Psychache, or mental pain, is considered an independent predictor of suicide risk. Recent perspectives highlight the unbearable aspect of psychache as an imminent trigger for suicidal crisis. To assess this specific dimension, the Unbearable Psychache Scale (UP3) was developed from the original Psychache Scale (PAS). Although preliminary studies investigated UP3's psychometric properties, its discriminant validity in assessing suicide risk remains unclear. Thus, two cross-sectional studies were conducted on Italian community samples to examine the factorial structure, internal consistency, and scalability of the Italian UP3, and to compare its incremental and discriminant validity with PAS13/PAS10 in identifying individuals at risk for suicide. Study #1 (N = 707) confirmed the UP3's unidimensional structure, with good model fit, internal consistency, and scalability. In Study #2 (N = 257), the UP3 correlated moderately to strongly with PASs, depression, and suicide risk. ROC analyses indicated that UP3 achieved comparable accuracy to PAS13 and PAS10 for recent suicide risk (AUCs 0.75-0.83), but lower accuracy for lifetime suicidal ideation (AUC = 0.681) and behaviors (AUC = 0.777). Sensitivity analyses revealed that UP3 prioritized sensitivity over specificity, with low Positive Predictive Values across outcomes: PPV was 0.42 for recent suicidal ideation, and 0.21 for recent suicidal behaviors, compared with slightly higher but still limited values for PAS scales. Hierarchical models showed that UP3 did not demonstrate incremental validity over PAS13 in predicting either recent or lifetime suicide risk. The UP3 appears particularly sensitive to acute unbearable psychache, performing better in detecting recent than lifetime suicide risk. Although it does not outperform PAS scales, the UP3's brevity and focus on the intolerable component of psychache make it suitable for use alongside other measures as part of a comprehensive suicide risk evaluation in clinical or large-scale contexts.
At the end of life, patients frequently experience distressing symptoms. When they become refractory, sedating medications and palliative sedation (PS) may be used to alleviate suffering. PS is mainly practised in specialist settings, as it requires defined procedures and guidelines. Little is known, however, about how registered nurses (RNs) and healthcare assistants (HCAs) manage refractory symptoms and unbearable suffering in nursing homes and how sedating medications are used in this non-specialist setting. This study explored how RNs and HCAs in Swiss nursing homes recognise, assess, and alleviate unbearable suffering, the challenges they face, and the strategies they employ to alleviate residents' suffering by using sedating medications and PS. This qualitative study involved 22 RNs and six HCAs from nursing homes in German-speaking Switzerland. Seven semi-structured focus group interviews were conducted between October 2023 and January 2024, transcribed verbatim, and analysed using a grounded theory approach. The core category, 'Navigating palliative sedation in nursing homes - tension between alleviating suffering and over-sedating', was identified, with three subcategories: (1) recognising suffering, (2) assessing suffering, and (3) alleviating suffering. Challenges included distinguishing residents' suffering from that perceived by relatives or healthcare professionals, negotiating assessments with relatives and general practitioners (GPs), and uncertainties in the use of sedating medications - particularly morphine and midazolam. Strategies to address these challenges included 'double-checking' to validate symptom recognition, shared decision-making to 'get everyone on the same page' and align treatment goals, and the reliance on internal and external 'safety nets' (experienced colleagues and specialised palliative care services). Resource constraints such as personnel and financial resources, as well as beliefs and attitudes were reported to influence the management of unbearable suffering and the use of sedating medication. RNs and HCAs in nursing homes face complex challenges when recognising, assessing and alleviating suffering with sedating medications. Ensuring safe and ethical practice requires sufficient staffing, adequate training, clear protocols, and access to specialised palliative care support. Without sufficient expertise, interprofessional collaboration, and shared decision-making, residents risk either inadequate relief of suffering or inappropriate sedation.
