when simpler and cheaper ones have been shown to be inadequate or inappropriate. ### Collaboration with patients and families To win the collaboration of patients and their families, those providing care need to negotiate and agree on a definition of the problem they are working on with each patient. They must then agree on the … [1]: /embed/graphic-1.gif

Dear Editor, Friedberg and Adamowicz reviewed our paper about recovery from chronic fatigue syndrome (CFS) after treatment in the PACE trial.1–3 We write in order to correct some errors of fact and interpretation in their review. The authors suggest that we did not use any measures of patients’ perceptions of recovery. In fact we used the patient-rated clinical global impression change score of their overall health,4 which included those who rated their overall health as ‘much’ and “very much better”, and which was one of the five criteria …

FROM: Coventry P, Lovell K, Dickens C, et al . Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease. BMJ 2015;350:h638. Collaborative care, a treatment model in which a specialist mental health provider collaborates with primary care, often assisted by a care manager, aims to improve the management of depression, including depression comorbid with medical conditions.1 There is recent evidence from the TEAMcare trial in the USA that integrating depression management and the management of diabetes and cardiovascular disease achieves better outcomes for both.2 This study was a randomised trial in which patients were allocated to an intervention in clusters (by general practice). Patients had to have a Patient Health Questionaire-9 (PHQ-9) depression score of …

Objective The illness perceptions of the relatives of patients with functional neurological symptom disorders (FNSD) and the relation to patients9 illness perceptions have been little studied. We aimed to compare illness perceptions of relatives of patients with FNSD to those held by patients themselves. We used control pairs with neurological diseases (ND) to examine the specificity of the findings to FNSD. Method Patients with FNSD (functional limb weakness and psychogenic non-epileptic seizures) and patients with ND causing limb weakness and epilepsy, and their relatives, completed adapted versions of the Illness Perception Questionnaire Revised (IPQ-R). Results We included 112 pairs of patients with FNSD and their relatives and 60 ND patient and relative pairs. Relatives of patients with FNSD were more likely to endorse psychological explanations and, in particular stress as a causal factor than patients with FNSD (p Conclusion The main difference in illness perceptions between relatives and patients with FNSD was a tendency for relatives to see psychological factors as more relevant than patients. Some other differences were observed between FNSD relatives and patients but the same differences were also seen in ND pairs. These other differences were therefore not specific to FNSD. Discussion about possibly relevant psychological factors with patients suffering from FNSD may be helped by including relatives.

Twenty years ago Frances chaired the DSM ( Diagnostic and Statistical Manual of Mental Disorders ) taskforce, which emphasised “medically unexplained symptoms” as the key feature of somatoform disorders.1 Where did that get us? Patients feel that their problems are viewed as inauthentic, and doctors can’t agree about what is or is not medically unexplained. All of this reinforces …

Avid journal readers will have come across an explosion of editorials about the need to build bridges between the specialities of neurology and psychiatry (Ross 2003; Baker et al. 2002; Cowan & Kandel 2001; Martin 2002). Indeed, the fact they became separated at all might be regarded as a historical accident, driven by early scientific understanding of the simpler parts of the nervous system on the one hand and the need to contain the disturbed behaviour of those with psychosis on the other, all underpinned by mind body dualism. What advantages could there be in breaking down the barriers? The authors of these editorials have focused on opportunities for increased scientific understanding of the neurobiological basis of subjective psychiatric phenomena. And as a topic for research, linked to the promise of neuroscience in general and functional brain imaging in particular, this is indeed a desirable endeavour. But what are the

In a preliminary study, we tested the hypothesis that patients with medically unexplained symptoms attending the clinic of a general adult neurologist would have delayed earliest and continuous memories compared with patients whose symptoms were explained by neurological disease. Depression, adverse childhood experience, and low socioeconomic status have all been associated both with poor memory of childhood. Because these variables are also associated with medically unexplained symptoms we hypothesised that we would find a link between unexplained symptoms and impaired memories of childhood. One hundred consecutive neurology outpatients were asked the question “What is the very first thing that you can remember?” and “How old were you at the time?”. They were then asked “From what age from could you produce your own life story, biography, or CV without help from a parent or relative?” and “Do you have blanks in your memory?”. Neurological diagnoses were recorded and the patient completed the brief assessment scale for depression cards (BASDEC) scale for depression.1 This simple self rated …

Introduction Depression is common in cancer patients and often associated with increased morbidity, hospitalisation and reduced quality of life. Current opinion supports the use of antidepressants (AD) for moderate and severe depression in physical illness. However, AD may be inadequately prescribed to oncology patients and factors other than need may influence prescribing practice. Aims To explore oncology professionals views on the use of AD in the management of emotional distress in cancer patients. Methods 18 randomly selected professionals from the Yorkshire Cancer Network (oncologists, surgeons, clinical nurse specialists and ward nurses) participated in a qualitative interview study. To explore their views on AD use in oncology they were asked: What leads you to prescribe AD? or Do you have any views on the use of AD? key themes were extracted via framework analysis. Results Despite recognising the value of AD in cancer care, professionals were reluctant to prescribe AD stressing a lack of knowledge I would be very worried about my ability to do that and overwhelmingly saw the general practitioner (GP) as most appropriate for this role. Overreliance on AD was voiced as were views that taking AD was defeatist medicating them is a slippery slope. Conclusion These findings highlighted a need for training on the use of AD in cancer care and to counteract negative views contributing to exclusion from treatment plans. A key prescribing role for the GP is described however it is unclear whether referrals are made. Future work should determine the role of the GP and map prescribing patterns elsewhere.

