The overall aim of this thesis is to illuminate and describe bodily changes and problems in incurable cancer, with focus on prostate cancer, from the patient’s perspective. The thesis consists of four papers, each of which illuminates various aspects of the phenomenon studied. The study population consisted of 24 participants, three women with different cancer diagnoses in the palliative phase, and 21 men with hormone refractory prostate cancer (HRPC) and skeletal metastases. Data are based on interviews (papers I–IV) and a quality of life questionnaire (paper I). The study design is cross-sectional (papers I–III) and longitudinal (paper IV). Qualitative description, descriptive statistics, phenomenological hermeneutics, and analysis of discourse were used to analyze data. The findings of study I show that the dominating symptoms for the men with HRPC (n=20) were pain and fatigue, and three different variants of each problem were described. The men said that changes in their sex life were not an extensive problem, even if it was scored as such. The symptoms differed in occurrence, extent, and meaning between the men, and were not necessarily experienced as problems. In study II, pain and fatigue were again the most prominent problems in men with HRPC (n=18), but pain and fatigue were seen to have different meanings. Pain was seen as synonymous with cancer. Pain can be alleviated, but it is a threat, both now and in the future, and symbolizes a painful death. Fatigue was viewed as a hindrance in the present. It was experienced as less threatening than pain, but as something that cannot really be changed. Fatigue represents the natural course death will take, as eventually sleep into death. An important finding of study II is that one meaning of bodily problems is to live in a cyclical movement of losing and reclaiming wellness. Understanding, and, to some extent, being in control of, bodily problems makes it possible to experience wellness. When the bodily problems increase or change, or when new problems appear or become a hindrance in the daily life, the experience of being ill returns. The findings of study III show that one meaning of fatigue in patients with cancer in the palliative phase (n=4) is a lived bodily experience of approaching death. This can be understood through the paradox of struggling against fatigue, and hoping to overcome it, yet expecting failure. The body, through fatigue, signals to the person that death is approaching, but the person is not yet “ready”. Paper IV shows that the way two of the men with HRPC talked about the past, present, and future changed during the disease trajectory. In the first interview, the men were open towards both the past and the future, while just before death, their narration was totally dominated by the concrete experience of the illness. The past became the past in the illness and not in life, and the present was flooded with extensive bodily changes. Also, the future had shrunk, although it also had been transferred to beyond death. Pain, fatigue, nausea, and other bodily problems figured largely in this change. This thesis provides important insights into the phenomenon of bodily changes when living with incurable cancer, with focus on prostate cancer. The thesis shows the connection between bodily changes and time, where different bodily changes have different meanings, and meanings seem to change during the illness trajectory (papers I–IV); and bodily changes close to death seem to take “all” time; what is left is the present filled with problems (paper IV). Further, it shows that bodily changes have a great influence on the cyclical movement between losing and reclaiming wellness in incurable cancer (paper II). The clinical implications of the thesis are that alleviation of pain and other bodily problems must be based on the meaning the patient gives the bodily changes taking place. That is, alleviation with the purpose to free time and to facilitate living in wellness as death is approaching.

The main aim of this thesis was to longitudinally investigate the potential occurrence of posttraumatic stress disorder (PTSD) among parents of children on cancer treatment (Study I). Additional aims were to describe parents’ perceptions of emotional support and satisfaction with the child’s care (II), perceptions of the child’s symptom burden (III), and parents’ stories about having a child on cancer treatment (IV). The design was prospective, longitudinal, and data was collected at: one week, two months, and four months after the child’s diagnosis and one week/six months after the end of successful treatment/transplantation. Parents (N=259) were consecutively included during the years 2002-2004 and answered questionnaires and open-ended questions over the telephone. Parenting a child with cancer is a very demanding, potentially traumatic, event. Approximately a fourth of the parents report symptoms corresponding to PTSD. The symptom level is related to being a mother, not working before the child’s diagnosis, and to previous trauma experience. Less than half of those who report a need to talk with a psychologist report having had the opportunity to do so. Parents are generally satisfied with the care and report the highest satisfaction with the technical care. Emotional distress, fatigue, nutrition, and pain are, according to parents, the most problematic symptom areas for their children. Pain is identified as especially problematic. Parents in paediatric oncology care should be acknowledged as potential care-recipients. In order to prevent development of PTSD parents of children on cancer treatment should be supported to maintain an ordinary life, for example pursue work and/or activities, and to get sufficient rest. As a means towards this parents need help with e.g. household duties and childcare. In addition to this, parents in approximately two fifths of the families need extended psychosocial support aiming at reducing posttraumatic stress.

