Prediction of end-of-life fears in COPD – hoping for the best but preparing for the worst

Objective: The diagnosis of a life-threatening illness can trigger end-of-life fears. Early studies show that end-of-life fears play an important role in chronic obstructive pulmonary disease (COPD). However, predictors of these fears have not yet been identified. This study investigated the relevance of socio-demographic variables, illness severity, psychological distress and disease-specific anxieties as predictors of end-of-life fears in COPD.

Design: A total of 131 COPD patients participated at two time points. Regression and mediation analyses, as well as cross-lagged panel analyses were conducted.

Main outcome measures: The participants completed questionnaires assessing end-of-life fears (Multidimensional Orientation toward Dying and Death Inventory), psychological distress (Hospital Anxiety and Depression Scale), and disease-specific anxieties (COPD Anxiety Questionnaire). Pulmonary function and a 6-min walk test served as measures of illness severity.

Results: Illness severity was not predictive of end-of-life fears. However, gender and psychological distress explained incremental variance. When disease-specific anxieties were included as additional predictors, psychological distress was no longer significant. Cross-lagged panel analyses mostly supported these results. Moreover, disease-specific anxieties mediated the association between psychological distress and end-of-life fears.

Conclusion: Administration and intensity of end-of-life care (especially concerning end-of-life fears) in COPD patients should be based not only on illness severity, but rather on psychological distress and disease-specific anxieties.     

Venerating Death

Abstract

In this paper, I am concerned with elucidating and expanding our attitudes toward our own death. As it is, our common attitudes toward our death are the following: we fear our premature death, and we dread our inevitable death. These attitudes are rational, but I want to argue that our attitudes toward death should be more complicated than this. A condition upon our value, our preciousness, as creatures is that we are vulnerable, and our vulnerability is, at bottom, a vulnerability to death. A corollary of this is that we could not be loved, either by ourselves or by others, for one cannot love—be concerned for—a being invulnerable to death. As a consequence, death plays a deep and abiding role in our value systems. Our susceptibility to premature and inevitable death is a condition upon our being valuable creatures and, in turn, it is a condition upon our being loved. Given the high value that we place on being valuable creatures who deserve love, we should equally place a high value on the constitutive conditions for being precious and loved. If, as I suggest, one of these conditions is that we will die, we should see our deaths not simply as something to fear or dread, but as something of great importance in our lives. Our deaths should be treated with awe, respect, and even praise.     

The Id and the Regulatory Principles of Mental Functioning by Max Schur

The authors draw on their experience as male and female cotherapists with a group of adults having a history of incest. These patients repeat in therapy numerous roles learned in childhood. These roles influence countertransference through projective identification, inducing role suction and/or role reversals. Acknowledging the pressure to assume these roles facilitates treatment. The role fluctuations may cause additional confusion.

Countertransference experiences are described, ranging from disbelief, revulsion, and rage, to fantasies of rescue, feelings of attraction, and defensive fears. The authors were, on and off, deskilled by their extraordinarily intense countertransference responses when treating the emotional scars of incest.     

Depth of processing and recall of threat material in fearful and nonfearful individuals

Abstract

Although many studies have examined the nature of memory distortions in anxious individuals, few have considered biases in specific memory processes, such as encoding or retrieval. To investigate whether the presentation of threat material facilitates encoding biases, spider fearful (n=63), blood fearful (n=73), and nonfearful (n=75) participants encoded spider related, blood related, and neutral words as a function of three levels of processing (i.e., structural, semantic, and self referent). Participants subsequently completed either a free recall or a recognition task. All participants demonstrated a partial depth of processing effect, such that they recalled more words encoded in the self referent condition than in the other two conditions, but groups did not differ in their recall of stimuli as a function of word type. Relative to participants in the other groups, spider fearful participants had fewer spider related intrusions in the recall condition, and they made fewer errors in responding to structural and semantic encoding questions when spider related words were presented. These results contribute to an increasingly large body of literature suggesting that anxious individuals are not characterized by a memory bias toward threat, and they raise the possibility that individuals with spider fears process threat-relevant information differently than individuals with blood fears.     

Exploring patient perspectives of prediabetes and diabetes severity: a qualitative study

Abstract

Objective: This qualitative study sought to identify and describe patients’ variant perceptions of disease severity after receiving a type 2 diabetes (T2DM) or prediabetes (preDM) diagnosis.

Design: Researchers interviewed 29 patients from two US medical centers to ascertain perceptions of severity. We used the constant comparative method from a grounded theory approach to identify themes from patients’ perspectives that inform their disease severity. This approach was used to help translate research to practice and ultimately identify intervention strategies informed by authentic experiences of preDM and T2DM patients.

