bluuebunny/crossref_metadata_2025 huggingface dataset:
Module 8: Emotion Exposures for Countering LGBTQ-Related Stress
Authors: Pachankis John E. , Jackson Skyler D. , Harkness Audrey R. , Safren Steven A.
Published: August 2022

This chapter discusses how “emotion exposures” allow patients to approach situations and feelings that they usually avoid. It reviews LGBTQ-related stress, which often leads LGBTQ people to feel strong negative emotions. Because LGBTQ people have these emotional experiences frequently, they can often lead to emotional behaviors like avoiding close relationships, avoiding being vulnerable, or avoiding situations that produce uncomfortable feelings. The chapter mentions how some people experience bodily feelings like knots in their stomach, cramping, or nausea when faced with uncomfortable situations. It emphasizes that bodily feelings themselves are not the problem; instead, it is the interpretation of these feelings that makes them so scary and uncomfortable.
Module 9: Recognizing Accomplishments and Looking to the Future
Authors: Pachankis John E. , Jackson Skyler D. , Harkness Audrey R. , Safren Steven A.
Published: August 2022

The aim of this chapter is for patients to see how they have tools to cope with LGBTQ-related stress and other difficulties on their own. It will also help patients think about what their goals are for the future and how they can use the skills they’ve learned in the treatment program to help them get there. Doing an emotion exposure or an internal exposure may not always work out as planned; for example, the patient’s emotional experience might not change during the emotion exposure. The chapter reviews the goal of this program, which is to teach patients helpful skills for responding to their emotions, including those that are triggered or made worse by LGBTQ-related stress situations. Although it is very common for patients to have made some noticeable progress, this treatment program is short, and there is still room to improve after treatment ends.
Low intensity therapy: a parent’s perspective
Authors: O’Neill Lauran
Published: August 2022

In this chapter, I present my perspective as a parent who received a low intensity (LI) intervention to support my child with anxiety. I think the mind set of many schools and mental health services is that children have to be very poorly before they get any input for emotional or behavioural problems. If they don’t meet a certain threshold for symptoms, you’re told from the offset there’s nothing for you. It’s crazy that you have to reach such a damaging level before you can access help. Having LI therapy as a preventative or first step is really important. We heard all the time that our daughter was ‘good as gold, just quiet in the corner’. Six weeks of LI therapy gave us the strategies to help her anxiety, and through this we learnt that she had symptoms of autism. She then had an autism assessment and now she’ll get more resources and help. It all started with 6 weeks of LI therapy and that’s brought our family so many benefits.
Prevention and early intervention in children and young people
Authors: Sung Jenna , Schleider Jessica L.
Published: August 2022

This chapter outlines how prevention and early intervention efforts are critical in alleviating the rise of youth psychopathology and fostering healthy development. Prevention programmes have traditionally utilized resource-intensive intervention formats such as multisession designs and administration by mental health professionals as opposed to brief interventions or self-guided, online programmes; such intensive designs may hinder wide dissemination of effective programmes as it may not be feasible to implement the interventions in diverse settings. Thus, characteristics of low intensity interventions offer an untapped potential to extend and complement the goals of existing prevention work. The chapter briefly reviews existing low intensity prevention programmes and highlights the limitations as well as recommendations for future research.
Low intensity interventions for behavioural difficulties
Authors: Coughtrey Anna , Bennett Sophie D.
Published: August 2022

Early-onset behavioural difficulties are common in children and, for some, can be associated with significant long-term social, emotional, and academic difficulties. There is promising early evidence that low intensity parent interventions including guided self-help or self-administered parent learning approaches are effective in promoting positive nurturing parent–child relationships and confident parenting as well as in increasing children’s social and emotional competence and reducing common behaviour problems. Further research is needed to understand which families and children may benefit from low intensity interventions and how to optimize effective delivery to ensure prevention of future antisocial child behaviour into adolescence and beyond.
Low intensity interventions for obsessive–compulsive disorder in children and adolescents
Authors: Krebs Georgina , Lewis Angela
Published: August 2022

A range of low intensity (LI) interventions show promise for treating obsessive–compulsive disorder in youth. However, research in this field is limited and there is a need for more rigorous evaluation of LI interventions, particularly to establish their effectiveness in routine clinical settings and to identify optimal levels of therapist input. Another important avenue for future research will be to establish predictors and moderators of response to LI intervention among young people with obsessive–compulsive disorder. Factors such as age, comorbidity, and insight may well influence treatment outcomes. A key priority is to understand who is likely to benefit from LI approaches, so that clinicians can make empirically grounded decisions about treatment and ensure a personalized approach to care planning.
Low intensity interventions for mental health problems in children with chronic physical illness
Authors: Catanzano Matteo , Bennett Sophie D.
Published: August 2022

