Diss. (sammanfattning) Umeå : Umeå universitet, 2009. / Härtill 5 uppsatser.

This qualitative interview study examines the shared and discrepant experiences that nine professionals, three from each field of psychiatry, social service, and housing have from working with people with hoarding disorder, and their view on help. The main difficulty when working with hoarding disorder is described as lack of insight and understanding of the severity and consequences of the disorder among people with the disability. Professionals highlight the importance of proper diagnosis and cooperation among disciplinary teams working with hoarding disorder. Approaches differ regarding the issue of how to best help a person with hoarding disorder, especially as the emphasis of autonomy becomes more prevalent. The landlords who were interviewed expressed the hoarders’ need of help from the society, whereas the social service interviewees accentuated voluntariness and motivation as a favorable long-term management. The psychiatry interviewees stressed that coercive measures are devastating, but sometimes necessary. The opinion that the view of normality in the context of hoarding needs to be questioned, was shared by the interviewees from all the three fields. In conclusion, the professionals describe their work with hoarding behavior as complex and emphasize the need for more knowledge concerning this subject. Empowerment theory is applied in the study.

Bakgrund: Lag om psykiatrisk tvångsvård innebär att sjukvården har rätt att ta bort självbestämmanderätten från en individ om denne lider av en allvarlig psykisk störning. Restriktioner och tvångsåtgärder som tvångsmedicinering, avskiljning och fastspänning kan förekomma. Syfte: Syftet är att belysa hur patienter upplever tvångsåtgärder inom psykiatrisk vård. Metod: En allmän litteraturstudie baserad på 12 vetenskapliga artiklar med kvalitativ ansats. Antonovskys Känsla av sammahang har använts som teoretisk referensram. Resultat: Det framkom att patienter generellt upplevde tvångsåtgärderna som negativa. Åtgärderna väckte en rad olika känslor hos patienterna såsom obehag, rädsla och förlorad autonomi, även återuppväckta minnen förknippade med våldtäkt och andra trauman. Det var många patienter som hade svårt att förstå varför dessa åtgärder utfördes, vilket visade sig som brister i kommunikationen mellan patient och sjuksköterska. Patienterna uttryckte önskan om att få utnyttja sin medbestämmanderätt, själva påverka tvångsåtgärderna och eftersökte en närmare relation till vårdpersonalen. Även om tvångsåtgärderna i största utsträckning var en negativ upplevelse så fanns det patienter som förstod att det var för deras eget bästa liksom för andra patienters och personals säkerhet. Slutsats: Patienterna rapporterade att de ville bli informerade, förstådda och bemötta som medmänniskor med respekt och inte behöva känna sig ensamma och övergivna. Tvångsåtgärder och lidande kan lindras genom att personal utvecklar sitt aktiva lyssnande och kunskap genom att ge adekvat information. Klinisk betydelse: Ökad förståelse för patienter som utsatts för tvångsåtgärder kan ge sjuksköterskor möjligheten att stärka patientens känsla av sammanhang vid tvångsåtgärder genom ökad begriplighet, hanterbarhet och meningsfullhet. Nyckelord: KASAM, tvångsåtgärder, patient upplevelse, psykiatrisk vård & litteraturstudie / Background: The Compulsory Psychiatric Care Act means that healthcare is entitled to remove the autonomy of an individual if he or she suffers from a serious mental disorder. Coercive measures may occur, such as forced medication, isolation and physical restraint. Aim: The aim is to illustrate how patients experience coercive measures in psychiatric care. Method: A literary review based on 12 scientific articles with qualitative approach. Antonovskys Sense of coherence has been used as a theoretical framework. Result: The results show that patients experienced coercive measures as negative. The measures provoked feelings in patients, such as discomfort, fear and loss of autonomy. There were patients who had trouble understanding why these measures were performed, which showed flaws in communication between patient and nurse. The patients expressed the desire to use their right to co-decide, to influence the measures and sought a closer relationship to the caregivers. Although the coercive measures were found to be a highly unpleasant experience, there were patients who understood that it was in their best interests. Conclusion: The patients reported that they wanted to be informed, listened to and treated with respect, and not have to feel alone and abandoned. Coercive measures and the associated suffering could be alleviated by active listening from the staff and the skills to provide adequate information. Clinical Implications: Increased understanding of patients subjected to coercive measures can give nurses the opportunity to strengthen the patients’ sense of coherence when exposed to coercive measures, by increasing their comprehensibility, manageability and meaningfulness.  Keywords: SOC, coercive measures, patient experience, psychiatric care & literature review