Cognitive Science and its allied disciplines have now accepted diversity as a core requirement for understanding human nature in its true essence. We propose here two types of diversity mindsets that reflect distinct individual-difference attributes or personality types specifically linked to bilingualism and its adaptability. We conceptualize diversity as one's past and current "immersive" strategies in any society, both as an individual and a member of a collective, with distinct practices, cognitive strategies, language behavior, and even consciousness. The two types are "broad" and "narrow," defined by a person's adaptive competence in linguistic, social, cognitive, emotional, and cultural life. In our framework, variables such as language proficiency, educational background, occupational and socioeconomic status, and ethnocultural background interact to modulate diversity mindsets. The framework predicts experimental outcomes in a wide range of tasks for individuals identified as either "broad" or "narrow" in their diversity mindset type. We draw from evolutionary psychology, cultural neuroscience, current theories of psycholinguistics, and cognitive science to argue that it is not enough to include the non-WEIRD (Western, Educated, Industrialized, Rich, and Democratic) populations into research designs, but it is critical to study how individuals in different cultures adapt to diversity given their own cognitive, linguistic, and social constraints. Our framework explains how people with these diversity mindsets automatically stratify themselves into distinct groups and engage in distinct cognitive processes that influences bi-multilingualism in any context.
Hyperactive delirium in neurological wards frequently results in patient harm, falls, device removal, and caregiver injuries, alongside significant staff burnout. To address inconsistent management practices, we developed the Prevention of Unbearable Situations and Harms (PUSH) protocol, a structured multidisciplinary approach to proactively manage hyperactive delirium. This study evaluated the effectiveness of the PUSH protocol in reducing delirium-related adverse events (primary outcome), and improving clinical workflow, staff burnout, and satisfaction (secondary outcomes). We conducted a pre-post study in three phases: pre-implementation (November 2021-May 2022), pilot testing (June-August 2022), and post-implementation (September 2022-March 2023). The PUSH protocol includes Standard Care (routine delirium prevention), Preparation (anticipatory medication planning for patients at risk, Nursing Delirium Screening Scale ≥2), and Action (rapid response for escalating delirium) phases. Outcomes included delirium rates, hyperactive delirium episodes, adverse event incidence, medication response times, and staff burnout and satisfaction surveys. We compared pre- and post-implementation data using Poisson regression. Among 2,457 patients, 174 developed delirium during 2,958 observed person-days. Unbearable situations or harms decreased from 5.6 to 4.2 events per 100 person-days, with a fully adjusted incidence rate ratio of 0.539 (95% confidence interval: 0.368-0.788, p=0.001). Response times to sedative medication administration improved markedly (16 to 0 min; p<0.001). Staff burnout significantly decreased (32 to 27; p<0.001), and satisfaction notably increased (3 to 4; p=0.009). The PUSH protocol significantly reduced delirium-related harms, enhanced clinical workflow efficiency, decreased staff burnout, and increased satisfaction, supporting its broader implementation in neurological settings.
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This commentary commends Evers et al.'s multidimensional heuristic for structuring artificial consciousness research while arguing it cannot, as stated, adjudicate the nomological possibility of phenomenal consciousness, which is at stake in current debates. Behavioral-cognitive "profiles" lack a justified principle linking function to experience, and the awareness case study illustrates how externally specified goals can just as well underwrite as-if (pseudo-intentional) control rather than original intentionality. Moreover, the proposed heuristic overlooks that substrate similarity is currently indispensable for justifiably inferring the presence of consciousness beyond the validated case of the adult human brain. Given all this, the framework seems to provide a blueprint for building a more sophisticated philosophical zombie; it does not-and cannot-tell us whether anyone is there.
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Since the enactment of Belgium's euthanasia law in 2002, clinical psychologists have played an increasingly significant role in the multidisciplinary approach to euthanasia, particularly regarding cases involving unbearable mental suffering (UMS euthanasia). This cross-sectional study examined the attitudes, roles, and competencies of clinical psychologists in Flanders concerning UMS euthanasia using an online questionnaire (n = 242). The survey explored attitudes towards UMS euthanasia, as well as self-perceived competencies and involvement. Results indicate that most psychologists hold a generally positive stance towards UMS euthanasia and believe in supporting patient requests under appropriate conditions. Their roles are seen as essential in decision-making, exploring alternatives, and providing aftercare for families, though opinions vary about their involvement during the actual procedure. Demographic factors such as age, gender, work setting, and prior involvement in euthanasia showed no significant influence on attitudes; however, greater knowledge and skills were reported among those in specialized settings, palliative care, or with prior euthanasia involvement. A pronounced lack of training and education in this area was reported, highlighting the need for targeted measures. The findings underscore the necessity of clarifying psychologists' roles, expanding legal guidelines, and improving training to enhance care quality in the context of UMS euthanasia.