Common chronic physical illnesses in children include asthma, eczema, and diabetes. Some chronic physical illnesses, particularly neurological conditions, are associated with increased rates of intellectual and/or neurodevelopmental disabilities such as autism spectrum disorder. Rates of mental health disorders are elevated in children with a chronic physical illness compared to children who are otherwise healthy. The most common mental health disorders in this group are the same as the most common in children without a chronic physical illness: anxiety disorders, depressive disorders, and disruptive behaviour disorders. This chapter describes how low intensity and/or brief interventions may be used to treat these common mental health disorders in the context of chronic physical illness.
A problem-solving self-help approach for family and friends of young people with first-episode psychosis
Authors: McCann Terence V. , Lubman Dan I.
Published: August 2022

This chapter describes a guided self-help programme focusing on carers of young people with first-episode psychosis, based on a problem-solving approach. Problem-solving bibliotherapy is an alternative, non-threatening, cost-effective, low intensity intervention for first-episode psychosis, with potentially good reach and penetration, in comparison to other more complex and resource-intensive family interventions. It can be used by carers more or less independently of healthcare professionals; however, it seems to work best when integrated with other therapeutic approaches. Bibliotherapy gives carers the chance to refamiliarize themselves with material at a later date. It increases access to support for carers whose caregiving and other commitments, and geographical, financial, and other constraints prevent them from accessing face-to-face family interventions.
Overview of training and implementation considerations
Authors: Parker Jonathan , Gallop Catherine
Published: August 2022

There are indications of a growing prevalence of mental health problems in children and young people. In England, the government has responded by targeting the expansion of the children and young people’s mental health workforce. Focusing on offering support at a stage of early intervention, the education mental health practitioner and the well-being practitioner for children and young people have been developed as new professional mental health roles. These new roles have required the development of specialist training in support of delivering low intensity, evidenced-based interventions for emerging mental health difficulties in children, young people, and families. These new roles are intended to improve access to early intervention mental health support through the effective implementation and integration into community-based (children and young people well-being practitioner) and education-facing (education mental health practitioner) settings.
Single-session interventions for children and adolescents
Authors: Ahuvia Isaac , Schleider Jessica L.
Published: August 2022

‘Single-session interventions for children and adolescents’ provides an overview of single-session interventions (SSIs) designed to meet the needs of children and youth experiencing mental illness. A subset of low intensity interventions, SSIs are those designed to be completed in only one visit or encounter with a provider or programme. Many SSIs have been studied and show promising effects for a variety of disorders in youth. SSIs can be guided (requiring facilitation from a trained practitioner) or unguided; this chapter highlights some promising interventions in both categories as well as their evidence base. In addition, it provides a detailed look at an unguided SSI that has reduced depression in youth, and outline design principles for developing future SSIs. A weblink is included to this intervention, which is free and publicly available.
New ideas: one-at-a-time therapy
Authors: Dryden Windy
Published: August 2022

The terms ‘single-session therapy’ and ‘one-at-a-time therapy’ (OAATT) are used interchangeably in the literature; in this chapter, OAATT is referred to throughout. The chapter defines OAATT as a single session of therapy where therapist and client agree to meet to address the client’s most pressing concern in that session, but with the understanding that further help is available if the client needs it. This help may be another single session or whatever other support the therapist and client decide the client needs. There are no papers investigating the use of OAATT as defined in this chapter in child and adolescent services. Why then is it being including in a book about children and young people? Previous chapters have demonstrated a clear need for novel approaches within child and adolescent mental health services in order to cope with the current demands worldwide. There are numerous advantages of this innovative approach. While the approach is typically used and has been researched within adult services, the mindset and practice can and should be translated into mental health settings for children and young people.
Airway Obstruction, Bleeding, and Pain Control After Tonsillectomy
Authors: Johnson II Selby B. , Vail Emily Anne
Published: August 2022

Pediatric patients frequently undergo adenotonsillectomy (T&A). Complications, when they occur, can be delayed and life-threatening. In patients with uncontrolled pain, inadequate oral intake can lead to dehydration and malnutrition. Prevention of this complication requires multimodal analgesic treatment throughout the perioperative period. Post-tonsillectomy airway obstruction and bleeding are surgical emergencies and clinical challenges for both the anesthesiologist and surgeon. Resultant hypovolemia, difficult intubation, or aspiration significantly increase risks of morbidity and mortality. This chapter reviews complications related to T&A and discusses the need for adequate pain treatment, including education of caregivers at time of discharge, to prevent patient discomfort, dehydration and malnutrition.
Pulmonary Hypertension and Hemorrhage Requiring Lung Isolation
Authors: Shin Hannah , Eng Tracey , Teo Elrond
Published: August 2022

Pulmonary arterial hypertension is a progressive disease that results from sustained increases in pulmonary vascular resistance and is caused by several different and diverse processes. Treatment requires a detailed understanding of the pathophysiology. A case of a patient with suprasystemic pulmonary arterial hypertension is discussed including diagnosis, pathophysiology, and complications. A comprehensive assessment of medical and surgical options is presented in the setting of intraparenchymal bleeding resulting in a hemorrhagic pleural effusion and diffuse unilateral airway bleeding requiring emergent intervention. Management and mitigation strategies to stabilize the patient are discussed including medical, non-surgical, and surgical options.
Ventilator and Chest Tube Management for Pneumothorax in a Patient With Bullous Emphysema
Authors: Thompson Shaun L. , Sullivan James N.
Published: August 2022

