This article introduces the concept of 'cognitive comorbidity,' which lays emphasis on common cognitive deficits that cut across different disorders. The concept is illustrated with the help of two commonly reported overlapping conditions (autism and epilepsy). It is further explained by concentrating on two important cognitive processes of facial emotional recognition and emotional memory, shown to be compromised in both conditions; and their underlying neural substrates. Cognitive comorbidity is then contrasted with 'comorbidity,' a (...) term which is more commonly used for describing cognitive disorders. The paper closes by providing directions for rehabilitative and theoretical efforts that could be inspired by the newly introduced concept. (shrink)

We agree with Cramer et al. that pure cases of behavioral disorders with no symptom overlaps are rare. However, we argue that disorders do exist and the network idea is limited and limiting. Networks of symptoms are observed mainly at behavioral levels. The core deficit is commonly at the cognitive or brain levels, and there the story is completely different.

There is a high prevalence of comorbidity between neurodevelopmental disorders. Contemporary research of these comorbidities has led to the development of multifactorial theories of causation, including the multiple deficit model. While several combinations of disorders have been investigated, the nature of association between literacy and motor disorders remains poorly understood. Comorbid literacy and motor disorders were the focus of the two present studies. In Study 1, we examined the prevalence of comorbid literacy and motor difficulties relative to isolated literacy (...) and motor difficulties in a community sample. The prevalence of comorbidity was five times greater than expected by chance alone, implying some relationship between difficulties. In Study 2, we examined the cognitive profiles of children with literacy and motor disorders amongst a subsample of children from Study 1. Children with literacy disorder had deficits in phonological processing, selective attention, and memory whilst children with motor disorder had deficits in visuospatial processing and memory, suggesting the disorders should be considered to have both independent and shared cognitive risk factors. Children with comorbid literacy and motor disorder demonstrated an additive combination of these deficits. Together, these findings are consistent with predictions from the MDM. (shrink)

ObjectivesTo document the auditory processing, visual attention, digit memory, phonological processing, and receptive language abilities of individual children with identified word reading difficulties.DesignTwenty-four children with word reading difficulties and 28 control children with good word reading skills participated. All children were aged between 8 and 11 years, with normal hearing sensitivity and typical non-verbal intelligence. Both groups of children completed a test battery designed to assess their auditory processing, visual attention, digit memory, phonological processing, and receptive language.ResultsWhen compared to children (...) who were good readers, children with word reading difficulties obtained significantly lower average scores on tests of auditory processing, including the frequency pattern test, gaps in noise, frequency discrimination, Dichotic Digit difference Test, and Listening in Spatialized Noise. The two groups did not differ on the discrimination measures of sinusoidal amplitude modulation or iterated rippled noise. The results from children with word reading difficulties showed that 5 children (21%) had comorbid deficits in auditory processing, visual attention, and backward digit memory; whereas 12 children (50%) had comorbid auditory processing and visual attention deficits only, and 2 children (8%) had comorbid deficits in auditory processing and digit memory; the remaining children had only auditory processing, visual attention, or digit memory deficits.ConclusionThe current study highlights the general co-existence of auditory processing, memory, and visual attention deficits in children with word reading difficulties. It is also noteworthy, however, that only one fifth of the current cohort had deficits across all measured tasks. Hence, our results also show the significant individual variability inherent in children with word reading difficulties. (shrink)

Applying a necessary condition communication theory formalism roughly similar to that of Dretske, but focused entirely on the statistical properties of long sequences of signals emitted by the interacting cognitive modules of human biology, we explore the regularities apparent in comorbid psychiatric and chronic physical disorders using an extension of recent perspectives on autoimmune disease. We find that structured psychosocial stress can literally write a distorted image of itself onto child development, resulting in a life course trajectory to characteristic (...) forms of comorbid mind/body dysfunction affecting both dominant and subordinate populations within a pathogenic social hierarchy. (shrink)