This study aims to highlight patients´ experiences about and thoughts of side effects fromelectroconvulsive therapy (ECT), a therapeutic method commonly used when having severedepressions. The framing of questions were how the respondents of this study describe theirlife before, during and after ECT-treatment, how the treatment has affected their daily life andhow these experiences may contribute to the awareness of power in professional relations.The study is based on three semi-structured narrative interviews and the main result showedthat, according to my interpretation, ECT as a treatment obliterated memories, quality of lifeand daily structure for all participants. Unfortunately they have all become subjects ofpsychiatric power and have faced considerable difficulty in getting professional recognitionaccording to their severe memory issues. The respondents have lost the ability to relate totheir past which clearly makes them struggle in their present context. A point in commonamong them is that neither of them wanted ECT but, because of the lack of communicationbetween them as patients and the health care in general, they all ended up getting it.

Background Studies on course and outcome of schizophrenia coming from low income countries are increasingly becoming important to challenge the existing dogma claiming good outcome in these countries. Besides clinical course and outcome, mortality is considered a very important outcome measure for schizophrenia. Culture and tradition play a significant role in the manifestations of severe mental illnesses (SMI). Khat is a culturally accepted plant endemic to Eastern Africa, which is chewed by people for its stimulating effect. It is believed that Khat influences the course and outcome of schizophrenia although systematic studies are scarce. Patients with SMI continue to chew khat despite advice from their doctors to desist. Reasons for this behavior were not fully investigated before. Objectives              -     To describe the 5-year clinical course and outcome and mortality of schizophrenia in Butajira. -       To explore traditional views on psychosis in the semi-nomadic Borana population. -       To describe the perceived causes and preferred treatment for SMI in the semi-nomadic Borana population -       To explore reasons for khat chewing behavior in people with SMI in Butajira. Methods The studies were done in two sites: Butajira and Borana. The Butajira study involved screening, using CIDI and Key Informants (KIs), of more than 68,000 adults aged 15-49. Of these, 321 people were diagnosed with schizophrenia and were followed-up for five years to look into their clinical course and outcome, including mortality. A qualitative study involving 37 men with SMI and 30 female caregivers was conducted in Butajira to study reasons why patients continue to chew khat despite their physicians’ advice against it. The Borana study of a remote semi-nomadic population in southern Ethiopia, used qualitative methods involving 56 KIs to identify descriptions of psychosis, perceived causes and preferred treatment in the community. Cases identified by the KIs also underwent SCAN interview for confirmatory diagnosis.   Results The five year follow-up of schizophrenia patients showed that 45% of participants were continuously symptomatic with 30.3% having had continuous psychotic episode. About 20% had experienced continuous remission. Being single (OR = 3.41, 95% CI = 1.08-10.82, P = 0.037), on antipsychotic treatment for at least 50% of follow up time (OR = 2.28, 95% CI = 1.12-4.62, P = 0.023), and having a diagnosis of paranoid subtype of schizophrenia (OR = 3.68, 95% CI = 1.30-10.44, P = 0.014) were associated with longer period of remission. A total of 38 (12.4%) patients, thirty four men (11.1%) and four women (1.3%) died during the 5-year follow-up period. The mean age (SD) of the deceased for both sexes was 35 (7.35): 35.3 (7.4) for men and 32.3 (6.8) for women. The most common cause of death was infection, 18/38 (47.4%) followed by severe malnutrition, 5/38 (13.2%) and suicide 4/38 (10.5%). The overall SMR was 5.98 (95% CI = 4.09 to 7.87): 6.27 (95% C I = 4.16 to 8.38) for men and 4.30 (95% CI = 1.02 to 8.52) for women. Patients residing in rural areas had lower mortality with adjusted HR of 0.30 (95% CI = 0.12-0.69) but those with insidious onset had higher mortality with adjusted HR 2.37 (95% CI = 1.04-5.41). Treatment with antipsychotics for less than 50% of the follow-up time was also associated with higher mortality, adjusted HR 2.66 (1.054-6.72). In the Borana study, the incongruity between local and psychiatric concepts in the CIDI lay mainly in the fact that KIs described characteristics of marata (madness) in terms of overt behavioral symptoms instead of thought disturbances. Following the focus group discussions, participants identified 8 individuals with schizophrenia and 13 with a psychotic mood disorder, confirmed by SCAN interview. Supernatural causes such as possession by evil spirits, curse, bewitchment, ‘exposure to wind’ and subsequent attack by evil spirits in postnatal women; bio-psycho-social causes such as infections (malaria), loss, ‘thinking too much’, and alcohol and khat abuse were mentioned as causes of SMI. The preferred treatments for severe mental illness included mainly traditional approaches, such as consulting Borana wise men or traditional healers, prayer, holy water treatment and, finally, seeking modern health care. Regarding khat and SMI in Butajira, reasons given by patients as well as caregivers were more or less congruent: social pressure, a means for survival by improving function, combating medication side effects, to experience pleasure and curbing appetite.  Conclusion Schizophrenia runs a chronic and non-remitting course and was associated with very high premature mortality in Butajira. Continued treatment with antipsychotics has been a consistent predictor of favorable outcome and reduced mortality. Case identification in studies of psychotic disorders in traditional communities are likely to benefit from combining structured interviews with the key informant method. Planning mental health care in traditional communities needs to involve influential people and traditional healers to increase acceptability of modern mental health care. Patients with SMI chewed khat for some important reasons that clinicians need to consider in their management.