A pneumothorax can be a life-threatening condition for patients that have underlying lung disease such as chronic obstructive pulmonary disease. Rapid diagnosis and treatment can avoid a potentially poor outcome. Following diagnosis, treatment of the pneumothorax with tube thoracostomy may be indicated, especially for a large pneumothorax. These patients may also require mechanical ventilation for significant respiratory or hemodynamic compromise. Appropriate mechanical ventilator settings are necessary to avoid an increase in size of the pneumothorax and further injury to the lungs. Positive pressure ventilation can still be utilized in patients with pneumothorax with a chest tube in place to evacuate air that may still be escaping from damaged airways.
Ruptured Esophageal Varices and Complications of Massive Blood Transfusion
Authors: Mucci Joti Juneja , McNamara Connor
Published: August 2022

Ruptured esophageal varices can lead to extreme hemodynamic instability due to rapid blood loss. Esophageal varices are commonly seen in patients with portal hypertension and thus often seen in cirrhotics. Because of rapid and large volume blood loss, massive blood transfusion may be necessary. The large amount of blood products can lead to many complications, but can be attenuated if anticipated by the diligent clinician.
Treatment for Hemorrhagic CVA/Aneurysm with Cerebral Arterial Vasospasm
Authors: Coleman Matthew D. , Roldan Oscar
Published: August 2022

Subarachnoid hemorrhage (SAH) describes a category of strokes that involve hemorrhage between the pia and the arachnoid mater of the brain. Spontaneous SAH accounts for 5% to 10% of all strokes. Although SAH is most commonly seen in the traumatic brain injury patient, spontaneous rupture of an aneurysm resulting in subarachnoid hemorrhage (aSAH) occurs in approximately 80% of nontraumatic SAH. aSAH carries a very high morbidity and mortality profile that can be greatly improved by timely and diligent management. Successful management requires coordinated, multidisciplinary care between intensivists, neurosurgeons, neurologists, emergency medicine providers, and the many layers of team members in these categories and beyond.
Motor Vehicle Accident With Skull Fracture and C-Spine Compromise, Elevated ICP, and Spinal Shock—A Case Presentation
Authors: Fried Eric , Zimick Nicholas C.
Published: August 2022

This chapter discusses the case of a 43-year-old patient presenting with loss of consciousness after a motor vehicle accident. In a problem-oriented approach, the authors review the definition and calculation of the Glasgow Coma Scale, primary and secondary surveys for initial management of trauma patients, and the specific considerations for the presenting pathology including spinal shock and intracranial hypertension. Further discussion centers on the diagnosis, pathophysiology, management, and potential complications of each. Finally, they provide review questions for each learning objective to self-assess one’s knowledge at the conclusion of the discussion.
Management of Acute Ischemic Stroke With Interventional Clot Retrieval
Authors: Nadkarni Neil A. , Batra Ayush
Published: August 2022

The care of patients with acute ischemic stroke has rapidly changed in domains of diagnostic expediency and options for management. Coordinated multidisciplinary specialty care, improving technology, and favorable outcomes in clinical trials have increased the number of patients eligible for intervention by both systemic thrombolytic therapy and directed mechanical clot retrieval. The extended time window for reperfusion of cerebrovascular flow has subsequently increased salvage of the ischemic penumbra, decreasing overall infarct size and improving patient functional outcomes. The advances in mechanical thrombectomy, specifically in regards to the extended time windows for treatment eligibility, now offer hope to patients who were previously destined to severe morbidity and mortality. The authors of this chapter review indications for acute stroke therapy, methods for streamlining immediate care, key diagnostic imaging findings, results of the major thrombectomy trials, and complications for the post-interventional patient.
In-Hospital Acute Coronary Syndrome
Authors: Wells Dennis , Bennett Suzanne
Published: August 2022

In-hospital acute coronary syndrome (ACS) represents a complex problem generally occurring in a high-risk patient population. Diagnosis and intervention should be prompt but this process can be hindered by comorbid conditions in various ways including atypical presentations and potential contraindications to standard therapies. For patients with significant risk factors or known coronary artery disease, a high index of suspicion and well-developed protocols for assessment and intervention in the intensive care unit should lead to improved outcomes for patients with in-hospital ischemic events. This chapter will review principles for assessment, diagnosis, and intervention in acute coronary syndrome and particularly focus on an example of ACS presenting in a hospital patient with a history of known coronary artery disease and prior percutaneous coronary intervention with coronary stents.
Postpartum Hemorrhage
Authors: Miranda Haley Goucher
Published: August 2022