The overall aim was to follow the development of nutritional status and its significance for general health status using an epiemiologic method in a representative population‐based selection of older individuals in two cohorts. The main focus was to prospectively examine the significance of demographic, social and medical factors and to establish a basis to investigate the possibilities of preventive measures. Methods: Five hundred and eighty‐three individuals (278 women and 305 men), 75 and 80 years old, when included, living in a municipality in Östergötland in Sweden, participated in this study. Data collection took place 2001‐2006 with one examination yearly. The examination included a single question regarding self‐perceived health demographical questions, different questionnaires in the areas of nutritional status, symptoms of depression, cognitive function, health‐related quality of life and well being and objective assessments such as anthropometrical, physical and biochemical measurements. Results: Fifty percent of the women (I) and 58% of the men (II) perceived themselves as healthy. Important factors for women’s health (I) at baseline were no or few symptoms of depression, better physical mobility and better physical health. Among men who perceived themselves as healthy (II) at baseline, important factors were better physical health, maintaining a social network and the ability to walk outdoors. After one year 69% of the women and 75% of the men still perceived themselves as healthy. Among those women (I) who perceived themselves as healthy after one year, better physical mobility and better physical health were still important, with the addition of less or no pain. Important predictors for preserving health among men (II) were no symptoms of depression and the ability to walk up and down stairs. The prevalence of risk for malnutrition (III) was 14.5% (n=84), among women 18.8% and men 10.6%. Risk factors for malnutrition at baseline were a lower TSF, lower handgrip strength and worse physical health according to the PGC MAI. The incidence was 7.6%‐16.2%, and was distributed equally among women and men over time. Predictors for developing malnutrition were lower self‐perceived health, increased number of symptoms of depression.  Especially men with symptoms of depression ran a higher risk. Reported energy intake (IV) was low in relation to the estimated requirement, on average 74% among women and 67% among men. Intake of vitamins A, D, E and folate was below the recommended intake and the same pattern was found over time. A smaller weight loss was found among women and men from baseline to Follow‐up 2. Conclusions: The experience of a good physical health was the only common factor for a good self‐perceived health among women and men. The highest risk for developing malnutrition was a combination of impaired self‐perceived health and increased number of symptoms of depression. Clinical implications: A combination of nutritional status, self‐perceived health and symptoms of depression can be a base for clinical judgement and can be used by different professionals in ealth and medical care and in home care service.

Elderly committing suicide can be in a “preclinical phase” of dementia. Depressive symptoms may indicate a risk to develop a disease of dementia, for example Alzheimer’s Disease. Today almost 10% of the Swedish population older than 65 years suffer from a cognitive impairment diagnosed as dementia. Symptoms of dementia are associated with degenerative changes in the brain caused by a deposition of amyloid, leading among others things to a nerve cell death. A clinical diagnosis can be hard to set, and a definitive diagnose can only be set after a pathological examination, which only is possible after death. For this study we used Congo red staining of brains sections to find amyloid in autopsies from elderly people committing suicide. 35 cases (>60 year) were studied. Of the 35 cases 1/3 showed to be positive for amyloid deposition. This result in addition to other studies suggest that depressive symptoms is a “preclinical phase” of dementia, and therefore the suicide risk for this group must be consider to be elevated. However, more reliable prospective studies most be done to confirm this retrospective study.

Mental illness is a significant contributor to the global burden of disease. As public health practitioners, we must generate more than sufficient knowledge about mental health and illness in order to identify risk factors, increase awareness, improve treatment, eliminate the overall disparity associated with mental illness, and improve access to care to all affected, including those disproportionally affected by mental illness. Over time, there has been an overall lack of sufficient research studies on depression among African American women. As research in this area grows, it is critical to examine the underlying causative factors that are correlated with this disease and this population in order to provide better treatment options and a global understanding. This project will examine and analyze data obtained from the study assessment as it relates to psychosocial factors as reported by the study participants and generate a conclusion based on these findings. Additionally, this project will look to determine the help‐seeking behaviors of these women with access to a primary care physician and/or clinic. Overall, findings from this thesis project will provide an understanding of the specific psychosocial variables affecting African American women with depression and depressive symptoms, as well as provide an understanding of the help‐seeking behaviors of African American women, and contribute to the improvement of research in mental health in the United States.