Results: Perceptions of disease severity fell into two groups: high and low severity. Patients diagnosed with T2DM and preDM emerged in both groups and were comparative in terms of sample size, gender, and ethnic diversity. Several factors contributed to patients’ beliefs, including what they were told about the disease, observations from experiences within their own social network, and information from formal diabetes classes and their own research. The two perspectives diverged when patients described how their belief was informed by three thematic properties or personal factors: (i) fears; (ii) clinician communication; and (iii) social comparisons.

Conclusions: Beliefs about severity are influenced by patients’ fears, interactions with clinicians, and experiences within their social networks. These findings show that when interacting with patients with T2DM or preDM, clinicians should elicit patient perceptions of disease severity so they may then tailor the discussion to address these perceptions and help patients grasp the severity of these conditions.     

“True Religion”: Individuation,Alchemy, and Poetry

The most vital urge in every being, the urge to self-realize, is the motivating force behind the individuation process. With the internal compass of our very nature set toward self-realization, the thrust to become who and what we are derives its power from the instincts. On taking up the study of alchemy, Jung realized his long-held desire to find a body of work expressive of the psychological processes involved in the overarching process of individuation. Here, Jung saw the individual's opus in the individuation process mirrored in the opus of the alchemical procedure.

Like alchemical images, poetry can also shed light on individuation. Poetry's languages of symbol, imagery, and feeling are able to bring the concept of individuation vibrantly to life, adding nuance and conveying the numinous energy associated with an individuating experience. In this presentation, I entrust to poetry—one poem by D. H. Lawrence and several of my own—the task of bringing individuation and its underlying alchemical processes to life.     

Psychiatric diagnoses, ‘thought styles’, and ex post facto fact fallacies

Living in two-way, dialogical relations with our surroundings, rather than in monological, one-way causal relations with them, means that we can no longer treat ourselves as inquiring simply into a world of objective ‘things’ already existing in the world around us. We need to see ourselves instead as always acting ‘from within’ a still-in-process world of flowing streams of intermingling activities affecting us as much, if not more, than we can affect them. In such a world as this, instead of discovering pre-existing things in our inquiries, we continually bring such ‘things’ into existence. So, although we may talk of having discovering certain nameable ‘things’ in our inquiries, the fact is, we can only see such ‘things’ as having been at work in people’s activities after they have performed them. This, I want to argue, is also the case with all our diagnostic categories of mental distress – thus to see the ‘things’ they name as the causes of a person’s distress is to commit an ex post facto fact fallacy. Something else altogether ‘moves’ people in the performance of their actions than the nameable ‘things’ we currently claim to have discovered in our inquiries.     

To Apologize or Justify: Leader Responses to Task and Relational Mistakes

Abstract

Leadership roles are complex, creating an environment where leaders are likely to make mistakes that result in negative outcomes. We shift the conversation in the literature from examining the effectiveness of mistake responses toward exploring why leaders use different mistake recovery methods. We employ an online experimental method to distinguish between task and relationship mistakes for leaders and suggest that different attributions are made for these two types of mistakes (Study 1). We found that task mistakes are viewed by leaders as more specific and less personal, and that relationship mistakes are viewed as more global, describing the leader’s stable characteristics rather than a specific event. From these findings, we predict that leaders are more likely to apologize for task mistakes and are more likely to justify their relationship mistakes rather than admit wrongdoing for them. We find support for these predictions using a mixed methods approach, employing a laboratory experiment (Study 2) and a critical incident method surveying a panel of leaders (Study 3). As such, this paper extends our understanding of the mistake recovery process for leaders by demonstrating that 1) leaders’ relationship mistakes are viewed as more globally representative of the leader than task mistakes, and 2) leaders are more likely to apologize for task mistakes but more likely to justify relationship mistakes. Relational and task mistakes, however, were not found to be different in regard to their ambiguity or the extent to which they were viewed as a mistake.     

Basic anxieties affecting psychiatric staff and their attitudes to psychotic patients

SUMMARY

Institutions can be used by their individual members to strengthen mechanisms of defence, especially against early paranoid and depressive anxieties. This is not to imply that institutios become psychotic, but that we would expect to find in them manifestations of unreality, splitting, hostility, suspicion and other forms of maladaptive behaviour which are the equivalent of psychotic symptoms of an individual.

This paper describes some of the attitudes of those who care for psychotic patients in a hospital setting. These attitudes seem to be influenced by basic fears that are provoked by the relationship with the patients and by coming in contact with their needs and disturbance from a position of responsibility. Such fears are accompanied by phantasies and are related to specific defence mechanisms.     

