Background: Traumatic musculoskeletal injury (TMsI) often leads to chronic pain and post-traumatic stress disorder (PTSD). This study examined factors of a modified diathesis-stress model in the development of PTSD symptoms following TMsI. Methods: 205 patients were recruited in this prospective, observational study. Within 14 days of injury, participants completed an in-hospital questionnaire investigating acute symptoms of anxiety, depression, pain, and PTSD. Results: Logistic regression identified multiple factors associated with symptoms of PSTD (p<.0001). Neuropathic pain (odds ratio[OR]=1.091, 95% confidence interval[CI] 1.020-1.168), general anxiety (OR=1.176, 95%CI 1.046-1.318), pain anxiety (OR=1.056, 95%CI 1.018-1.094), and pain catastrophizing (OR=1.168, 95%CI 1.016-1.348) were associated with acute symptoms of PTSD. Conclusions: The results support the modified diathesis-stress model indicating that neuropathic pain, general anxiety, pain anxiety, and pain catastrophizing are associated with symptoms of PTSD. Future studies should examine the influence of these acute factors on the development of chronic pain and PTSD following TMsI.

Background: Until recently, qualitative researchers have avoided interviewing participants with brain injuries because of the ethical and practical dilemmas which may arise and because it has been argued that they may not be able to reflect and accurately report upon their experiences. Therefore, little research has been produced which explores the personal experience of living with a brain injury. Recently, however, some researchers have challenged the view that people with brain injuries are unsuitable as interviewees in qualitative research and have, through their own research, highlighted the importance of understanding their views and perspectives in order to provide them with the best care and rehabilitation. Aims: With this in mind, and in line with current calls for more research gaining the brain injured person’s perspective, this study attempted to gain an in depth understanding of what it is like from the brain injured person’s perspective, to live with an acquired brain injury. The study focussed upon the experience of gaining consciousness following a brain injury, the experience of living with permanent memory loss, the experience of gaining awareness of deficits, the experience of losing an identity and adjusting to a new identity, the impact on relationships with friends and family and experiences as an inpatient in a Brain Injury Unit. Sources of strength and coping mechanisms were also explored. Method: Semi-structured interviews were conducted with six individuals who had severe acquired brain injuries and were inpatients in a post-acute neuro-rehabilitation unit. The verbatim transcripts of the semi-structured interviews were then analysed using Interpretative Phenomenological Analysis (IPA). Results: The analysis produced four master themes. These were: ‘Piecing together the past and becoming aware of the present’, ‘The transition from old self to new self’, ‘Sources of strength and survival’ and ‘Experiences in rehabilitation’. A description of these themes is presented with the corresponding subordinate themes. Conclusions: The clinical implications of the research and guidance for future research are discussed. The study produced a valuable insight into the personal experience of living with a severe acquired brain injury that could be used to inform rehabilitation interventions. The results also indicated that people with acquired brain injuries may experience Post Traumatic Growth.

Research investigating the role of two evolutionary constructs – perceptions of defeat and entrapment – in various psychological problems and processes has burgeoned over recent years. This meta-analysis quantitatively summarised the findings from 38 studies (11,343 participants) which examined relationships between perceptions of defeat and entrapment and four psychological problems commonly encountered in NHS clinical services: depression, suicidality, anxiety problems and Post-Traumatic Stress Disorder (PTSD). All correlations between defeat and entrapment and the four psychological problems were large by Cohen’s (1988) criterion. Correlations between defeat and entrapment and depression were larger than those for the other psychological problem groups, and significantly larger than those for anxiety problems and PTSD. The magnitude of the observed correlations introduces the possibility that defeat and entrapment, and perhaps other evolutionary constructs, may be integral components or driving forces behind all psychological problems. A robust approach to sensitivity analysis provided confidence that the population effect size estimates are robust and were not severely inflated by unpublished studies not included in the meta-analysis. As there was no significant between-study heterogeneity, moderator analyses were undertaken on an exploratory basis. Findings are generally consistent with theoretical predictions from the Involuntary Defeat Strategy, the theoretical model underpinning the literature. Overall, perceptions of defeat and entrapment appear to be strong risk factors for the four psychological problems examined, perhaps representing transdiagnostic processes that are common across various psychological problems. The potential role of defeat and entrapment in mental health assessment, formulation, intervention and evaluation, is considered in detail and limitations of this meta-analysis and of the literature on which it is based are discussed, highlighting areas of research where future work is needed.