Background: Type D personality, or the "distressed personality", is a psychosocial factor associated with negative health outcomes, although its impact in younger populations is unclear. The purpose of this study was to investigate the prevalence of Type D personality and the associations between Type D personality and psychosomatic symptoms and musculoskeletal pain among adolescences. Methods: A population-based, self-reported cross-sectional study conducted in Vastmanland, Sweden with a cohort of 5012 students in the age between 15-18 years old. The participants completed the anonymous questionnaire Survey of Adolescent Life in Vastmanland 2008 during class hour. Psychosomatic symptoms and musculoskeletal pain were measured through index measuring the presence of symptoms and how common they were. DS14 and its two component subscales of negative affectivity (NA) and social inhibition (SI) were measured as well. Results: There was a difference depending on sex, where 10.4% among boys and 14.6% among girls (p = < 0.001) were defined as Type D personality. Boys and girls with a Type D personality had an approximately 2-fold increased odds of musculoskeletal pain and a 5-fold increased odds of psychosomatic symptoms. The subscale NA explained most of the relationship between Type D personality and psychosomatic symptoms and musculoskeletal pain. No interaction effect of NA and SI was found. Conclusions: There was a strong association between Type D personality and both psychosomatic symptoms and musculoskeletal pain where adolescent with a type D personality reported more symptoms. The present study contributes to the mapping of the influence of Type D on psychosomatic symptoms and musculoskeletal pain among adolescents.

Evidence from clinical patient populations indicates that affective dysregulation is strongly associated with reality distortion, suggesting that a process of misassignment of emotional salience may underlie this connection. To examine this in more detail without clinical confounds, affective regulation-reality distortion relationships, and their clinical relevance, were examined in a German prospective cohort community study. A cohort of 2524 adolescents and young adults aged 14–24 years at baseline was examined by experienced psychologists. Presence of psychotic experiences and (hypo)manic and depressive symptoms was assessed at 2 time points (3.5 and up to 10 years after baseline) using the Munich-Composite International Diagnostic Interview. Associations were tested between level of affective dysregulation on the one hand and incidence of psychotic experiences, persistence of these experiences, and psychotic Impairment on the other. Most psychotic experiences occurred in a context of affective dysregulation, and bidirectional dose-response was apparent with greater level of both affective dysregulation and psychotic experiences. Persistence of psychotic experiences was progressively more likely with greater level of (hypo)manic symptoms (odds ratio [OR] trend = 1.51, P < .001) and depressive symptoms (OR trend = 1.15, P = .012). Similarly, psychotic experiences of clinical relevance were progressively more likely to occur with greater level of affective dysregulation (depressive symptoms: OR trend = 1.28, P = .002; (hypo)manic symptoms: OR trend = 1.37, P = .036). Correlated genetic liabilities underlying affective and nonaffective psychotic syndromes may be expressed as correlated dimensions in the general population. Also, affective dysregulation may contribute causally to the persistence and clinical relevance of reality distortion, possibly by facilitating a mechanism of aberrant salience attribution.

Syfte: Syftet med studien var att beskriva vilka symtom som påverkade den hälsorelaterade livskvaliteten hos svårt leversjuka patienter samt beskriva hur symtomen påverkade patientens hälsorelaterade livskvalitet. Metod: Vetenskapliga artiklar söktes i databaserna Cinahl, Ovid Medline, Pubmed och PsycINFO. 15 vetenskapliga artiklar godkändes efter kvalitetsgranskning och låg till grund för resultatet. Resultat: I litteraturstudien framkom att patienternas hälsorelaterade livskvalitet påverkades av trötthet, hjärnpåverkan orsakat av sviktande leverfunktion, vätskeansamling i kroppen, klåda, smärta, muskelkramper, symtom från mag-tarmkanalen, benskörhet samt torrhet i ögon och mun. Symtomen påverkade i olika grad den psykiska-, fysiska- och sociala hälsorelaterad livskvaliteten. Psykiskt upplevde patienterna bristande energi och motivation, försämrad sömn, koncentrationssvårigheter, försämrad självkänsla, osäkerhet, frustration, skuld, otillräcklighet, rädsla, oro, ångest, depression och självmordstankar. De fysiska följderna innebar utmattning, andnöd, ökad smärtupplevelse och begränsad förmåga till fysisk aktivitet. Besvären innebar problem att hantera relationer, gav begränsningar i det yrkesverksamma livet, inskränkning i sociala aktiviteter samt svårigheter att klara av det dagliga livet. Slutsatser: Många symtom påverkade den svårt leversjuka patientens hälsorelaterade livskvalitet. Symtomen gav patienten problem att klara av olika vardagssituationer. Den genomförda litteraturstudien ger sjuksköterskan kunskap för att kunna tolka och bedöma de symtom som patienten beskriver.