Man on a Pendulum by Israel J. Gerber

Group therapy provides the ideal arena for helping individuals cultivate the observing ego—that part of the sensorium that has the power of witnessing oneself in the world. The essence of our method is to employ the group as a temporary observing ego, out of which members may develop their own observing egos. A five-step process is presented to (1) help the members see how they are affecting others when they do not see this themselves, (2) help the members see how they produce this effect, (3) help the members see the self-injurious nature of their behavior, (4) resolve resistances to seeing any of this, and (5) help the members arrive at new modes of behavior.     

Some comments on the future of analytical psychology

We… have to follow the difficult way of our own experiences, produce our own reactions, and assimilate our own sufferings and realizations. Only then will the truth that we bring to manifestation be… our own flesh and blood… We cannot borrow God… Divinity must descend… into the matter of our own existence and participate in this peculiar life-process. —Heinrich Zimmer, Philosophies of India

The goal of Eastern religious practice is the same as that of Western mysticism: the shifting of the centre of gravity from the ego to the self. —C.G. Jung, Collected Works, Vol. II     

A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children

ABSTRACT

Background: It has been widely suggested that over 80% of transgender children will come to identify as cisgender (i.e., desist) as they mature, with the assumption that for this 80%, the trans identity was a temporary “phase.” This statistic is used as the scientific rationale for discouraging social transition for pre-pubertal children. This article is a critical commentary on the limitations of this research and a caution against using these studies to develop care recommendations for gender-nonconforming children.

Methods: A critical review methodology is employed to systematically interpret four frequently-cited studies that sought to document identity outcomes for gender-nonconforming children (often referred to as “desistance” research).

Results: Methodological, theoretical, ethical, and interpretive concerns regarding four “desistance” studies are presented. The authors clarify the historical and clinical contexts within which these studies were conducted to deconstruct assumptions in interpretations of the results. The discussion makes distinctions between the specific evidence provided by these studies versus the assumptions that have shaped recommendations for care. The affirmative model is presented as a way to move away from the question of, “How should children's gender identities develop over time?” toward a more useful question: “How should children best be supported as their gender identity develops?”

Conclusion: The tethering of childhood gender diversity to the framework of “desistance” or “persistence” has stifled advancements in our understanding of children's gender in all its complexity. These follow-up studies fall short in helping us understand what children need. As work begins on the 8th version of the Standards of Care by the World Professional Association for Transgender Health, we call for a more inclusive conceptual framework that takes children's voices seriously. Listening to children's experiences will enable a more comprehensive understanding of the needs of gender-nonconforming children and provide guidance to scientific and lay communities.     

The Origins of Fears of Compassion: Shame and Lack of Safeness Memories,Fears of Compassion and Psychopathology

Empirical and clinical research suggests that some individuals find self-generating compassion and receiving compassion from others difficult and aversive. However, it is unclear how these fears of compassion are linked to early experiences and to psychopathological symptoms. This study explores the relationship between shame traumatic memories, centrality of shame memories, early memories of warmth and safeness, fears of compassion, and depression, anxiety and paranoid symptoms. Participants were 302 individuals from the general community population, who completed self-report measures of fears of compassion, shame memories, early affiliative memories, and psychopathology. Shame traumatic and central memories were positively associated with fears of compassion for self, for others and from others, whereas early memories of warmth and safeness were negatively related to such fears. Path analyses revealed that fears of compassion for self and of receiving compassion from others mediated the effects of shame traumatic memory, centrality of shame memory and early memories of warmth and safeness on depressive, anxious and paranoid symptoms. These findings have implications for therapeutic interventions as these fears, as well as the negative shame-based emotional memories fuelling them, may need to be addressed in therapy to assist patients in self-generating and receiving compassion.     

TEXT COMPREHENSION RESEARCH TO CLASSROOM APPLICATION: DEVELOPING AN INSTRUCTIONAL TECHNIQUE

Abstract

Reading comprehension skills are routinely taught and they are often learned to a point of “mastery” on criterion referenced tests; but students relatively seldom apply them effectively when they read content‐area materials. In this paper we argue that the problem can best be solved not by abandoning skill‐centered teaching but by discovering ways to help students make effective use of the skills they acquire through skill‐centered instruction. Our approach is to develop procedures for glossing expository text; that is, we are using marginal and other intratext notations‐‐gloss‐‐to direct students’ attention while they read in order to help them internalize, direct, and apply specific skills and strategies. We describe the purpose and rationale for our developmental approach and show how we are attempting to bring research implications to bear on our work.     

Relational Psychoanalysis and the Tragic-Existential Aspect of the Human Condition

I suggest we may benefit by opening relational thinking to a certain aspect of a classical psychoanalytic worldview. Opening to what we can call the tragic and existential dimensions of the human condition: the universal experience of a certain inner dividedness, hiddenness, and self-deception—a strangeness within the “otherness” that constitutes ordinary, good-enough human environment; as well as the equally universal experience of impermanence—lack, inevitable loss, and finitude. Such openness entails listening to themes we hear in many critiques of relational thinking—critiques that often devolve into caricaturing relationality as avoiding the dark, internally divided side of our nature. It entails listening well enough to these universal themes in ourselves and in our patients so that we can radically reframe them—without recourse drives—in expanded, relational terms. As in Mitchell’s words, “dialectical tensions not taken as polarities … but rather as interpenetrating and, in some sense, as mutually creating each other.”     