Diss. Åbo : Åbo akademi, 2005. / Myös verkkojulkaisuna.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2006. / Härtill 4 uppsatser.

<p>The feeling of anxiety, a conscious experience, is associated with uneasiness, painfulness, or disturbing suspense. The current paper presents the phenomenology of anxiety disorders based on diagnostic criteria and reviews neuroimaging studies on anxiety including dissociation studies. Activity in the anterior cingulate cortex, medial prefrontal cortex, insula, temporal poles and amygdala suggest neural correlates of anxiety. The relevance of the neural correlates, how the feeling of anxiety differs from fear and worry, and the construct validity of anxiety are addressed. Anxiety and pain correlate with activity in the anterior cingulate cortex, which warrants further studies on the painfulness–anxiety relationship.</p>

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Bakgrund I Sandviken är vården av vuxenpsykiatrisk problematik uppdelad mellan primärvård och specialistpsykiatri. Patientöverföringen via remisser innebar en osäker vård och fördröjd tid till specialistpsykiatriska insatser då cirka 50 % av remisserna avvisades från två av hälsocentralerna.   Syfte Syftet med förbättringsarbetet var att minska andelen avvisade remisser och korta tiden från remiss vid hälsocentral till psykiatriska insatser vid specialistpsykiatrin. Studiesyftet var att ta reda på vilka antaganden som fanns bland samverkande aktörer och betydelsen av dessa för förbättringsarbetet.   Metod Den förutbestämda förbättringsidén utgjordes av en remissmall. Flera olika förbättringsverktyg användes i förbättringsarbetet med central utgångspunkt från att basera beslut på fakta. Studien var en empirisk fallstudie med kvalitativ innehållsanalys av dokument, observationer och följande intervjuer.   Resultat Förbättringsarbetets syfte uppnåddes inte med den testade remissmallen. Studien visade att antaganden kring vad som behövde och kunde göras bidrog till att remissmallen inte blev en hållbar lösning.   Slutsatser Förbättringsarbetet visade vikten av att testa nya idéer. Den förutbestämda remissmallen var inte en hållbar lösning. En koppling sågs mellan de samverkande aktörernas antaganden kring vad som behövde och kunde göras, liksom på vilket sätt, till vad som gjordes och hur. Detta bidrog till förbättringsarbetets utfall. / Background In Sandviken, the adult psychiatric care is divided between Primary Health Centers and Psychiatry. The transferral of patients was unsafe and meant prolonged time before psychiatric treatment was started as 50 % of the referrals were declined. Purpose The improvement project aimed to reduce the proportion of declined referrals and to reduce time between referral and psychiatric treatment. The study aimed to find out beliefs existing among stakeholders and the effect of these on the improvement work. Methods The idea to test, a referral template, was chosen in advance of the project start. Several improvement tools were used and one primary focus was to base decisions upon facts. The study was an empirical case study with qualitative analysis made on documents and interviews. Results The improvement project didn’t achieve the set aims. The study showed that beliefs about what was needed and possible to do, contributed to the results of the improvement work. Conclusions The improvement project showed the importance of testing new ideas. The referral template wasn’t a working solution. Stakeholders beliefs about what was needed and possible to do, and how to do it, was shown to contribute to the results of the improvement work.