This thesis examined the factors correlated with rapid and benign progression of disease in a group of 1452 Parkinsons disease (PD) patients. The data were collected in a movement disorders clinic at the Royal University Hospital, University of Saskatchewan run by Dr. Alex Rajput and Dr. Ali Rajput. This data is a clinical dataset of PD patients collected from 1970 through to February, 2005. This was a retrospective cases-only study, with anticipated analytical follow-up if any correlations were detected between progression type of PD and the many independent variables available in the dataset. <p>Rapid progression was defined as those subjects who reached Hoehn and Yahr stage 3 within three years or H&Y stage 4 or 5 within five years. Subjects who remained in Hoehn and Yahr stage 1 or 2, ten years after onset of disease, were defined as having benign progression. The study analyzed demographic and clinical findings at first visit to this clinic associated with rapid and benign progression of PD. <p> Analysis revealed that, at first clinic visit, benign progression was positively associated with disease duration (OR=1.41; 95% CI 1.27, 1.57), male sex (OR=3.23; 95% CI 1.70, 6.16), and current smoking habit (OR=2.33; 95% CI 0.67, 8.11). Benign progression was negatively associated with older age of onset (OR=0.36; 95% CI 0.25, 0.50), past history of smoking (OR=0.46; 95% CI 0.24, 0.89), current or past use of levodopa (OR=0.45; 95% CI 0.21, 0.98), and mild to severe rigidity (OR=0.43; 95% CI 0.23, 0.80). <p>Analysis also revealed that, at first clinic visit, rapid progression was positively associated with older age of onset (OR=2.45; 95% CI 1.80, 3.33) and mild to severe rigidity (OR=1.73; 95% CI 1.02, 2.94). Rapid progression was negatively associated with disease duration (OR=0.52; 95% CI 0.44, 0.62), male sex (OR=0.58; CI 0.35, 0.95), and mild to severe resting tremor (OR=0.47; CI 0.28, 0.77). <p>The results of this study indicate that age of onset, disease duration, male sex, and rigidity are good potential predictors of disease progression in PD because they have opposite associations with rapid and benign progression. History of levodopa use was negatively associated with benign progression and as such may be good indicator of non-benign progression. Although previous studies found no predictive value for smoking history, the current study reported a unique association between smoking history and benign progression. Past smoking history was negatively associated with benign progression. While there was a positive association with current smoking history, the result was not statistically significant. Resting tremor was negatively associated with rapid progression and as such may be a good indicator of non-rapid progression. <p> Disease characteristics collected at first clinic visit are useful in predicting the course of progression of PD. With more rapid progression of PD closer and more frequent follow-up of patients may be necessary.

This thesis dissertation assessed workers who work in poultry barns and their occupational environment in relation to the type of bird housing in which they were exposed (cage-housed birds (CH) or floor-housed birds (FH)) and examined the environmental variables including dust and endotoxin and potential relationships to respiratory symptoms of workers. <p>A cross sectional study was undertaken to assess the environmental exposure levels and respiratory health effects of workers who worked in CH and FH poultry operations. The respiratory results suggested an asthma-like syndrome in these workers. Workers who worked in CH facilities reported greater current and chronic respiratory symptoms and significantly greater current and chronic phlegm as compared to workers from FH facilities. Workers from CH poultry facilities were exposed to greater endotoxin load than workers from FH facilities, but workers from FH operations were exposed to greater levels of total dust. It was found that endotoxin load (EU/mg) was a significant predictor of chronic phlegm for all poultry workers.<p>The effects on dust and endotoxin measurements when utilizing a Marple impactor with greased or ungreased impaction surfaces when sampling in an agricultural environment were unknown, and the potential for effects was tested. There were no significant differences in the aerosol mass median aerodynamic diameters between the greased and ungreased Marple impactors. Endotoxin analysis results appeared to be influenced by impaction grease particularly when very low amounts of endotoxin were present. <p>Size fractioning the dust and endotoxin using Marple impactors in CH and FH poultry operations showed that endotoxin load (EU/mg) was significantly higher in the respirable fraction of area samples in CH poultry operations as compared to FH operations. There were no differences in endotoxin load in the non-respirable size fractions for area samples between CH and FH operations. FH poultry operations had significantly greater dust mass and dust concentration in both respirable and non-respirable fractions for FH operations. There was significantly greater endotoxin load (EU/mg) in the 3.5-6.0 micron size fraction for the CH poultry operations as compared to the FH operations.