The comorbidity of chronic pain and opioid addiction is a serious problem that has been growing with the practice of prescribing opioids for chronic pain. Neuroimaging research has shown that chronic pain and opioid dependence both affect brain structure and function, but this is the first study to evaluate the neurophysiological alterations in patients with comorbid chronic pain and addiction. Eighteen participants with chronic low back pain and opioid addiction were compared with eighteen age- and sex-matched healthy individuals in (...) a pain-induction fMRI task. Unified structural equation modeling (SEM) with Lagrange multiplier (LM) testing yielded a network model of pain processing for patient and control groups based on 19 a priori defined regions. Tests of differences between groups on specific regression parameters were determined on a path-by-path basis using z-tests corrected for the number of comparisons. Patients with the chronic pain and addiction comorbidity had increased connection strengths; many of these connections were interhemispheric and spanned regions involved in sensory, affective, and cognitive processes. The affected regions included those that are commonly altered in chronic pain or addiction alone, indicating that this comorbidity manifests with neurological symptoms of both disorders. Understanding the neural mechanisms involved in the comorbidity is crucial to finding a comprehensive treatment, rather than treating the symptoms individually. (shrink)

We suggest that the network approach to comorbidity (Cramer et al.) is best examined by using longitudinal, multi-measurement, intra-individual data. Employment of time-series analysis to the examination of the generalized anxiety disorder and major depressive disorder comorbidity enables a detailed appreciation of fluctuations and causal trajectories in terms of both symptoms and cognitive vulnerability.

ABSTRACTAnxious individuals report disproportionately negative expectations concerning the future, termed the negative expectancy bias. In contrast, ageing is associated with an inflated expectancy for positive future events. A recent study [Steinman, S. A., Smyth, F. L., Bucks, R. S., MacLeod, C., & Teachman, B. A.. Anxiety-linked expectancy bias across the adult lifespan. Cognition and Emotion, 27, 345–355. doi:10.1080/02699931.2012.711743] found using an interpretation bias task, a negative expectancy bias in young adults and positive expectancy bias in older adults with high trait (...) anxiety. Extending this, the current study examined expectancy bias for positive, negative and ambiguously emotionally toned information in younger and older adults with clinical levels of depression and anxiety to community control groups, thus allowing examination of both disorder status and age on biases. Clinical participants reported a pervasive tendency to expect negative events relative to positive regardless o... (shrink)

The literature on brain activity in depression and anxiety is reviewed with an on highlighting discrepancies and inconsistencies. In particular, and posterior asymmetries have been reported for both depression anxiety, but the magnitude and direction of these asymmetries has been We propose that by identifying subtypes of depression and anxiety of these inconsistencies can be explained. In addition, we review suggesting that issues of comorbidity are important to consider in to account for regional brain activity in depression and anxiety.

Patients with insomnia complain of problems with sleep onset or sleep maintenance or early morning awakenings, or a combination of these, despite adequate opportunity and circumstances for sleep. In addition, to fulfill the diagnostic criteria for insomnia the complaints need to be associated with negative daytime consequences. For chronic insomnia, the symptoms are required to be present at least 3 days per week for a duration of at least 3 months. Lastly, for insomnia to be defined as a disorder, the (...) sleep complaints and daytime symptoms should not be better explained by another sleep disorder. This criterion represents a diagnostic challenge, since patients suffering from other sleep disorders often complain of insomnia symptoms. For instance, insomnia symptoms are common in e.g., obstructive sleep apnea and circadian rhythm sleep-wake disorders. It may sometimes be difficult to disentangle whether the patient suffers from insomnia disorder or whether the insomnia symptoms are purely due to another sleep disorder. Furthermore, insomnia disorder may be comorbid with other sleep disorders in some patients, e.g., comorbid insomnia and sleep apnea. In addition, insomnia disorder is often comorbid with psychological or somatic disorders and diseases. Thus, a thorough assessment is necessary for correct diagnostics. For chronic insomnia disorder, treatment-of-choice is cognitive behavioral therapy, and such treatment is also effective when the insomnia disorder appears comorbid with other diagnoses. Furthermore, studies suggest that insomnia is a heterogenic disorder with many different phenotypes or subtypes. Different insomnia subtypes may respond differently to treatment, but more research on this issue is warranted. Also, the role of comorbidity on treatment outcome is understudied. This review is part of a Research Topic on insomnia launched by Frontiers and focuses on diagnostic and treatment challenges of the disorder. The review aims to stimulate to more research into the bidirectional associations and interactions between insomnia disorder and other sleep, psychological, and somatic disorders/diseases. (shrink)