Intact white matter is critical for normal cognitive function. In traumatic brain injury (TBI), chronic cerebral hypoperfusion and Alzheimer’s disease (AD) damage to white matter is associated with cognitive impairment. However, these conditions are associated with grey matter damage or with other pathological states and the contribution of white matter damage in isolation to their pathogenesis is not known. Furthermore, TBI is a risk factor for AD and cerebral hypoperfusion is an early feature of AD. It is hypothesised that white matter damage following TBI or chronic cerebral hypoperfusion will be associated with cognitive deficits and that white matter changes after injury contribute to AD pathogenesis. To investigate this, this thesis examined the contribution of white matter damage to cognitive deficits after TBI and chronic cerebral hypoperfusion and furthermore, investigated the role of white matter damage in the relationship between TBI and AD. Three studies addressed these aims. In the first, mild TBI was induced in wild-type mice and the effects on axons, myelin and neuronal cell bodies examined at time points from 4 hours to 6 weeks after injury. Spatial reference learning and memory was tested at 3 and 6 weeks after injury. Injured mice showed axonal damage in the cingulum, close to the injury site in the hours after injury and at 6 weeks, damage in the thalamus and external capsule were apparent. Injured and sham animals had comparable levels of neuronal damage and no change was observed in myelin. Injured animals showed impaired spatial reference learning at 3 weeks after injury, demonstrating that selective axonal damage is sufficient to impair cognition. In the second study mild TBI was induced in a transgenic mouse model of AD and the effects on white matter pathology and AD-related proteins examined 24 hours after injury. There was a significant increase in axonal damage in the cingulum and external capsule and parallel accumulations of amyloid were observed in these regions. There were no changes in tau or in overall levels of AD-related proteins. This suggests that axonal damage may have a role in mediating the link between TBI and AD. The third study used a model of chronic cerebral hypoperfusion in wild type mice and investigated white matter changes after one and two months of hypoperfusion as well as a comprehensive assessment of learning and memory. Chronic cerebral hypoperfusion resulted in diffuse myelin damage in the absence of ischaemic neuronal damage at both 1 and 2 months after induction of hypoperfusion. Hypoperfused animals also showed minimal axonal damage and microglial activation. Cognitive testing revealed a selective impairment in spatial working memory but not spatial reference or episodic memory in hypoperfused animals, showing that modest reductions in blood flow have effects on white matter sufficient to cause cognitive impairment. These results demonstrate that selective damage to white matter components can have a long-term impact on cognitive function as well as on the development of AD. This suggests that minimisation of axonal damage after TBI is a target for reducing subsequent risk of AD and that repair or prevention of white matter damage is a promising strategy for rescuing cognitive function in individuals who have experienced mild TBI or chronic cerebral hypoperfusion.

Some sections of the appendices are not available in the electronic copy of this thesis due to their format. The full version is available for consultation at the University of Leicester Library.

Bakgrund: Traumatisk hjärnskada (THS) orsakas av våld mot huvud i samband med fallolyckor eller trafikolyckor. Varje år söker 20 000 personer vård på grund av skallskador. Vården för traumatiskt hjärnskadade patienter i Sverige skiljer sig åt, mycket beroende på avstånden som finns till specialistsjukhus, tiden och rätta åtgärder är avgörande faktorer för denna patientgrupp. Syfte: Att undersöka vikten och intensivvårdssjuksköterskors behov av rutiner i samband med vård av patienter med hjärnskador på allmänintensivvårdsavdelningar och på neurointensivvårdavdelningar. Metod: Kvalitativ studie med fokusgruppsintervjuer av tio intensivvårdsjuksköterskor som arbetar på en allmänintensivvårdsavdelning (IVA) och specialistneurointensivvårdavdelningen (NIVA). Resultat: På NIVA finns väl inarbetade rutiner och tydliga riktlinjer nedskrivna. Sjuksköterskornas upplevelse var att det fanns tillräckligt med rutiner, men några rutiner kunde utvecklas. På IVA fanns det inga nedskrivna riktlinjer och inga tydliga rutiner för att vårda denna patientgrupp. Vården och kontrollerna ordinerades av läkare som är i tjänst. Slutsats: Vården kring hjärnskadade patienter är ytterst viktigt då man ständigt måste förebygga sekundära skador/insulter. Rutiner är väl inarbetade på specialistsjukhuset, men vården börjar först på hemsjukhuset på IVA där tydliga rutiner och riktlinjer saknas. / Introduction: Traumatic brain injury caused by violence against the head during a fall or traffic accident. Each year 20000 people gets medical care because of head injuries. The care for traumatic brain injured patients in Sweden differ greatly depending on the distances available to specialist hospitals, the time and the proper measures are crucial factors in this population. Aim: The study aims to examine the importance and intensive care nurses need routines in connection with care of patients with brain injuries in general intensive care units and in neurological intensive care units. The study consists of three group interviews in a general ICU unit in Falun and specialist unit (NIVA). Method: A qualitative study with focus group interviews. Results: The results showed that the level have clear procedures and written guidelines regarding the "avoidable factors" which are well established, their experience was that there were enough procedures, but that some could continue to develop. IVA there were no written guidelines and no clear procedures to care for this population without the care and controls prescribed by the doctor who is on duty. Conclusion: The conclusion is that care about the brain-damaged patients is extremely important when you constantly have to prevent secondary injury / insults and check the "avoidable factors". Routines are well established on specialist hospital care but starts first at home hospital where the importance of working towards the same goal and have clear procedures and guidelines from the start.