Aims To provide the basis for the development of active components of complex interventions for distress and rigorous evaluation of process measures and patient outcomes. A staged co-ordinated approach was adopted, with collaborative members completing different components of the work. Methods To supplement COMPASS trials evaluating screening for distress and testing complex interventions for depression in cancer patients, preparatory work for an intervention for distress was undertaken. Systematic meta-review of the use and meaning of the terms ‘psychological distress’ and ‘psychological interventions’ were completed. A prospective study of the outcomes of moderate distress over time (n=326) and a qualitative study of patient9s views on potential treatments for moderate psychological distress (n=25) was undertaken in Edinburgh. The views of hospital-based oncology professionals about the assessment and management of psychological distress were explored in an interview study across the Yorkshire Cancer Network. Results Moderate distress is common in cancer patients and persistent in a substantial minority at 7 months (36%). Distressed patients prefer information and guidance provided by those who understand the effect of cancer but are reluctant to see mental health professionals. 23 cancer professionals were interviewed (8 oncologists, 4 surgeons, 6 clinical nurse specialists (CNS) and 5 nurses). The CNS was pivotal to the detection and management of distress and overall, effective management was not optimal due to a lack of referral guidance and limited access to specialist psychological care. These studies supplement ongoing work evaluating screening for distress and depression and the evaluation of intensive treatments for depression in cancer patients. Future research Future research generated from the COMPASS collaboration includes development of a training programme to enable clinicians to use output from screening measures and self-help interventions for psychological distress incorporating e-health technology.

Introduction and aims Psychological distress is common in cancer patients. It can be viewed as a continuum from no symptoms at one end to psychiatric diagnoses such as major depression at the other. While major depression is likely to persist and to require treatment, there is much we need to know about patients with milder symptoms of distress. This study aimed to: (1) Describe the course of distress over 7 months in patients with clinically significant distress (HADS ≤15) at routine symptom monitoring but who did not meet criteria for major depression, (2) Determine whether demographic and clinical characteristics and severity and short-term persistence of initial distress predict significant distress at 7 months. Methods 326 patients with a relatively good prognosis (>12 months) were recruited from two specialist NHS Cancer Centres in Scotland, UK. Patients completed the HADS at routine symptom monitoring on touch screen computers and at 1, 2, 4 and 7 months by telephone. Results Preliminary results showed that more than a third of patients (36%) had clinically significant distress at 7 months. The data is currently being analysed to look at the characteristics of patients with persistent distress at 7 months. These results will be presented at the conference. Conclusion A substantial group of patients with significant distress at routine symptom monitoring, but who do not meet criteria for major depression, have distress that persists over 7 months. These patients might benefit from treatment for their symptoms and services should be developed for these patients.

Editor—The editorial by Baker et al highlights the nonsensical way in which psychiatric and neurological disorders and the doctors who look after them have been divided over the past 100 years and how modern neuroscience is bringing them closer together again.1-1 Where is the wall between the two specialties at its thickest? Not in academic research, where distinctions between mind and brain in schizophrenia, Parkinson's disease, and depression are already largely abandoned. Perhaps in training? It is true that opportunities for a neurologist to gain psychiatric skills (and a psychiatrist to gain neurological skills)—in the United Kingdom and United States anyway—are limited and the scope for improvement is huge. But generally a patient with Parkinson's disease who also has delusional disorder will receive attention and treatment. Similarly, psychiatrists continue to look for neurological disease in their patients much more often than they find it. The thickest part of the wall and the greatest challenge to these two disciplines is in the area of functional neurological symptoms or neurological symptoms unexplained by disease. Freud, cited in the article as a prototypical neuropsychiatrist, was initially a neurologist, but he abandoned the clinicopathological model to explain hysteria. It was this proposal that drove the greatest schism between mind and brain 100 years ago. Up to one third of all new neurology outpatients have symptoms such as dizziness, numbness, pain, weakness, and blackouts that are neither explained by disease nor “functional.” Neither neurology nor psychiatry is particularly interested in them, and basic neuroscience has made only embryonic inroads into their understanding. Important aspects of functional neurological symptoms, such as illness beliefs and the interaction of cultural factors, may forever remain outside the reach of the scanner. To break down the wall truly, neurology and psychiatry must not simply focus on those symptoms where biology has permitted dialogue. In the 19th century physicians of nervous disorders brought important social, psychological, and biological perspectives to the symptoms they observed. Let's hope in our rush to examine the brains of our patients we do not forget to listen to what they are saying.

Source Citation Prins JB, Bleijenberg G, Bazelmans E, et al. Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial. Lancet. 2001 Mar 17;357:841-7. 1126...

Source Citation Powell P, Bentall RP, Nye FJ, Edwards RH. Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome. BMJ. 2001 Feb 17;322:387-90. 111...