Thesis (M.F.A.)--Georgia State University, 2009. / Title from title page (Digital Archive@GSU, viewed June 16, 2010) Sheri Joseph, committee chair; John Holman Josh Russell, committee members. Includes bibliographical references(p. 210).

Disorders of consciousness (DoC) are a group of disorders that can occur after severe brain injury. DOC have been subdivided based on behavioural observations into: Coma, lacking any signs of wakefulness or awareness; the vegetative state, showing signs of wakefulness but lacking any signs of awareness; and the minimally conscious state, showing signs of wakefulness and infrequent and irregular signs of awareness. The so-called locked-in syndrome, a state where both wakefulness and awareness are intact, but no communication is possible due to a lack of muscle function, does not belong to the disorders of consciousness. However, it is difficult to distinguish the locked-in syndrome from DoC diagnostically, because consciousness can only be shown through consistent responses to a command and current methods for assessing consciousness rely on behavioural responses. Patients with locked-in syndrome might not be able to move voluntarily at all in the most severe cases. Behavioural assessment would then classify them as unaware. While this is an extreme and rare case, it illustrates the problem behavioural assessment poses. Such assessments are unable to distinguish the effects of impaired muscular control from impaired awareness, when either has reached an extreme level of severity. Brain damage that does not affect consciousness itself can nevertheless affect the results of the behavioural assessment of consciousness. It is then hardly surprising that the diagnosis of DoC is associated with a high level of uncertainty. The advantage of brain imaging methods is that they do not rely on the patients ability to produce a consistent behavioural response. There have therefore been efforts to use the brain imaging methods electroencephalography, positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) to aid diagnosis of disorder of consciousness. PET and fMRI have successfully been used to identify regions of difference in some patients in a DoC. Task-based fMRI has been used to identify intact consciousness, using tasks that require explicit understanding of instructions and wilful modulation of brain activity, but no motor control. One of these tasks consists of periods where the participant imagines playing tennis alternated with periods of rest. The ability to follow this paradigm is evidence of consciousness, and a few patients with a diagnosis of DoC have been shown to be able to do this task. However, the tennis task requires high order processing of the tasks requirements and the majority of patients does not respond to this task. fMRI tasks that test sensory modalities instead of consciousness have been used to show retained brain function even in DoC patients that do not respond to the tennis task. In this work the tennis task and a battery of other tasks including tactile, visual and auditory stimulation, were studied on a group of DoC patients. It was found that none of the patients responded to the task of imagining playing tennis, but retained sensory function could be identified in three out of seven patients. This highlights a strength of fMRI, namely that it can identify retained brain function below the level that is necessary for consciousness. However, the results also show that more than half of the patients studied here, did not show retained brain activation during the fMRI scan. For any of the patients that did not show a response, this can be due to an actual lack of retained brain function, but it can also be due to limitations of the task-based fMRI analysis. The fMRI tasks only test one sensory function at a time, for a short time. Thus a visual fMRI task for example, can only provide information about areas of the brain, that are involved in visual processing. And when vigilance is fluctuating, retained brain function can remain undetected, if vigilance is low during the scan. Functional connectivity analysis is a method to study internal connections between brain areas that is not dependent on an external task. It models the brain as a network of interconnected regions and studies the characteristics of this network. Graph theory is a mathematical field that has found application on many other fields using network analysis, like social sciences, metabolic network modelling or gene network modelling. In fMRI analysis, graph theory has been used to study different phenomena and pathologies and global network properties have been shown reproducibly. The work presented here aims to develop new methods based in graph theory aiding the identification of residual brain integrity. To allow an assessment of the brain network topology and its use in the assessment of residual brain integrity, a novel method was designed based on a graph theoretical measure. The method, termed Cortical Hubs And Related network Topology (CHART) is a two stage procedure. The rst stage identifies statistically significant differences in functional connectivity between two groups, using a measure of the average connectivity of each voxel, the weighted global connectivity. The second stage highlights the topology of the networks associated with those differences. Two fMRI datasets, with different underlying tasks and pathologies were used to test the CHART method. The first dataset was acquired from a group of patients with severe depression. It contrasted the state of the brain before and after successful treatment with electroconvulsive therapy. In this patient group the CHART method was able to identify an area of hyperconnectivity in the depressed state, compared to the treated state. This area of hyperconnectivity was connected to areas that had priorly been shown to be overly connected in the depressed state. The second dataset consisted of DoC patients, that had been extensively assessed behaviourally. Half of the patients were diagnosed to be in a vegetative state, the other half was diagnosed to be in a minimally conscious state. The first stage of CHART identified several areas of difference based on the weighted global connectivity. The second stage highlighted that the observed global differences were due to an overall lack of extended functional connectivity in the vegetative state patients. The addition of a healthy control group in stage two allowed comparison not only between the two DoC groups, but also with the healthy group. In summary it was observed that the spatial extent of the connectivity seen in the minimally conscious group resembles the spatial extent of the connectivity seen in the healthy control group, while the spatial extent of connectivity observed in the vegetative state group was minimal, compared to both healthy and minimally conscious group. Thus the spatial extent of connectivity is a distinguishing property for the vegetative state group studied here. However the first stage of the CHART method is a group based method. In disorders of consciousness, where the underlying pathology is different from case to case, this concept is problematic. Finding a meaningful group of interest is difficult or impossible, because lesions differ in location and extent. Individual differences in connectivity can be expected to be large, and a generalisation of the CHART result might not lead to improved diagnosis for every patient. For diagnosis, the patients individual characteristics must be taken into account. An additional objective of this work was therefore to develop a method to compare a single patient to a group of controls. An approach based on regression modelling was tested but failed to provide the necessary statistical sensitivity to detect impaired connectivity. In conclusion the CHART method developed in this work provides insights into the functional connectivity of a group of DoC patients. To assist diagnosis, further development of a method to compare a single subject to a group of controls will be important.