The concept of the unconscious is at the heart of psychoanalytic study and practice since its beginnings. A human being's awareness is bounded, and the deeper layers of the mind are mostly inaccessible. Sensations, emotions, dreams, symptoms or creative work may give us a glimpse of the landscape and mediate our relationship with the forgotten, the unknown and the unknowable. The mind has its ways to remain organized and balanced through the development of barriers or shields. However, overwhelming emotional experiences may break through and confront us with the unbounded, infinite and chaotic nature of the unconscious. Resorting to Matte-Blanco's bi-logical theory, this paper aims to explore the effects of trauma on the mind, both as a disruption of psychic barriers and as an unbearable emotional experience of infinity within.
[This corrects the article DOI: 10.3389/fpsyg.2025.1720110.].
This study explored how smiles and laughter unfolded in five psychotherapy training processes, comprising two psychodynamic, two metacognitive, and one integrative. Using a multimodal approach, video observations from naturalistic therapy and supervision sessions served as a springboard for Interpersonal Process Recall interviews with therapists, clients, and supervisors. Transcripts from supervision sessions and interviews were analyzed with Reflexive Thematic Analysis. The analysis yielded four themes: 1. Smiles and laughter sometimes served to strengthen the therapeutic alliance, while at other times they functioned as emotion-regulating strategies or carried profound personal significance; 2. The therapists intuitively tended to downregulate their responses to clients' expressions of laughter, to modulate and contain the clients' underlying emotions; 3. The way therapists handled laughter and smiles in the therapeutic setting seemed to be related to their degree of security and the quality of the therapeutic relationship; and 4. In supervision, smiles and laughter were not explicitly addressed as a distinct theme but occasionally surfaced spontaneously during sessions. By showing how clinical practice unfolds on observable and inferred emotional levels, the study highlights the importance of empirical grounding and the difficulty of verbalizing subtle nonverbal processes.
Although the issue of medical-assisted dying or medical aid in dying (MAID, euthanasia, and medical-assisted suicide) has a long history, it has become an increasingly important topic in recent years. Around the world, many governments remain opposed to MAID. In places where MAID is legally permitted, it is highly regulated, and typically, unbearable suffering limited to a few serious and incurable medical conditions determines eligibility. MAID eligibility based on unbearable suffering but limited to a few medical conditions is unfair because suffering is inescapable in life, is not limited to medical conditions, and is highly subjective. Indeed, the subjectivity and individual differences in the experience of pain and suffering make it inaccurate to suggest that suffering is lesser for a person dealing with trigeminal neuralgia, extreme poverty, treatment-resistant depression, or the grief of losing a loved one compared to someone with a MAID-eligible condition. The subjectivity and individual differences in the experience of suffering mean that its intolerability can only be fairly defined by the individual experiencing it. So, the use of a third party (e.g., a physician) to evaluate severity, burdensomeness, or prognosis in determining MAID eligibility unfairly restricts people suffering who may not meet the clinical or physician's threshold of intolerability. Also, suffering is often imposed on humans by forces outside their control, making denying the right to exit suffering with dignity through MAID unfair. In this position paper, an argument is made for MAID to be made broadly legal without age limits and available to anyone who requests it based on patient-defined unbearable suffering or fear of future suffering.
Suicide stigma is a multifaceted social issue with far-reaching consequences for mental health. While previous research has linked it to suicidal thoughts and behaviors (STBs), the roles of perceived and internalized forms of suicide stigma in influencing STBs remain unclear. This study investigated the potential causal relationships between perceived and internalized suicide stigma, hopelessness, unbearable pain, and thwarted connectedness in relation to STBs among 546 Chinese college students (mean age = 20.92 years). Three-wave longitudinal data with a time gap of roughly 3 months were analyzed by using structural equation modeling. The results showed that the second-wave internalized stigma mediated the relationship between baseline perceived stigma and the third-wave unbearable pain, hopelessness, and thwarted connectedness, which are considered risk factors of STBs. Furthermore, the coexistence of unbearable pain and hopelessness, and the coexistence of unbearable pain and connectedness mediated the influences of perceived and internalized suicide stigma on STBs. These findings demonstrated that the temporal evolution of perceived and internalized suicide stigma contributes to risk factors predicting STBs.