Postpartum hemorrhage (PPH) complicates 2% to 5% of all pregnancies and remains a leading cause of maternal morbidity and mortality. Multiple risk factors have been identified that allow for identification of high-risk patients. High-risk patients identified in the antepartum period should be referred to a tertiary care center for appropriate multidisciplinary consultation. However, up to 40% of cases of PPH occur in patients with no previously identifiable risk factors. Patients with severe PPH may develop disseminated intravascular coagulation (DIC), placing them at risk for exsanguination and death if left uncorrected. Critical care providers must thus be facile with the comprehensive management of PPH, including recognition and treatment of the DIC syndrome.
Amniotic Fluid Embolism
Authors: Zheng Xiwen , Ring Laurence
Published: August 2022

Amniotic fluid embolism (AFE) is a rare, life-threatening obstetric disorder that may occur at any time during labor and delivery. AFE has a reported incidence of 1.9 to 7.7 per 100,000 pregnancies and a mortality rate of up to 43%. While the name suggests a physical obstruction of the pulmonary circulation by amniotic fluid, the disease is better understood to be an abnormal maternal inflammatory response to fetal or amniotic material that has crossed the maternal–fetal barrier. This inflammatory response triggers activation of the coagulation cascade, leading to disseminated intravascular coagulation as well as profound pulmonary vasoconstriction, leading to hypoxia, pulmonary hypertension, right ventricular failure, and subsequent left ventricular failure. Treatment is supportive and usually includes mechanical ventilation, the administration of inotropes, vasopressors, and blood products. Many AFE patients suffer cardiac arrest and standard Advanced Cardiovascular Life Support protocol should be modified to account for lateral displacement of the gravid uterus and perimortem cesarean delivery. Successful rescue often utilizes mechanical cardiac support devices. Sequelae of AFE include acute respiratory distress syndrome and cardiogenic pulmonary edema, end organ failure, sepsis, and long-term neurologic deficits.
Complications of Bariatric Surgery Including Rhabdomyolysis with Acidosis and Acute Kidney Injury
Authors: Chae Floria E. , Satyapriya S. Veena
Published: August 2022

Bariatric surgery has become increasingly common. Current data suggest that 35.9% of the adult population in the United States fits the criteria for morbid obesity—typically defined as body mass index greater than 35, or weight 100% greater than ideal body weight. The morbidly obese patient can pose significant challenges in terms of perioperative airway and ventilation management, positioning, and cardiovascular risk factors. Infertility, obstructive sleep apnea, some types of cancer, osteoarthritis and gastro-esophageal reflux disease are all more prevalent in this patient population. In addition, these patients are at risk for postoperative surgical complications such as anastomotic leak and bleeding and medical complications such as venous thromboembolism, acute kidney injury, nephrolithiasis, and rhabdomyolysis.
Abdominal Compartment Syndrome
Authors: Woods Brian
Published: August 2022

Intra-abdominal hypertension (IAH) with new organ injury defines abdominal compartment syndrome (ACS). Common phenomena among the critically ill, IAH and ACS result from a wide range of medical and surgical disorders. ACS has devastating effects on multiple organ systems but is underrecognized with often misunderstood management. Complex interactions between the abdominopelvic organs, the chest, the cardiovascular, and the central nervous system occur with pathologic increases of abdominal pressure. Physical exam and usual measures of perfusion or hemodynamics require careful interpretation in IAH/ACS. Stepwise diagnosis and intervention permit a rational approach. Recognition, continued surveillance, and rapid treatment of IAH/ACS improve outcomes.
Atrial Fibrillation with Rapid Ventricular Response Post Mitral Valve Repair
Authors: Hance John , Mechlin Maggie , Grawe Erin S.
Published: August 2022

Atrial fibrillation is a common postoperative complication after cardiac surgery, especially mitral valve surgery. The cause is often multifactorial related to patient’s predisposing medical comorbidities, anatomical factors including size of the left atrium, and perioperative triggers including inflammatory response, autonomic stimulation, neurohormonal activation, and atrial stretch. The morbidity associated with postoperative is significant as it can affect hemodynamic outcome, length of stay, readmission rates, hospital cost, and even mortality. Treatment for postoperative atrial fibrillation is variable depending on hemodynamic circumstances. It is important to understand the incidence, risk factors, pathophysiology, and treatment options of atrial fibrillation to effectively manage this disease and minimize its impact on morbidity and mortality in the postoperative period.
Ventricular Fibrillation/Ventricular Tachycardia After Coronary Artery Bypass Grafting
Authors: Feduska Eric , Rock Kristen Carey
Published: August 2022

Malignant ventricular arrhythmias (sustained ventricular tachycardia [VT] and ventricular fibrillation [VF]) are uncommon, but serious complications after coronary artery bypass grafting. Patient factors and surgery-related factors place post-operative CABG patients at higher risk for malignant ventricular arrhythmias. Although establishing the diagnosis in the immediate postoperative period is fairly straightforward in the era of continuous telemetry monitoring, establishing a cause of VT/VF is more challenging. Treatment options are varied, from pharmacologic to surgical to long-term prophylaxis. Patients may be candidates for electrophysiologic ablation or ICD therapy. As the cardiac surgical population becomes older with more comorbidities, skilled postoperative management of VT and VF will be essential to favorable outcomes.
An LVAD Patient Presenting With Intracranial Hemorrhage
Authors: Miranda Haley Goucher
Published: August 2022