This imaginative work of fiction depicts the lives of the Foley family. After a brutal car accident, Kate Foley has lived for the past fourteen years at Gregg Catastrophic Care Center in a persistent vegetative state, leaving her daughter Grace and husband Tom to reconstruct their lives around her. Aside from her mother’s condition, life is relatively normal for Grace; she worries about school, boys, her friends. Then her mother slowly regains consciousness. The family gathers around Kate’s bedside. Grandmother Helen arrives along with Aunt Liz, family that Grace cannot remember, and their stories of her mother’s past are vastly different from the ones her father has told her. Over the next emotional months, secrets are revealed, new alliances forged and others broken as each member of the family grapples with their own issues of memory, self and what it means to be fully present.

Thesis (M.A.)--Catholic Theological Union at Chicago, 1996. / Vita. Includes bibliographical references (leaves 80-85).

Thesis (M. A.)--Trinity Evangelical Divinity School, Deerfield, Ill., 1997. / Abstract. Includes bibliographical references (leaves 108-114).

Thesis (M.A.)--Catholic Theological Union at Chicago, 1996. / Vita. Includes bibliographical references (leaves 80-85).

Thesis (M.A.)--Catholic Theological Union at Chicago, 1996. / Vita. Includes bibliographical references (leaves 80-85).