This study began testing the Sewell and Williams (in press) model that differing trauma types yield differing presentations in social versus event processing domains. Other hypotheses explored trauma type with levels of guilt, and shame-proneness with anxiety. Volunteers were 44 male combat veterans being treated for PTSD. Data analyses determined whether trauma type related to guilt and perceived social support and whether shame-proneness related to levels of anxiety. High shame persons may process anxiety and social support differently than low shame persons. Results can assist professionals understand how a person's functioning is affected by certain types of trauma. Future research should focus on increasing social support for persons who have experienced trauma.

Bakgrund Posttraumatiskt stressyndrom bör betraktas som en folkhälsosjukdom där diagnostisering och behandling behöver uppmärksammas. Ungdomar som överlevt livshotande händelser tenderar att återuppleva dessa traumatiska händelser och undviker att handskas med känslorna som uppkommer, vilket kan leda till psykiska besvär. Syfte Att undersöka riskfaktorer som finns för att utveckla posttraumatiskt stressyndrom bland ungdomar samt undersöka vilka datainsamlingsmetoder de inkluderade artiklarna valt. Metod Deskriptiv design användes i litteraturstudien som inkluderar 13 stycken vetenskapliga artiklar från databaserna PsycInfo och PubMed. Likheter och skillnader i artiklarnas resultat identifierades och använda datainsamlingsmetoder sammanställdes. Huvudresultat Att vara utsatt för våld och traumatiska händelser såsom fysisk skada eller se någon lida/dö, vara tjej, äldre ungdom, utsatt för daglig stress, splittrad familj och sämre socialt stöd var riskfaktorer för att utveckla posttraumatiskt stressyndrom. Tio av tretton artiklar hade kvantitativ ansats och använde frågeformulär för att få svar på vilka riskfaktorer det fanns. En artikel hade kvantitativ ansats men använde inte frågeformulär och två hade endast kvalitativ ansats i form av intervju som datainsamlingsmetod. Slutsats Denna litteraturstudie identifierade olika riskfaktorer som ligger till grund för utveckling av PTSD bland ungdomar. De vanligaste som återkom i nästan alla studier var att utsättas för våld, vara med om traumatiska händelser, vara tjej, sämre socialt stöd inom familj och skola, förlora en anhörig och vardagliga stressorer. Att som sjuksköterska och övrig vårdpersonal inneha denna kunskap kan bidra till att tidigare kunna identifiera ungdomar med PTSD samt anpassa omvårdnaden till denna grupp på bästa sätt. / Background Posttraumatic stress disorder should be considered as a public health disease where diagnosing and treatment require attention. Adolescents who have survived life-threatening events tend to relive these traumatic events and avoid to deal with the emotions that occur, which can lead to mental disorders. Aim Identify which risk factors there is to develop posttraumatic stress disorder among adolescents and examine which data collection methods the included articles have chosen. Method Descriptive design has been used in this literature study including 13 articles collected from the databases PsycInfo and PubMed and has been categorized by similarities and differences. The articles data collection methods has been presented from the methodological aspect. Main results To be exposed to violence and traumatic events as physical injury or see someone suffer/die, be a girl, older adolescent, exposed to daily stress, broken family and have less social support were some risk factors for developing posttraumatic stress disorder. Ten of thirteen articles had a quantitative approach and used questionnaire to get responses for which risk factors there was. One article had a quantitative approach but did not use a questionnaire and two articles had qualitative approach and used interview as data collection method. Conclusion In this literature study different risk factors were identified underlying to develop PTSD among adolescents. The most common risk factors in almost all of the studies were to be exposed to violence, experience traumatic events, be a girl, have less social support from family and school, lose a family member and daily stress. As a nurse it is important to keep this in mind so the care for the adolescents are as good as possible and that coping is used in the right way.