Patients with implanted durable left ventricular assist devices (LVADs) are increasing in prevalence as expertise with surgical implantation and subsequent management continues to improve. LVAD patients require chronic anticoagulation due to the risk of thrombus formation in the pump motor. They are thus at risk of both hemorrhagic and thromboembolic events, which pose significant challenges for the intensivist. LVAD patients are at high risk for hemorrhagic expansion due to their multiple mechanisms of coagulopathy, but reversal of anticoagulation must be done cautiously due to the risk of LVAD pump thrombosis. Management may also be complicated due to reduced pulsatility associated with continuous-flow devices in addition to the lack of formal guidelines for blood pressure goals in the setting of acute stroke.
Vasoplegia Syndrome Management Post Cardiac Surgery
Authors: Tam Christopher
Published: August 2022

Vasoplegia syndrome is a form of vasodilatory shock often seen in patients after cardiac surgery. It is characterized by profound vasodilation with low systemic vascular resistance resulting in high cardiac output and severe hypotension despite fluid resuscitation. It is associated with significant morbidity and mortality and is an important diagnosis to identify and manage accordingly. Although the exact mechanism is unclear, it is theorized that systemic inflammatory response via multiple mechanisms following cardiopulmonary bypass is the main cause of this syndrome. Initial treatment includes vasopressor support (i.e., norepinephrine, epinephrine, phenylephrine, high-dose dopamine) and vasopressin. Some patients may be vasopressin deficient and as a result may respond with improved results. Alternative treatment includes using methylene blue as an initial bolus dose and potentially an infusion. Angiotensin II receptor agonist can also be considered. Maintaining fluid and blood product resuscitation, avoiding acidosis and correcting hypocalcemia are also other mechanisms of treatment for vasoplegia syndrome. Recent studies have provided some evidence for treatment with methylene blue infusion and angiotensin.
Diagnosis of Brain Death and Management of the Brain Dead Patient
Authors: Bacon J. David , Hatton Kevin W.
Published: August 2022

Brain death, the irreversible cessation of all brain function, is a difficult diagnosis in patients with severe neurologic injury. The diagnosis is based, primarily, on physical examination findings and central reflex testing, after confounding factors have been excluded. When confounding factors cannot be eliminated or when clinical exam findings are equivocal, additional or ancillary testing may be necessary to confirm the diagnosis. Once the diagnosis of brain death has been made, a discussion of the potential for organ donation should occur with the family, and, if consent is given, the critical care management goals change to focus on optimization of transplantable organ function. Common problems in the brain dead patient include hemodynamic instability, endocrine gland dysfunction, coagulopathy, and nosocomial infections. Aggressive treatment of these problems has been associated with improved recovery and function of transplanted organs.
When the Loss Is Not Just Personal, but Is of One’s Self
Authors: Rowland Julia H.
Published: August 2022

This deeply personal account delves into the experience of loss of an adult child to suicide. No stranger to death professionally or personally, the author lays bare the profound shock, horror, and heartbreak she experienced in the wake of losing her thirty-three-year-old son, Ben, to bipolar disease. She examines the unique challenges posed by a loss where the one gone is both victim and perpetrator and the stigma attached to mental illness and self-harm that still runs deep in our culture. She lays bare her own struggles—shared by so many survivors of suicide—with at times overwhelming guilt, self-blame, anger and helplessness for which even a career as a psychological professional could not prepare her. What helps and harms and the unique hurdles to recovery, including the fundamental threat posed to her sense of self, are woven into the author’s story with compassion, courage, and self-discovery.
Speechless
Authors: Loscalzo Matthew
Published: August 2022

At the end, in my mother’s final moments, I was not with her, although the rest of my family was. I arrived at my mother’s bedside one hour after she died. In that moment, I also did not realize that she was dead: I thought she was sleeping. When my brother said, “Go say goodbye to your mother,” I was confused even further. After touching her, I felt the cold, reflexive shock and heard my internal dialogue: “My mother is gone.” I remember my father saying, “She held on as long as she could. Your mother kept looking around the room for you. She knew you were missing.” Concetta Greco Loscalzo died searching for another lost child. Until her last breath, my mother was reassured she would recover, all pain-wracked, dwindling seventy-five pounds of her. Yet we knew she was dying. We all knew that concentration camp look. We, the “courageous” men in her life, believed she was not able to handle the truth. But we were the ones too afraid to handle it. How could I have not remembered that secrecy is fertile ground for evil?
“Did Your Mother Ever Die?”
Authors: Wasserman Fredda
Published: August 2022