Zielsetzung: Der Nachweis eines Apallischen Syndroms (APS) ist trotz der diagnostischen Kriterien der Multi Society Task Force on persistent vegetative state (MSTF) selbst für erfahrene Kliniker eine diagnostische Herausforderung. Das Ziel der vorliegenden Arbeit ist, inwieweit etablierte neurologische Untersuchungstechniken die Anwendung der MSTF-Kriterien vereinfachen und so zur Diagnose des APS beitragen. Design: Prospektive diagnostische Studie Patienten: Von initial 24 Patienten mit der Differentialdiagnose eines APS wurden 16 Patienten endgültig in die Studie eingeschlossen und einer prospektiven klinischen Untersuchung unterzogen. Das Studienprotokoll umfasste die Untersuchung der spontanen Motorik sowie Reiz korrelierter motorischen Reaktionen, der Primitivreflexe, Habituation und der Okulomotorik. Ergebnisse: Die Diagnosekriterien der MSTF waren bei allen Patienten nachweisbar, die in die Studie eingeschlossenen wurden. Darüber hinaus wurde durch die Studie weitere, ebenfalls häufig auftretende klinischen Symptome identifiziert, die als Markersymptom für eine APS bewertet wurden: spontane Automatismen (N=12), periodisch-alternierende Augenbewegungen (N=12), startle Reaktion nach externer Reizung (N=10) und Spastik (N=9). Klinische Symptome, die erhaltene Bewusstseinsleistung voraussetzen wie reflektorische Sakkaden, Habituation, der optokinetische Nystagmus und Augenfolgebewegungen oder Symptome, die auf eine schwere Hirnstammschädigung hinweisen wie eine Dezerebrationshaltung, wurden als Ausschlusskriterien eines APS vorgeschlagen. Zusammenfassung: Die Erweiterung der MSTF-Diagnosekriterien um obligatorische und unterstützende Schlüsselsymptome sowie klar definierte Ausschlusskriterien erleichtert die klinische Differentialdiagnose des APS und führt zu einer größeren Diagnosesicherheit des Syndroms. / Objective: Although the Multi Society Task Force (MSTF) on persistent vegetative state (PVS) published diagnostic criteria ten years ago, differentiation of PVS from similar syndromes remains a diagnostic challenge. The aim of our study was the prospective identification of clinically assessable symptoms supplementary to the MSTF criteria which supports or rejects the diagnosis of a PVS and to reevaluate the parameters after 30 month. Design: Prospective diagnostic study Setting: The 90-bed department of Neurology of the University hospital of Berlin. Patients and participants: Out of 24 screened patients with the differential diagnosis PVS, 16 patients were finally included to the study and prospectively assessed by a clinical examination, comprising spontaneous and reflexive motor activities, primitive reflexes, habituation and eye movements. Measurements and results: Mandatory symptoms of the MSTF were found in all 16 patients. In addition, clinical features like spontaneous automatisms (n=12), periodic alternating gaze deviation (n=12), startle reaction to external stimuli (n=10), and spastic muscular tone (n=9) were found frequently and considered supportive for the diagnosis. In contrast to previous observations, periodic alternating eye movements and increased muscular tone were found more frequently in our patients. Symptoms linked to a preserved consciousness like reflexive visually guided saccades, habituation, an optokinetic nystagmus and eye tracking or symptoms indicating a severe functional impairment of the brainstem like a decerebrated posture were proposed as excluding PVS. Conclusion: The application of mandatory and supportive symptoms lead to a further improvement of diagnostic certainty in PVS, particular in patient presenting exceptional clinical phenomena. Clearly defined exclusive criteria prevent from misdiagnosis.