Suicidal ideation (SI) is interpreted through a biomedical lens across health care systems, framing it as a pathology requiring treatment and leading to approaches aimed at controlling or eliminating these thoughts. Within this dominant medical model, illness treatment and death prevention are prioritized, eclipsing attention to health and well-being. Our previous research shows that women make efforts to improve their health despite living with SI. Using a feminist grounded theory approach, we sought to understand how women with SI manage their health. Data from interviews with 32 Canadian women were analyzed using the constant comparative method, elevating the data to a higher level of abstraction. We found that women with SI manage health by making room to be OK, creating space within their environments that allows them to better manage unbearable psychological pain. Making room to be OK becomes possible through acceptance, social recognition that ending unbearable psychological pain is a legitimate health need. Approaches critical to helping women make room to be OK include offering spaces within healthcare and community settings where SI can be discussed without pressure to think or feel otherwise. These trauma- and violence-informed approaches diverge from dominant medical services that seek to control women's suicidality.
Cardioversion (CV) is commonly used in the emergency department (ED) to treat recent-onset atrial fibrillation (AF) or flutter (AFL). The AFFELECT trial (NCT04267159) is an investigator-initiated, prospective, unblinded randomized controlled non-inferiority trial comparing experimental delayed rhythm control (elective CV performed within 5-9 days after the index visit) to standard acute rhythm control (CV performed in ED) in patients with recent-onset (duration <48 h) symptomatic AF/AFL suitable for rhythm control. A total of 500 patients are randomized in a 2:3 ratio to the acute and delayed groups, respectively, accounting for a possible one-third unplanned early CV rate in the delayed group due to higher symptom burden. Unplanned early CV means that patients with unbearable symptoms are offered the option for an earlier CV (before the 5-9 days target timeline) if needed. Patients randomized to delayed group are discharged immediately after adequate heart rate control (heart rate <110 bpm) and anticoagulation and are scheduled an appointment for delayed CV at a cardiology outpatient clinic (in transoesophageal echocardiography guidance if required). Patients randomized to acute CV undergo cardioversion in the ED within 48 h of arrhythmia onset and are assigned to a cardiologic outpatient clinic visit also within 5-9 days. The primary end-point is the presence of sinus rhythm on electrocardiogram at 4 weeks after the outpatient clinic visit. The AFFELECT trial tests whether delayed management of recent-onset AF/AFL is a non-inferior alternative to acute CV, aiming to reduce ED burden, number of needed CVs, and redirect care to specialized arrhythmia units.
Psychic pain (PsyPn) refers to intense emotional suffering that is experienced as both unbearable and irreversible. PsyPn has been shown in cross-sectional studies to be associated with greater depression, distress, and suicide risk. Although PsyPn is frequently discussed as a primary driver of suicide, few studies have evaluated its short-term predictive value for detecting changes in risk, and few have examined how PsyPn influences risk in interaction with other established factors, such as hopelessness. To address these gaps, the current study utilized ecological momentary assessment (EMA) to identify links between PsyPn, well-established psychosocial risk factors for suicide (hopelessness, loneliness, and burdensomeness), and the short-term emergence of suicidal ideation (SI) and planning. Thirty-nine adults across three clinical sites enrolled in the study after being identified during prescreen as being at elevated suicide risk. Subjects completed a baseline measure of vulnerability to PsyPn (Psychic Pain Scale), followed by an EMA protocol evaluating negative mental states, PsyPn, and SI and planning six times daily over a 14-day period. Multilevel modeling was used to estimate both within-and between-person associations between PsyPn, negative mental states, and SI and planning. Across suicide-related outcomes and timescales, PsyPn was associated with increased suicide risk, and greater PsyPn at both baseline and near-term levels amplified the influence of other daily living risk factors on suicide-related outcomes. The implications of these findings for suicide risk assessment and intervention are discussed, particularly in terms of informing specific targets and timescales of interventions.