BackgroundCognitive Behavioral Therapy is delivered in most of the early intervention services for psychosis in different countries around the world. This approach has been demonstrated to be effective in decreasing or at least delaying the onset of psychosis. However, none of them directly affect the comorbidity of these types of patients that is often the main cause of distress and dysfunctionality. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders is a psychological intervention that combines cognitive-behavioral and (...) third-generation techniques that address emotional dysregulation as an underlying mechanism that these disorders have in common. The application of this intervention could improve the comorbid emotional symptoms of these patients.Materials and methodsThe study is a randomized controlled trial in which one group receives immediate UP plus standard intervention and the other is placed on a waiting list to receive UP 7 months later, in addition to standard care in one of our early psychosis programs. The sample will be 42 patients with UHR for psychosis with comorbid emotional symptoms. The assessment is performed at baseline, at the end of treatment, and at 3-months’ follow-up, and includes: general psychopathology, anxiety and depression, positive and negative emotions, emotional dysregulation, personality, functionality, quality of life, cognitive distortions, insight, and satisfaction with the UP intervention.DiscussionThis will be the first study of the efficacy, acceptability, and viability of the UP in a sample of young adults with UHR. The results of this study may have clinical implications, contributing to improving the model of care for young people who consult for underlying psychotic, anxiety, and/or depressive symptoms that can lead to high distress and dysfunctionality.Clinical trial registration[https://clinicaltrials.gov/], identifier [NCT04929938]. (shrink)

BackgroundResearch on prevalence of cognitive frailty phenotypes in community-dwelling older adults in different countries is important to estimate their prevalence and to determine the influence of cognitive reserve and mental health in order to prevent frailty. The aims of this study were to estimate the prevalence of reversible and potentially reversible cognitive frailty in a Portuguese sample of old adults and explore the associations between these phenotypes and demographic, comorbidity, social support, cognitive reserve and mental (...) health factors.MethodsWe assessed frailty in 250 community-dwelling older adults aged 60 years or over without dementia, neurological or psychiatric disorders. Subjective cognitive decline and Mild cognitive impairment were diagnosed according to standard criteria. The questionnaires Charlson Index, Medical Outcomes Study Social Support, Cognitive Reserve Index and General Health were used for assessing comorbidity, social support, cognitive reserve and mental health, respectively.ResultsPrevalence of R-CF was 14%, and that of PR-CF, 15.2%. Cognitive frailty profiles differed significantly in relation to education, comorbidity, mental health, and cognitive reserve, but not in age or sex. Multivariate logistic regression showed that age, sex, comorbidity, social support, mental health, and cognitive reserve together predicted R-CF and PR-CF with significant OR for mental health and cognitive reserve.DiscussionCognitive reserve and mental health are important factors predicting R-CF and PR-CF. We recommend assessing these factors for early detection of cognitive frailty and promoting psychological well-being and lifestyles that increase cognitive reserve in adults. (shrink)