A assistência aos pacientes com doenças neurológicas de longa duração não é reconhecida na produção científica brasileira; entende-se por doença neurológica de longa duração: doenças neurológicas de curso longo, fase final de difícil identificação, com sintomas variados e condição de dependência moderada ou grave e comprometimento cognitivo de difícil avaliação. Neste estudo, foram consideradas as seguintes condições: estado vegetativo persistente, estado mínimo de consciência e síndrome do encarceramento (ou síndrome de locked-in). Em busca bibliográfica, verificou-se que não há artigo em língua portuguesa sobre o tema. No cotidiano, a assistência é focada em higiene e observação clínica. Entretanto, na perspectiva do Cuidado, algo mais é necessário ao se pensar este tipo de prática, para a promoção da dignidade humana. Os objetivos deste estudo são: relatar uma prática junto a pessoas com doenças neurológicas de longa duração focada no seu resgate biográfico, e fundamentar a mesma de maneira interdisciplinar, a partir do Cuidado como categoria reconstrutiva. É uma pesquisa qualitativa, na qual foram utilizados primariamente registros de um diário de campo da primeira autora, sobre intervenções em Terapia Ocupacional com esta população; a partir destes, foram produzidas narrativas e reflexões sobre a metodologia de intervenção. A partir do resgate biográfico, busca-se resgatar a condição de sujeito do paciente neurológico muito grave. Na segunda etapa, tem-se a fundamentação teórica numa perspectiva interdisciplinar; o conceito de Cuidado é a referência principal, compreendido como o sentido existencial da experiência de adoecimento. Também foi utilizado o referencial da psicanálise de orientação freudiana e lacaniana para aprofundamento teórico dos achados empíricos descritos através de narrativas. A reconstrução da biografia do paciente ocorre por diversas perspectivas, mas especialmente pela estimulação sensorial - não com foco de recuperação neurológicas, mas a partir do repertório do paciente e em busca da validação de sua condição de sujeito. Junto com uma detalhada avaliação e acompanhamento, o terapeuta faz um monitoramento contínuo, propondo atividades e dando especial atenção ás reações observadas, para que possa nomeá-las ou traduzi-las, bem como discriminar os estímulos agradáveis e desagradáveis; isto também possibilita ampliação das possibilidades de encontro deste sujeito com o mundo. Os conceitos psicanalíticos: estágio do espelho, real, lalíngua e constituição do sujeito apresentam-se como fundamentais para a compreensão das experiências empíricas vividas e, posteriormente, elaboração de uma fundamentação teórica. Memória, história, identidade, dignidade e subjetividade qualificam a prática junto a pessoas com doenças neurológicas de longa duração. A despeito das reações neurológicas apresentadas, tal prática possibilita a reconstrução de um cotidiano significativo e as teorias psicanalíticas de orientação freudiana e lacaniana constituem importante marco para fundamentação da reconstrução da assistência / The care of people with Long Term Neurological Conditions (LTNC) isn´t recognized in the Brazilian Palliative Care scientific production; in daily basis, the assistance is focussed on hygiene´s care and clinical observation. However, from the perspective of palliative care, something more is needed, to promote the dignity of the human person. To describe an occupational therapy intervention for patients with LTNC based on biographical rescue. Records and field diaries of an Occupational Therapy intervention promoted by the first author were used to produce narratives and reflections about this intervention´s methodology. The concept of Comprehensive Care is the main reference, designed as care interested in the existential sense of the illness process. It was also used the framework of Freud´s and Lacan´s psychoanalysis for theoretical studies of the empirical findings reported through narratives. The beginning of the reconstruction of the patient´s biography occurs by several perspectives, especially through sensory stimuli related to prior patient´s occupational repertoire. Along with the detailed evaluation, the therapist does a careful and continuous monitoring, proposing activities, giving special attention to their reactions, being able to discriminate what pleases or not, and expanding the possibilities of encounter of people with LTNC and the environment which surround them. The psychoanalytic concepts: mirror stage, real, lalangue and subject´s constitution had major importance to understand the empirical experiences and to develop a theoretical basis. Memory, history, identity, dignity, and subjectivity qualify the practice of occupational therapist with people with LTNC. Regardless of neurological reactions presented by the patients this practice helps reconstructing the meanings of the daily life of person with so severe disability. Sensory stimuli are shown as potential tools for a reconfiguration of the assistance with someone seriously affected by a neurological disease. Psychoanalytic theories of Freudian and Lacanian orientation are also an important framework for the reconstruction assistance