There I sat in the hospital waiting room, stunned, disoriented, suspended in disbelief. I was twenty-eight years old, the only child of my precious mama who had not been seriously ill a day in her life. A physician, whom I had never met before, had just informed me that my mother had died. I wasn’t prepared for this. On the contrary. Only thirty minutes before, I had been at her hospital bedside rejoicing over how well she was recovering from her sudden heart attack. I vividly recall the myriad of emotional and visceral sensations I experienced during those pivotal seventy-two hours which led up to the moment that was to change my life forever.
Panel 19, Number 9, East
Authors: Golant Mitch
Published: August 2022

Poem by Mitch Golant
Lost and Found
Authors: Block Susan D.
Published: August 2022

This chapter traces a series of losses and their vicissitudes through ten years in the life of a palliative care leader. It explores their impact on family, relationships, work, planning for the future, and the process of moving through and beyond this difficult time.
“In Sickness and in Health, ’ Til Death Do Us Part”
Authors: Forstein Marshall
Published: August 2022

My husband died from prostate cancer after a five-year struggle, ending with an acute crisis leading to a precipitous death. After thirty-eight years, this was an incalculable loss, and the loss and grief that ensued was very personal, unlike the deaths of many hundreds of patients I lost to AIDS or to other deaths in my family that were painful in a different way. Four months into grieving, I was diagnosed with esophageal cancer and began a very intensive treatment including chemotherapy, radiation, and surgery. My grief about my loss was stilled while I dealt with the prospect of my two grown boys potentially losing their other father within a year. The fear of having them deal with these two losses, one after the other, was more devastating than the thought of my own death. Grief is a beast in the simplest of losses; this felt like the universe was being cruel. After treatment, scans, and blood tests, all of us on hold while awaiting the outcome of pathology and testing, I appeared to have been extraordinarily fortunate in having the prospect of surviving, even being cured. What I hadn’t anticipated was the vehemence with which the grief on hold roared back more powerful than I could imagine, confusing the multiple losses of my husband and what this cancer means for me and my family. As this story comes to print, I am aware that grief and loss are different but inextricably related to each other.
For Better or for Worse
Authors: Miller Joan Heller , Miller Ken
Published: August 2022

After fifteen years of marriage, life felt fulfilled with three young children, family and friends, and busy careers, along with a good dose of stress. Then Joan developed worsening fatigue and shortness of breath, bruising, severe pain, and high fever, leading to the diagnosis of acute leukemia with a slim chance of survival. Overnight, she became “Miller, J” the “acute leuk in room 263,” and Ken went from being an experienced cancer doctor to a scared husband, navigating unimaginable conflicting roles. Treatments were traumatic, and the journey toward recovery was punctuated by a depression for Joan that was also life-threatening. Finding meaning and purpose led to personal growth and professional commitment to advocate for global psycho-oncology support and bereavement services for patients and their families.
Watching My Wife Move
Authors: Simone Joseph V. , Simone Patricia Ann Sheahan
Published: August 2022

Poem by Joseph V. Simone
Life Is Loss (. . . and How I Tolerated It when I Became a House Officer)
Authors: Stein Cy A.
Published: August 2022

It was not until my internship and residency program, at age thirty-two, that I suffered the greatest loss of my life. This involved what I perceived as a complete loss of agency due to my perception of a catastrophic diminution in my status as a valued member of society and my inability to derive much pleasure in life when my days and nights were devoted solely to working and sleeping. My unrelenting schedule and the acute and chronic sleep deprivation caused marital problems and robbed me of any quality time with our new baby. When I express these thoughts to many physicians who are my contemporaries, they are incredulous. “But,” many of my flabbergasted contemporaries will insist, “internship and residency were where I learned so much, and where I acquired the technical skills and ways of thinking that allowed me to become a practicing physician. It was an invaluable experience that cannot not be replicated. And if this experience were to be modified in any way, God help us all!”
Mourning and Restoration
Authors: Blinderman Craig D.
Published: August 2022

The COVID-19 pandemic has brought unfathomable loss and grief. In the early months of the pandemic, when New York City was its epicenter, the loss of one patient highlighted for me what we have all lost. The pandemic has helped me to clearly see how everything is interconnected and woven into every moment. Our past experiences cannot be separated out of how we encounter each other, our patients, and ourselves. In this chapter, I bring these past experiences and reflections to help clarify who is it that is experiencing this loss and how this shapes the loss and the lessons it can bring. How can we allow loss to awaken our concern for injustice? How do we create the spaciousness necessary for mourning our losses? And how can we begin the difficult and necessary work of restoring ourselves and the world to a more just and compassionate place?
Conclusion Loss
Authors: Loscalzo Matthew , Forstein Marshall , Klein Linda A.
Published: August 2022