The goal of the present study was to investigate whether children’s cognitive strengths can compensate the accompanied weaknesses related to their specific learning difficulties. A Bayesian multigroup mediation SEM analysis in 281 fourth-grade children identified a cognitive compensatory mechanism in children with mathematical learning difficulties : Children with weak number sense, but strong rapid naming performed slightly better on mathematics compared to peers with weak rapid naming. In contrast, a compensatory mechanism was not identified for children with a (...) comorbid mathematical and reading difficulty. One explanation for the latter finding could relate to the lack of ability to compensate, because of the difficulties these children experience in both academic domains. These findings lead to a new direction in research on learning difficulties in mathematics and/or reading by suggesting that children with a learning disability each have a unique profile of interrelated cognitive strengths and weaknesses. Children might compensate with these strengths for their weaknesses, which could lead to learning gains in the affected domain. (shrink)

Opioid use disorder can encompass a number of behavioral, psychological, physiological, and interpersonal symptoms which collectively impair one’s functioning to different degrees. Of all the personal and societal problems associated with OUD, the most destructive and absolute is death. Given the caustic effects of OUD on quality of life and mortality, evidence-based pharmacotherapy and psychosocial interventions are necessary. It is the collective potential for buprenorphine to increase safety and concurrent cognitive-behavioral group therapy to address substance use triggers as well (...) as comorbid psychiatric conditions, which makes this combination particularly promising for RCT of effectiveness. The purposes of this article are to identify specific ethical issues which may hinder community partners from collaborating with clinical trialist wishing to conduct CBGT buprenorphine efficacy-effectiveness trials at their agency and provide some basic guidelines and methods for addressing these community partner ethical concerns. The purpose of the manuscript is to facilitate university and substance use/mental health center community collaborations that will result in ethical clinical trial methodology and findings that meaningfully translate to efficacious, effective, and generalizable CBGT and buprenorphine hybrid interventions for OUD. (shrink)

Generalized anxiety disorder (GAD) and social phobia (SP) are major anxiety disorders identified by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). They are comorbid, overlap in symptoms, yet present with distinct features (worry in GAD and fear of embarrassment in SP). Both have also been explained in terms of conditioning-based models. However, there is little reasoning currently to believe that GAD in adulthood reflects heightened conditionability or heightened threat processing—though patients with SP may show heightened processing (...) of social threat stimuli. Moreover, the computational architectures that maintain these disorders in adulthood are different. For GAD this may reflect the development of an inefficient “worrying” strategy of emotional regulation. For SP this appears to reflect the atypical processing of self-referential information. (shrink)