A assistência aos pacientes com doenças neurológicas de longa duração não é reconhecida na produção científica brasileira; entende-se por doença neurológica de longa duração: doenças neurológicas de curso longo, fase final de difícil identificação, com sintomas variados e condição de dependência moderada ou grave e comprometimento cognitivo de difícil avaliação. Neste estudo, foram consideradas as seguintes condições: estado vegetativo persistente, estado mínimo de consciência e síndrome do encarceramento (ou síndrome de locked-in). Em busca bibliográfica, verificou-se que não há artigo em língua portuguesa sobre o tema. No cotidiano, a assistência é focada em higiene e observação clínica. Entretanto, na perspectiva do Cuidado, algo mais é necessário ao se pensar este tipo de prática, para a promoção da dignidade humana. Os objetivos deste estudo são: relatar uma prática junto a pessoas com doenças neurológicas de longa duração focada no seu resgate biográfico, e fundamentar a mesma de maneira interdisciplinar, a partir do Cuidado como categoria reconstrutiva. É uma pesquisa qualitativa, na qual foram utilizados primariamente registros de um diário de campo da primeira autora, sobre intervenções em Terapia Ocupacional com esta população; a partir destes, foram produzidas narrativas e reflexões sobre a metodologia de intervenção. A partir do resgate biográfico, busca-se resgatar a condição de sujeito do paciente neurológico muito grave. Na segunda etapa, tem-se a fundamentação teórica numa perspectiva interdisciplinar; o conceito de Cuidado é a referência principal, compreendido como o sentido existencial da experiência de adoecimento. Também foi utilizado o referencial da psicanálise de orientação freudiana e lacaniana para aprofundamento teórico dos achados empíricos descritos através de narrativas. A reconstrução da biografia do paciente ocorre por diversas perspectivas, mas especialmente pela estimulação sensorial - não com foco de recuperação neurológicas, mas a partir do repertório do paciente e em busca da validação de sua condição de sujeito. Junto com uma detalhada avaliação e acompanhamento, o terapeuta faz um monitoramento contínuo, propondo atividades e dando especial atenção ás reações observadas, para que possa nomeá-las ou traduzi-las, bem como discriminar os estímulos agradáveis e desagradáveis; isto também possibilita ampliação das possibilidades de encontro deste sujeito com o mundo. Os conceitos psicanalíticos: estágio do espelho, real, lalíngua e constituição do sujeito apresentam-se como fundamentais para a compreensão das experiências empíricas vividas e, posteriormente, elaboração de uma fundamentação teórica. Memória, história, identidade, dignidade e subjetividade qualificam a prática junto a pessoas com doenças neurológicas de longa duração. A despeito das reações neurológicas apresentadas, tal prática possibilita a reconstrução de um cotidiano significativo e as teorias psicanalíticas de orientação freudiana e lacaniana constituem importante marco para fundamentação da reconstrução da assistência / The care of people with Long Term Neurological Conditions (LTNC) isn´t recognized in the Brazilian Palliative Care scientific production; in daily basis, the assistance is focussed on hygiene´s care and clinical observation. However, from the perspective of palliative care, something more is needed, to promote the dignity of the human person. To describe an occupational therapy intervention for patients with LTNC based on biographical rescue. Records and field diaries of an Occupational Therapy intervention promoted by the first author were used to produce narratives and reflections about this intervention´s methodology. The concept of Comprehensive Care is the main reference, designed as care interested in the existential sense of the illness process. It was also used the framework of Freud´s and Lacan´s psychoanalysis for theoretical studies of the empirical findings reported through narratives. The beginning of the reconstruction of the patient´s biography occurs by several perspectives, especially through sensory stimuli related to prior patient´s occupational repertoire. Along with the detailed evaluation, the therapist does a careful and continuous monitoring, proposing activities, giving special attention to their reactions, being able to discriminate what pleases or not, and expanding the possibilities of encounter of people with LTNC and the environment which surround them. The psychoanalytic concepts: mirror stage, real, lalangue and subject´s constitution had major importance to understand the empirical experiences and to develop a theoretical basis. Memory, history, identity, dignity, and subjectivity qualify the practice of occupational therapist with people with LTNC. Regardless of neurological reactions presented by the patients this practice helps reconstructing the meanings of the daily life of person with so severe disability. Sensory stimuli are shown as potential tools for a reconfiguration of the assistance with someone seriously affected by a neurological disease. Psychoanalytic theories of Freudian and Lacanian orientation are also an important framework for the reconstruction assistance