Background: Providing care to individuals with multifaceted mental health needs can be very demanding and in turn leave mental health professionals at an increased risk for compassion fatigue (CF). Comprised of Burnout (BO), Secondary Traumatic Stress (STS), and a lack of Compassion Satisfaction (CS), CF is the state of exhaustion and dysfunction, emotionally, biologically, and physiologically, due to prolonged exposure to compassion stress. CF can leave healthcare providers at an increased risk for experiencing their own health issues, contributing to tardiness and absenteeism, as well as increasing the risks for such adverse effects as clinical and medication errors, poor treatment planning, and decreased patient satisfaction. Purpose: The purpose of this paper is to identify the risk factors for CF and describe the perceptions of CF among outpatient mental health providers employed in urban community-based mental health outpatient organization. Method and Sampling: A qualitative descriptive study design utilizing two focus groups, each having four participants was conducted to assess outpatient mental health providers’perceptions of CF. Purposeful sampling of current providers in two community-based mental health outpatient organizations was performed to protect the privacy and enhance the comfort of each participant as they discussed elements of CF. Findings: Five themes were identified from the focus group analysis: the participant’s perceived definition of CF, participant perceptions of prevalence of CF in the mental health setting, participant perceptions regarding the triggers, perceived participant causes of CF, and self-care practices. These results reflect data collected in a mental health setting however, the findings are consistent with current research contributed from other specialties. Conclusion: Personal descriptions of the experiences and insights of these providers expand the current CF literature and will contribute to the development of quality improvement projects committed to reducing compassion fatigue among outpatient mental health providers.

Bakgrund: Ryggmärgens huvudsakliga funktion är att skicka och ta emot nervimpulser för rörelse och känsel. När en ryggmärg skadas innebär det förluster eller nedsättningar av kroppsliga funktioner och förmågor. Omfattningen av funktionsnedsättningen är beroende på vilken nivå i ryggmärgen som skadan sker. Vid en traumatisk ryggmärgsskada har omvårdnaden en stor betydelse för den fortsatta hälsan och sjuksköterskor har beskrivit att de har en mångsidig roll i arbetet. Att ha en funktionsnedsättning kan innebära ett behov av hjälp från andra personer, samt upplevelser av utanförskap och en exkludering från samhälleliga arenor. Syfte: Att belysa personers upplevelser av att leva med en traumatisk ryggmärgsskada. Metod: En litteraturöversikt baserad på tolv vetenskapliga artiklar; elva kvalitativa och en med mixad metod från databaserna CINAHL complete och Psycinfo. Vid sökning i databaserna användes ämnesord som Spinal Cord Injuries, Patients attitudes. Artiklarna har analyserats i enlighet med Fribergs metod. Resultat: Två huvudteman identifierades utifrån Roys adaptionsmodell, Adaptiv respons och ineffektiv respons. Varje huvudtema har tillhörande underteman. Under adaptiv respons återfanns, anhörigas roll i vardagslivet, hoppets betydelse, nya insikter och förändrade perspektiv och betydelsen av meningsfulla aktiviteter. Under ineffektiv respons återfanns upplevelser av att vara beroende, upplevelser av en förändrad identitet, viljan att avsluta sitt liv, upplevelser av ett förlorat hopp och livets ständiga kamp. Diskussion: I metoddiskussionen diskuteras metodens styrkor respektive svagheter. Under rubriken resultatdiskussion diskuteras litteraturöversiktens viktigaste resultat som var anhöriga, hopp, psykisk ohälsa och aktiviteter mot litteraturöversiktens bakgrund, ny litteratur samt mot Roys adaptionsmodell. / Background: The Spinal cord's main function is to send and receive nerve impulses for movement and sensation. Damage of the spinal cord means loss or impairment of bodily functions and abilities. The extent of the disability depends on the level of the spinal cord injury. At a traumatic spinal cord injury, care has a great importance for the continued health. Nurses have described that they have a versatile role in that work. Having a disability can mean a need for help from other people and the experiences of alienation and exclusion from social arenas. Aim: To illustrate people's experiences of living with a traumatic spinal cord injury. Method: A literature review based on twelve scientific articles; eleven qualitative and one with mixed method from the databases CINAHL Complete and PsycINFO. When searching in the databases, some of the terms that was used were Spinal Cord Injuries, Patients, Attitudes. The articles were analyzed according to Fribergs method. Results: Two main themes were identified from the Roy Adaptation Model, adaptive response and ineffective response. Each main theme has related sub-themes. Sub themes in adaptive response are, relatives role in everyday life, importance of hope, new insights and altered perspectives and the importance of meaningful activities. In ineffective response there are experiences of being dependent, experiences of an altered identity, the desire to end one’s life, experiences of a lost hope and life's constant struggle. Discussion: In the method discussion, strengths and weaknesses of the method are discussed. Under the heading discussion of results, the most important results of the literature overview that were relatives, hope, mental health and activities are discussed in comparison with the results overview background, new literature and Roy's adaptation model.