It is estimated that one in ten U.S. adults suffers from chronic insomnia. If left untreated, chronic insomnia reduces quality of life and increases risk for psychiatric and medical disease, especially depression and anxiety. There are two forms of insomnia: secondary insomnia, in which it is comorbid with another condition such as psychiatric disorders, chronic pain conditions, or cardiopulmonary disorders, and primary insomnia, which does not coexist with any other disorder. This treatment program uses cognitive-behavioral therapy methods to correct (...) poor sleep habits. CBT has been proven in multiple studies to improve sleep hygiene by reducing time spent in bed before sleep onset, reducing time spent awake after first sleep onset, and increasing the quality and efficiency of sleep. Developed by the authors, this evidence based treatment can be used for both primary and secondary insomnia sufferers. Patients are first given information about healthy sleep and the reasons for improving sleep habits, then a behavioral program is developed to address that patient's specific sleep problems. Use of sleep logs, assessment forms, and other homework allows client and therapist to work together to develop an effective sleep regimen tailored specifically for each client. Finally, several sessions are dedicated to increasing compliance and problem-solving.TreatmentsThatWork represents the gold standard of behavioral healthcare interventions!BL All programs have been rigorously tested in clinical trials and are backed by years of researchBL A prestigious scientific advisory board, led by series Editor-In-Chief David H. Barlow, reviews and evaluates each intervention to ensure that it meets the highest standard of evidence so you can be confident that you are using the most effective treatment available to dateBL Our books are reliable and effective and make it easy for you to provide your clients with the best care availableBL Our corresponding workbooks contain psychoeducational information, forms and worksheets, and homework assignments to keep clients engaged and motivatedBL A companion website offers downloadable clinical tools and helpful resourcesBL Continuing Education Credits are now available on select titles in collaboration with PsychoEducational Resources, Inc. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reifying Relevance in Mild Cognitive Impairment:An Appeal for Care and CautionJanice E. Graham (bio) and Karen Ritchie (bio)KeywordsAlzheimer’s disease, construction, dementia, market forces, mild cognitive impairmentWe thank the reviewers for their thoughtful comments that probe shadowy areas in our argument, and we welcome this opportunity to elucidate our position. First, we are not repudiating the natural and social facts of pathologic brain degeneration and the physical and (...) cognitive impairments that manifest in people affected by dementia disorders. We are, however, questioning the epistemology, politics, and persistence by some to harden the construct of mild cognitive impairment (MCI) prematurely as a "natural" precursor to dementia. We suggested insufficiencies in viewing MCI as prodromal to Alzheimer's disease (AD; Graham and Ritchie 2006, 36), and pointed to evidence for the prognostic irrelevance of some MCI subcategories (35). The commentators have read our manuscript as suggesting that AD and MCI are different kinds, and that a diagnosis of AD is more "real" than that of MCI. But AD is also fraught with classification issues, as we describe in the section of our paper that deals with consensus committees, published practice guidelines, and the determination of treatment efficacy. Like MCI, AD is a heterogeneous condition, but unlike MCI, AD is a constructed practical kind that does some "work" beyond essentialist (neural degeneration, brain atrophy) claims. Its criteria identify people with well-defined dementia symptoms and multiple cognitive and functional impairments who are in need of, and benefit from, support. Even with these criteria, however, there have been great attempts to achieve definitional accuracy in dementia diagnoses. Practical refinements to the differential diagnosis of dementia based on solid research evidence have made way for more specific recognitions of vascular dementias, dementia of the Lewy body type, and other subtypes beyond AD. So AD too has been subject to more careful, more cautious operationalization in recent years, with research supporting multiple factors and the comorbidity of several types (kinds) of dementia in any one individual.Our paper takes up concerns that are not resolved for dementia and suggests that the nascent category of MCI is still so insufficiently defined as to be ambiguous, and as such, is in danger of identifying individuals with what will be, and has [End Page 57] already been, linked to a debilitating and deeply stigmatizing and fatal disorder (AD). We are not contesting the reality that some people begin to display early signs of cognitive loss, nor are we suggesting that symptoms be ignored; as researchers, we stand behind the careful tracking of symptoms and signs in patients and research participants as an essential clinical and research practice. In a era where the public has been made wary of the potentially fatal effects of new treatments whose more careful scrutiny in specific populations would have saved lives (e.g., Fontanarosa, Rennie, and DeAngelis 2004; Psaty and Furberg 2005), and made all the more popular by what Kramer coined "diagnostic bracket creep" (1993, 15), we are questioning the drivers and value of a premature diagnostic classification whose definitional accuracy is neither sufficient nor effective for specific identification of individuals.That matters of fact are constructed does not take away from their natural fact. Some people have subjective reports or show objective evidence of cognitive decline while having preserved activities of daily living—the construction of this evidence indicates they are not normal and they are not demented. Based on such evidence, where then does the balance of probability for MCI lie? A multidisciplinary international group of experts gathered in Stockholm in 2003 to discuss MCI concepts (Winblad et al. 2004). They acknowledged that the heterogeneous etiology of MCI contributes to "some confusion concerning the specific boundaries of the condition", stating that this "not normal, not demented" condition is nonetheless "useful both clinically and as a research entity" (p. 241). Importantly, they concluded that MCI needs "better definition" (p. 246). It was at this stage that we first wrote our manuscript, and in the subsequent two years we have eagerly awaited new studies, and the recognition of flexible, practical subtypes to evolve.We state "that MCI cannot be considered to be a separate clinical entity" (Graham and... (shrink)