Loss and Grief: Personal Stories of Doctors and Other Health Care Professionals presents unflinching, deeply personal stories by doctors and other health care professionals, who did not take the “escape” of writing about walking in our patient’s shoes. They had the audacity to walk in their own shoes. A consistent theme was that professional training/identity offered no immunity/direction for a loss that is deeply personal. The professional veneer was too thin to be instructive or protective. This was a surprise. Perhaps, it should not have been. The psychological barriers for individuals who cannot share their own losses and distress with colleagues, reflects a society that denies the impact of loss and minimizes the emotional components of vulnerabilities. It does not have to be this way. It is our hope that such openly shared feelings of isolation and suffering will humanize the loss experience, ignite prospective discussions, and illuminate opportunities for education, research and interventions to prepare us for multiple loss experiences endemic to life. Paradoxically, in some of the most supportive health systems, the very professionals who compassionately care for patients feel so alone when they experience their own losses. Perhaps our most immediate goal could be to create an infrastructure within health care to best support professionals manage the relentless professional stream of losses and personal suffering? Ultimately, we must accept that if doctors and other health care professionals are not at the vanguard of making a world filled with loss and grief more realistic, loving, and kind, who will be?
Neuropathology of Tremors
Authors: Shill Holly
Published: August 2022

The neuropathology of tremor is increasingly being investigated. Pathology can be examined to explore the relationship between essential tremor and Parkinson disease and other neurodegenerative diseases such as Alzheimer’s disease and Progressive Supranuclear Palsy. The clinical findings of mild cerebellar impairments, including gait and limb ataxia, in essential tremor has prompted an interest in examining cerebellar pathology with findings of changes in the Purkinje cell layer and climbing fibers. Purkinje cell loss has been reported as well as axonal changes prompting consideration that essential tremor may be a neurodegenerative condition. Other tremor types have pathological findings that allow one to begin to understanding the underpinnings of tremor.
Genetics of Tremors
Authors: Haugarvoll Kristoffer , Ross Owen A.
Published: August 2022

This chapter of the textbook Tremors reviews the contribution of genetics to both isolated tremor, such as essential tremor (ET) and combined tremor syndromes, including tremors syndromes associated with dystonia, Parkinson disease (PD), and ataxia. The chapter builds on the revised criteria for classifying tremor disorders published by the International Parkinson and Movement Disorder Society in 2018. Clinical characteristics of tremor syndromes are used to group the genetic etiologies in order to provide clinicians with a framework to identify possible genetic etiologies in individual patients. The genetics of ET are discussed in detail, with a particular focus on future developments that may finally shed more light on the elusive etiologies of this common disorder.
Tremor in Medicine and Other Secondary Tremors
Authors: Patel Margi , Caughman Christopher Y. , Factor Stewart A.
Published: August 2022

This chapter on secondary tremors covers tremors that are commonly encountered but often underrecognized. Such tremors are caused by drugs, toxins, metabolic conditions, systemic diseases, and lesions in the central nervous system. The chapter systematically discusses the most common offenders in the mentioned categories. It also reviews clinical characteristics and possible mechanisms of action for each type, wherever defined. Additionally, a short review of diagnostic approaches for identifying tremor etiology, including laboratory tests, is discussed. Recommendations for treatment strategies are also made for each tremor category. Videos and MRI brain scan images are included for visual learning purposes, exemplifying some tremor categories.
Essential Tremor
Authors: Elble Rodger J.
Published: August 2022

Essential tremor is a neurological syndrome consisting of bilateral upper extremity action tremor of at least three years duration, with or without tremor in other locations, most commonly the head and voice, and there are no other associated neurological abnormalities. Essential tremor plus is the classification used for patients meeting the criteria for essential tremor except for exhibiting other signs or symptoms of uncertain clinical significance. A complex additive polygenic heritability of at least 75% appears to underly most cases of essential tremor, and only a few rare Mendelian dominant mutations have been found. Patients with essential tremor may eventually develop other neurological signs of more complex tremor syndromes such as tremor-predominant parkinsonism, dystonic tremor, and tremor-ataxia. Propranolol, primidone and topiramate are the only medications with double-blind placebo-controlled proof of efficacy, which is inadequate in most patients with moderate-severe tremor. Stereotactic surgery is the most effective treatment, but many aspects of deep brain stimulation, magnetic resonance-guided focused ultrasound and radiosurgery are still investigational.
Tremor, Dystonia, and Dystonic Tremor
Authors: Jinnah H. A. , Shaikh Aasef G.
Published: August 2022

Tremor is defined as a disorder of rhythmical oscillations of a body region, while dystonia is defined as a disorder of involuntary sustained or intermittent muscle contractions. Although tremor and dystonia are distinct movement disorders, there are multiple areas of overlap. One area of overlap is the many cohort studies that have shown that tremor and dystonia frequently co-exist. Another area of overlap is the concept of “dystonic tremor,” which has evolved over the years. The third area of overlap involves several disorders which some experts consider subtypes of tremor and others consider subtypes of dystonia. These include task-specific tremors such as writer’s tremor, isolated head tremors, isolated voice tremors, and others. The fourth area of overlap is the impact of many studies describing misdiagnosis of tremor or dystonia, because their clinical features are sometimes difficult to distinguish. The final area of overlap involves evidence that tremor and dystonia share certain biological mechanisms. This chapter reviews these overlapping areas, along with the ongoing debates regarding nosology and mechanism.
Tremor and Ataxia
Authors: Yang Chen-Ya , Kuo Sheng-Han
Published: August 2022

