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.
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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.
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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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.
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.
The study aims to determine the experiences of patients who suffer from post-burn pruritus and to evaluate the effect of pruritus on their quality of life. The research employed a mixed-methods approach, combining both quantitative and qualitative methods. The study was carried out at the burn center of a city hospital in Istanbul. Individuals aged 18 and over who suffered burns after April 15, 2019, and continued to experience pruritus complaints were included in the study. A total of 120 patients were included in the quantitative phase of the study. Data for the quantitative phase were collected using the Patient Information Form, the Pruritus Information Collection Form, the 12-Item Pruritus Severity Scale, and the Burn-Specific Health Scale between July 2019 and March 2020. The qualitative phase was conducted between August 2019 and February 2020, concurrently with the collection of quantitative data. In the qualitative phase, in-depth face-to-face interviews were carried out with 11 individuals using a Semi-Structured Interview Form. It was determined that the patients experienced pruritus ranging from mild to severe (3.00-19.00), with the average pruritus score indicating moderate severity (8.91 ± 3.90). Significant differences were found between groups in terms of pruritus severity based on length of hospital stay, depth of burn, total body surface area burned, burned body region, and the presence of grafts (p < 0.05). In the in-depth interviews, it was found that burn patients struggled to cope with pruritus, that pruritus had an impact on their daily and family lives, and that it had physical, social, and psychological effects. Additionally, patients reported experiences related to the treatment of pruritus. This study demonstrated that as the severity, distribution, and persistence of pruritus increased, it was perceived by patients as an unbearable symptom; and that pruritus is a significant factor reducing the quality of life in burn patients. It is suggested that the proper evaluation of pruritus using objective measurement tools, the development of appropriate protocols for the treatment and follow-up of post-burn pruritus, and providing education and counseling services to help burn patients cope with pruritus could improve the quality of life for burn patients experiencing pruritus.
In 2024, a Bill "On Palliative Care, End-of-Life Decision-Making and Euthanasia" was submitted to the Czech Parliament for consideration. This article evaluates the Bill through doctrinal and ethico-legal analysis and a comparative perspective centred on Belgium, whose model influenced the Czech proposal. The Bill is unusual in combining, within one statute, conventional end-of-life practices - palliative care, withholding or withdrawal of life-sustaining treatment, and palliative sedation - and "assisted death", covering euthanasia and physician-assisted suicide. With regard to conventional practices, the Bill gives legal form to a right to palliative care, introduces "medically inadequate treatment" as the threshold for limiting life-sustaining interventions, and embeds procedural safeguards (information, participation, mediation by an ethics committee, and judicial review) intended to enhance transparency, patient autonomy, and legal certainty for clinicians. With regard to assisted death, the proposal sets out eligibility criteria (adult legal competence, voluntariness, an incurable and irreversible illness, and permanent and unbearable suffering without any prospect of improvement) and a staged procedure: a preliminary request, independent consultation, a qualified written request, final verification immediately before the act, and mandatory ex post review by a commission based on a non-anonymous report. This article shows that the Czech Bill represents a serious and coherent attempt to bring end-of-life regulation in the Czech Republic into conformity with the human-rights standards developed in the case law of the ECtHR. It also advances several de lege ferenda recommendations that seek to synthesise the strengths of the Czech Bill and the Belgian model while avoiding identified shortcomings. These recommendations aim to ensure that any European end-of-life framework remains firmly anchored in human-rights requirements, while also taking into account the practical realities of clinical decision-making and the accumulated legal experience of European states that have already introduced forms of assisted death.
This paper explores Freud's concept of unconscious guilt (Freud, S. 1923. "The Ego and the Id". In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 19. 1-66), as illuminated in Sebald's masterpiece, Austerlitz (Sebald, W. G. 2001. Austerlitz, Translated by Anthea Bell. London: Penguin Books). Both writers examine the human impulse to look away from suffering, personal and collective, and the guilt inherent both in avoidance and in bearing witness. Sebald, preoccupied with Germany's post-war "self-amnesia" (Sebald, W. G. 2003. On the Natural History of Destruction, Translated by Anthea Bell. New York: Random House, p. 11), invoked Medusa's head to symbolise the terrors of confronting trauma, and his novel illuminates both the compulsion to see and the terror of doing so. Austerlitz's gradual uncovering of his past mirrors the analytic process, where unconscious guilt intensifies the dread of facing unbearable truths. A clinical example illustrates unconscious guilt in the countertransference, where a patient's pain provoked an impulse to turn away. The paper suggests psychic truths can emerge through the slowing of muscular psychic states and through sustained contact with an analyst who can bear painful projections and retain compassion in the face of guilt.
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.
Throughout history, end-of-life has posed profound ethical and emotional challenges. Today, the growing desire for control has led to two interconnected phenomena: death tourism and palliative care. Hopelessness and loss of control drive some patients to seek euthanasia or physician-assisted suicide abroad, especially where these practices are illegal in their home countries. For them, this difficult decision represents reclaiming agency in the face of unbearable suffering. In contrast, palliative care provides an alternative focused on improving quality of life for patients with life-threatening illnesses and their families. Its holistic approach-addressing physical, psychological, social, and spiritual needs-ensures dignity, comfort, and support. Expanding access to comprehensive palliative services can significantly reduce feelings of despair and diminish the demand for death tourism. By fostering a sense of being valued and supported, palliative care helps individuals face their final stages with meaning rather than fear. This underscores the critical role of nurses, whose professional preparedness is essential in addressing global ethical dilemmas and disseminating palliative practices effectively. Ultimately, the solution to protecting human dignity lies not in hastening death, but in alleviating suffering so that life, even in its final chapter, remains meaningful..