Teaching Approaches and Occupational Therapy Psychoeducation

Abstract

Patient education has become an important feature of any treatment program. Psychoeducational procedures dominate the treatment used by occupational therapy practitioners in psychiatric rehabilitation. Occupational therapy literature frequently describes the content of psychoeducational programs but rarely examines the teaching approach therapists use in them. It is necessary, therefore, to begin carefully questioning how we are approaching psychoeducation and justifying it as a method compatible with our basic philosophical principles and our growing understanding of occupation. Three approaches to teaching are examined and contrasted with occupational therapy values: the executive approach, the therapist approach, and the liberationist approach. Each of these approaches points to dramatically different outcomes of the therapeutic process. Ultimately, they bring into question the way in which we build a relationship with our clients. The liberationist approach is proposed as the best guide of how and why to use psychoeducation in the quest for providing authentic occupational therapy.     

The Analysis of Character Traits in Group Therapy

The author describes a support group led by two psychiatrists for individuals with AIDS set in the participants' residence, the AIDS Community Residence Association (ACRA) House. Similar to other AIDS groups described in the literature, the residents spoke of existential fears such as losing their physical beauty or intellect. In contrast to the intimate and familial atmosphere of many other AIDS groups, the members' strong sense of invasion by the facilitators and their ongoing ambivalence were striking. This reaction toward the group and the co-leaders appeared to be metaphorically related to the “invasion” of illness and health care workers into their lives. As members better tolerated and expressed these thoughts and feelings, a greater intimacy and sense of “family” emerged.     

Thai Transgenders in Focus: Demographics,Transitions and Identities

ABSTRACT

Data was analysed for a sample of 195 Thai transgendered females (i.e., male-to-female (MtF) transgenders) who had completed a questionnaire covering, inter alia, demographics, transition histories and sexual/gender identities. Mean age was 25.4 years.

For demographic data, we found that our participants were often among the youngest in their family, that females played a prominent role in their lives (often rearing them without any male help), and that around one in five brothers (natural or step) were also transgendered.

With regard to transition histories, we found that many participants had transitioned very early in life, beginning to feel different to other males, and identifying as non-male by middle childhood. By adolescence many were living a transgendered life. Many took hormones, beginning to do so by a mean age of 16.3 years, and several from as early as 10 years. Many underwent surgeries of various kinds, on average in the twenties, with one undergoing SRS as early as 15 years.

As to identity, most of our participants thought of themselves simply as phuying (women), with a smaller number thinking of themselves as phuying praphet song (a ‘second kind of woman’). A small number thought of themselves as kathoey (a more general Thai term embracing a variety of gender non-conformities). While most participants would prefer to be a woman, there were a few who seemed comfortable being transgendered. A few foresaw that they would not be living a transgendered life into old age. The vast majority expressed a sexual attraction to men.     

Attitude toward the Negro of Northern and Southern College Students

Summary

If we confine ourselves to the groups studied we may summarize as follows:

1. There are significant and true differences in the attitude toward the Negro of the three groups, students from Northern homes studying in the North being most favorable, students from Northern homes studying in the South being not so favorable, and students from Southern homes studying in the South being least favorable.

2. There is a slight positive relation between intelligence and attitude in all three groups, this relationship seemingly being highest for the Northern students studying in the North.

3. There is a consistent sex difference in the three groups, the women being slightly more favorable than men.

4. In the Northern group and in the Southern group upper-classmen are equally favorable or slightly more favorable in attitude than are freshmen, but among the Northern students studying in the South the upperclassmen are definitely less favorable than are the freshmen who have just recently come South.

5. No relation between size of community and attitude was found in any geographical group.

6. But slight if any relationship was found between occupation of the father and attitude.

Recognizing the limited nature of the study the writers hesitate to draw any general conclusions concerning the nature of differences in the attitude of college students toward the Negro. However, the study does suggest that Northern college students are on the average definitely more favorable toward the Negro than are Southern college students; but there are great individual differences within the groups and consequently overlapping between them. As to the causes of these differences our conclusions are only negative. They do not seem to be satisfactorily accounted for by intelligence, sex, degree of maturity, size of home community, or occupational level. Finally, when Northern students are transplanted into the Southern environment their attitude seems to change, gradually becoming more nearly that of the Southern students. Whether this change is the result of contact with the Negro or with the general Southern atmosphere cannot be said.