Tremor and ataxia, two very disabling symptoms leading to uncoordinated movements, are considered as distinctive movement disorders phenomenology. However, recent advances in the neuropathology, animal models, and physiology have indicated that these two symptoms are both related to the dysfunctional cerebellum and its connected network. In addition, tremor and ataxia can co-occur in certain cerebellar disorders, and the symptomatic treatment for tremor and ataxia poses a separate set of challenges. In this chapter, we will review the common ataxia disorders with tremor. We aim at highlighting the symptomatology, the distinct anatomy, the diagnostic approaches, and the evidence for existing therapeutic options. We will discuss the overlapping physiology and brain circuitries for these diseases.
Myorhythmia
Authors: Vial Felipe , Hallett Mark
Published: August 2022

This chapter will provide an overview of how myorhythmia, a particular type of tremor according to Movement Disorder Society criteria, has been described in the literature over time and how this concept encompasses other syndromes that share a slow, rhythmic, or semi-rhythmic activation of a muscle group. We discuss the phenomenology of myorhythmia by providing the definitions and descriptions by different authors, as well as the current knowledge of the pathology underlying this movement. Regarding the etiology, we discuss the most common causes with a special emphasis on Whipple disease and cerebrovascular disease. Finally, we conclude by emphasizing the need to agree on a standard definition for myorhythmia and give a proposal based on this review.
Functional Tremor
Authors: Schwingenschuh Petra
Published: August 2022

Functional tremor accounts for more than 50% of patients with functional movement disorders (FMD) and belongs to the spectrum of functional neurological disorders (FND). This chapter discusses how the diagnosis is made based on positive signs from history and clinical examination. It further describes how electrophysiological tremor recordings can be useful to complement the clinical findings in challenging cases. This chapter also reviews the evidence for cooccurrence of functional tremor with other movement disorders, which produces another layer of complexity in the workup of these patients. There has been remarkable progress in the management of patients with FMD in the last decade and this chapter finally summarizes the findings of clinical trials with a focus on functional tremor. Video content illustrating the key positive clinical features of functional tremors is included.
Diversity and Inclusivity in Parkinson Disease and Essential Tremor
Authors: Zesiewicz Theresa A. , Dohse Nicolas , Gooch Clifton L. , Bezchlibynk Yarema B. , Ghanekar Shaila
Published: August 2022

Despite millions of people being affected by tremor worldwide, information regarding tremor patients’ ethnicity and racial diversity is limited. We examined diversity and inclusivity in two diseases, essential tremor (ET) and Parkinson disease (PD), primarily in the United States. There is little information regarding regional and ethnic differences of ET, although several studies suggest that Blacks are less likely to be affected by PD than Whites. Blacks appear to have less chance of being diagnosed with PD, reduced access to outpatient care, and less chance of being treated with newer PD medications. Black patients with PD may also be less likely to undergo DBS than White patients. There appears to be a disproportionate lack of minority representation in PD clinical trials. Education regarding ET and PD is essential so that first line healthcare providers can make appropriate referrals to specialists. Greater diversity and inclusion of non-White ET and PD patients is needed in clinical research, and better and more equal access to healthcare is vital and long overdue.
Treatment of Tremor
Authors: Dash Deepa , Mestre Tiago A.
Published: August 2022

Tremor is one of the most prevalent movement disorders and can lead to significant disability and negatively impact quality of life. Treatment of tremors should be tailored based on the degree of disability and the risk-benefit assessment of the therapeutic option and the patient’s preference. There is a wide array of treatment options for tremors that include pharmacological interventions, chemo-denervation in the form of botulinum toxin, and surgical procedures like lesional surgery and deep brain stimulation. The most evidence supports the management of essential tremor. Ongoing research explores novel medications, non-invasive neuromodulation, and brain stimulation techniques, which may become part of clinical practice. This chapter will review available treatment options and the supporting evidence for pharmacotherapy, surgical interventions, and non-pharmacological non-surgical interventions with a focus on common tremor syndromes.
History and examination
Authors: McNaught Elizabeth , Treasure Janet , Pollard Nick
Published: August 2022

There are many types of eating disorder, and they may present in different ways. This chapter begins with a basic overview of the signs and symptoms for each condition, then goes on to detail how to take a history from a patient suspected of having an eating disorder. Examinations and investigations are then presented, with BMI for both adults and children covered.
Anorexia nervosa
Authors: McNaught Elizabeth , Treasure Janet , Pollard Nick
Published: August 2022

Anorexia nervosa (AN) is a complex disease that affects multiple systems. This chapter begins by covering the epidemiology of the disease, and details the biological, psychological, and socio-cultural risk factors. The presentation of the condition is examined, including clinical features and methods for taking a history. Differential diagnosis is outlined, and physical examination and laboratory investigations are explained. Diagnostic criteria are then given. The chapter then moves on to the neurobiological changes associated with AN, and an overview of treatments, both psychological, outpatient, and inpatient. Complications, comorbidities are then outlined, and finally prognosis is discussed.