Cancer in children and adolescents is frequently associated with pain, which is one of the most common and distressing symptoms reported by patients. Effective pain management remains a major concern for healthcare teams. Despite the availability of national and international pain management protocols since the mid-1980s, challenges persist in the assessment, treatment, and follow-up of pediatric patients. There is a lack of studies evaluating the most appropriate type and dosage of analgesics to achieve adequate pain control in pediatric oncology settings. The objective of this work was to assess the effectiveness of selected analgesics based on pain intensity and anatomical location in pediatric cancer patients. This pharmacoepidemiological study was conducted in a pediatric oncology hospital and included patients aged between 0 and 17 years with cancer who received analgesic drugs. Information regarding cancer diagnosis, hospitalization diagnosis, analgesic scale, pain intensity before and after drug administration, and pain site were collected from medical records. A total of 1,465 episodes of pain from 335 patients were analyzed, most of them in patients diagnosed with leukemia (30.1%). We included 576 episodes of pain treated with dipyrone or morphine, occurring in the abdomen (n = 283), head (n = 155), and lower limbs (n = 138). The final pain scores indicated pharmacological effectiveness in all patient subgroups. When pain was mild to moderate, dipyrone was the most commonly used drug: 105 (65.2%) episodes of pain that occurred in the abdomen, 93 (86.9%) in the head, and 50 (64.1%) in the lower limbs. However, when the pain was severe to unbearable, morphine was the most commonly used drug: 79 (64.7%) episodes in the abdomen and 36 (60.6%) in the lower limbs, except when the pain occurred in the head (17 episodes of pain, 35.4%). The use of dipyrone and morphine, guided by pain intensities and locations, demonstrated effectiveness. These findings support the tailored use of analgesics according to pain characteristics to optimize symptom control in pediatric oncology patients.
Benign paroxysmal positional vertigo (BPPV) is a common vestibular disorder characterized by brief vertigo episodes. It often leads to functional limitations, psychological distress, and fear of recurrence. The purpose of this phenomenological study was to gain a deep understanding of the lived experiences of patients with BPPV. Participants were initially recruited through convenience sampling at a BPPV specialist clinic, with additional participants identified via snowball sampling. Data were gathered through individual, in-depth interviews. A central theme, "Reconstructing meaning in the face of an unpredictable illness," captured patients' transformative journey from shock and confusion to adaptation and renewed self-awareness. Six themes emerged from data: "Shock and confusion from unexpected illness," "Unbearable symptoms affecting daily life," "Persistent anxiety about recurrence leading to emotional fatigue," "Heightened health awareness following the illness experience," "Disappointment with treatment support and efforts to seek alternatives independently," and "Empathy from others and support from family as emotional anchors." Patients with BPPV experienced fear and dread of recurrence, while simultaneously struggling to develop their own coping strategies to address unresolved questions and concerns. Recognizing this need can help identify areas requiring professional intervention. Although the symptoms and fears associated with BPPV may be underestimated due to the perceived mildness of the condition, the impact of BPPV on patients' overall well-being is significant. Patients and the public were not directly involved in the design or conduct of this study. However, the research was grounded in the lived experiences of individuals with BPPV, whose narratives were central to shaping the research questions and analysis. Their perspectives provided valuable insights into the physical, emotional, and social impacts of BPPV, ensuring that the findings reflect issues most relevant to those affected and guiding potential directions for future patient-centered nursing.
Vision Transformer (ViT) applied to structural magnetic resonance images has demonstrated success in the diagnosis of Alzheimer's disease (AD) and mild cognitive impairment (MCI). However, three key challenges have yet to be well addressed: 1) ViT requires a large labeled dataset to mitigate overfitting while most of the current AD-related sMRI data fall short in the sample sizes. 2) ViT neglects the within-patch feature learning, e.g., local brain atrophy, which is crucial for AD diagnosis. 3) While ViT can enhance capturing local features by reducing the patch size and increasing the number of patches, the computational complexity of ViT quadratically increases with the number of patches with unbearable overhead. To this end, this paper proposes a 3D-convolutional neural network (CNN) Enhanced Multiscale Progressive ViT (3D-CNN-MPVT). First, a 3D-CNN is pre-trained on sMRI data to extract detailed local image features and alleviate overfitting. Second, an MPVT module is proposed with an inner CNN module to explicitly characterize the within-patch interactions that are conducive to AD diagnosis. Third, a stitch operation is proposed to merge cross-patch features and progressively reduce the number of patches. The inner CNN alongside the stitch operation in the MPTV module enhances local feature characterization while mitigating computational costs. Evaluations using the Alzheimer's Disease Neuroimaging Initiative dataset with 6610 scans and the Open Access Series of Imaging Studies-3 with 1866 scans demonstrated its superior performance. With minimal preprocessing, our approach achieved an impressive 90% accuracy and 80% in AD classification and MCI conversion prediction, surpassing recent baselines.