Faculty Bibliography

Examined the relationship between disability and depression in 37 Ss with Parkinson's disease (PD), 32 with right hemisphere stroke, and 35 with amputation. Both Ss' (self) ratings and staff/family (other) ratings of disability were obtained. Self-reported disability and depression were significantly correlated for amputee and stroke groups. Self-reported disability ratings were better predictors of depression than were other ratings of disability. Depression and disability ratings were generally independent in the PD group. Discrepancies between self-rated and other-rated disability suggested that Ss who rated their disability as greater than staff/family ratings also were more depressed, and the converse. Self-perceptions of extent of disability are related to the subjective experience of depression for certain disabled Ss. Results support the presence of underrating of disability in the stroke group.

Management of agitation and inappropriate and disinhibited behavior is a major challenge in the rehabilitation of the head trauma or diffusely brain-impaired patient. A young woman with acute encephalitis presented to our inpatient rehabilitation unit 4 months postcoma. Profound behavioral disturbances, including agitation, physical assaultiveness, and disinhibition complicated physical rehabilitation, along with severe cognitive dysfunction (patient rated Rancho Level 4). Behavioral regression, including a significant increase in agitation and assaultiveness, occurred perimenstrually. The treatment strategy devised involved reducing or titrating regular activities, complexity, and demands upon her at the first sign of symptoms so as to better manage agitated behaviors. Consideration of potential perimenstrual cyclicity in diffuse brain dysfunction is suggested for behavioral management of agitated patients

The nature of association between depression and disabling illness, whether as an organic symptom or emotional consequence, has been the source of interest and controversy. Depression in three groups of medically ill, disabled patients (Parkinson's disease, right hemisphere stroke, and amputation) was studied. Mean depression severity and frequency of depression were equal for all groups. Severity of neurologic symptomatology was not consistently related to depression. Type of prosthesis, but not amputation type, was related to depression for amputees. Patterns of depression on discriminant analysis did differentiate the groups. A depression symptom conglomerate suggesting guilt and body image change with fatigue characterized the Parkinson patients most and the amputees least. A second depression conglomerate suggesting indecisiveness and thoughts of death or self-harm characterized amputees most and stroke patients least. Depression as an emotional response may not be a singular, specific feature of disabling illness in general, given uniformity of prevalence and severity, but differential etiology in specific instances should be considered

Symbols created during the process of psychotherapy serve psychological functions of giving form and substance to previously murky experiences, making what is private something shared, and forging meaningful linkages among thoughts, emotions, and perceptions. Symbols can also enable therapist and patient together to gain insight into transference themes, transformations in identity, and feelings about life changes, as well as serve as guides to articulating treatment goals. Clinical vignettes are used to illustrate the process.

Disability may challenge some basic assumptions about the world, and some psychological aspects of self may be profoundly violated, particularly when onset is sudden and functional changes seem catastrophic. The losses incurred in disability, broadly defined, whether minimal or major, physical, psychologic, symbolic, or all of the above, may lead to some predictable human emotional responses, although individual patients' responses do vary. Factors including prior life history, concurrent life stressors, social and financial resources, intrapsychic functions, psychodynamic issues, and personal/subcultural issues may influence the experience of disability. Depression, as a natural concomitant to loss, may present in clinical form or in bereavement and grief patterns, and warrants full consideration (both diagnostically and therapeutically). In treating the patient with a disabling loss, the dynamic nature of denial must also be considered. The often visible inability or disability may stand in sharp contrast to that which is denied. The risk/benefit ratio of denial is a consideration when the psychotherapist weighs the need to maintain denial defensively versus the advisability of confronting the denial in an attempt to soften its brittleness. Countertransference reactions are also of prime importance and may differ from more typical reactions by virtue of the enormity of the patient's losses and their tendency to evoke the psychotherapist's own sense of vulnerability, mortality, and humanity

Despite opinions to the contrary, psychotherapy can be conducted with probably all but severely brain-impaired patients, albeit with some modification. The challenge is for the clinician to tailor his/her training to meet the needs of brain-impaired patients. There are certain real limitations, however, of neuropsychologically impaired patients that make psychotherapeutic attempts difficult. Assessment of patients' awareness of their losses, and of the implications of these losses is basic to an understanding of the emotional reactions observed. Screening and/or evaluation of certain neuropsychological functions is vital, as these functions have direct impact upon treatment efficacy. Traditionally, brain impairment has been thought to exacerbate premorbid or underlying character traits. An explanation is proposed for this traditional view of 'exacerbation of premorbid style,' in terms of decreased problem-solving skills, greater rigidity, and inherent increased strain of brain impairment. Neuropsychological deficits may interact with premorbid character types to produce some (predictable) behavioral alterations. Adjustments are required to accommodate to the deficits of brain-impaired patients, while retaining the richness of subjective experience in the clinical interaction. In treating neuropsychologically impaired persons, a model of equilibrium is thus suggested to balance patients' deficits with the therapist's interactions

Proposes a tripartite model for conceptualizing lack of awareness after traumatic brain injury (TBI), that distinguishes potential contributants to 'not knowing,' The model's components include information, implication, and integration. Careful assessment of the causes of unawareness must precede treatment. Treatment in early inpatient rehabilitation should balance the patient's need to know with the implications, both positive and negative, of not knowing, at that point in time, for that individual patient. The challenge to the therapist is one of constant monitoring of dynamic fluctuations in a patient's readiness (neurological or emotional) over time to become more aware of losses without becoming devastated by shame or despair.