ABSTRACTThe aim of this study was to examine the extent to which cognitive emotion regulation strategies were “common or transdiagnostic correlates” of symptoms of depression and anxiety and/or “specific correlates” distinguishing one problem category from the other. The sample comprised 582 13- to 16-year-old secondary school students. Symptoms of depression and anxiety were measured by the SCL-90, and cognitive emotion regulation strategies were measured by the CERQ, in a cross-sectional design. Multivariate regression analyses were performed. Before controlling for (...) comorbidity, the same cognitive emotion regulation strategies that were related to symptoms of depression were also related to symptoms of anxiety. However, after controlling for comorbid anxiety symptoms, rumination, self-blame, positive reappraisal, and positive refocusing were uniquely associated with depression symptoms; and after controlling for comorbid depression symptoms, ca... (shrink)

ABSTRACTThe aim of this study was to examine the extent to which cognitive emotion regulation strategies were “common or transdiagnostic correlates” of symptoms of depression and anxiety and/or “specific correlates” distinguishing one problem category from the other. The sample comprised 582 13- to 16-year-old secondary school students. Symptoms of depression and anxiety were measured by the SCL-90, and cognitive emotion regulation strategies were measured by the CERQ, in a cross-sectional design. Multivariate regression analyses were performed. Before controlling for (...) comorbidity, the same cognitive emotion regulation strategies that were related to symptoms of depression were also related to symptoms of anxiety. However, after controlling for comorbid anxiety symptoms, rumination, self-blame, positive reappraisal, and positive refocusing were uniquely associated with depression symptoms; and after controlling for comorbid depression symptoms, ca... (shrink)

IntroductionPreoperative neurocognitive disorder is a common condition affecting 14–51. 7% of the elderly population. General anesthesia has already been associated with the one-year post-operative neurocognitive disorder, specifically, a deficit in executive function, measured by the Trail Making Test B, but its long-term effects on cognitive function have not been investigated. We aimed to detect preO-NCD prevalence in patients scheduled for cardiac surgery and further investigate the possible role of previous general anesthesia in general preoperative cognitive status [measured via (...) the Montreal Cognitive Assessment ] and/or in executive functioning.MethodsIn this observational, prospective study, 151 adult patients scheduled for elective cardiac surgery underwent MoCA and TMT-B. Data on age, education, pGA, comorbidities, and laboratory results were collected.ResultsWe discovered a general cognitive function impairment of 79.5% and an executive function impairment of 22%. Aging is associated with an increased likelihood and education with a decreased likelihood of general cognitive impairment, but only education was significantly associated with a decreased likelihood of executive function impairment. While pGA did not significantly affect preO-NCD, a noteworthy interaction between aging and pGA was found, resulting in a synergistic effect, increasing the likelihood of executive function impairment.ConclusionWe found a high prevalence of preO-NCD in patients scheduled for cardiac surgery. General cognitive function impairment is highly associated with advancing age. However, older patients with at least one pGA appeared to be at an increased risk of preO-NCD, especially executive function impairment, suggesting that TMT-B should be associated with MoCA in the preoperative cognitive evaluation in this population. (shrink)

Background: There is a growing interest in using cognitive behavioural therapy with people who have Asperger Syndrome and comorbid mental health problems. Aims: To examine whether modified group CBT for clinically significant anxiety in an AS population is feasible and likely to be efficacious. Method: Using a randomised assessor-blind trial, 52 individuals with AS were randomised into a treatment arm or a waiting-list control arm. After 24 weeks, those in the waiting-list control arm received treatment, while those initially randomised (...) to treatment were followed-up for 24 weeks. Results: The conversion rate for this trial was high, while attrition was 13%. After 24 weeks, there was no significant difference between those randomised to the treatment arm compared to those randomised to the waiting-list control arm on the primary outcome measure, the Hamilton Rating Scale for Anxiety. Conclusions: Trials of psychological therapies with this population are feasible. Larger definitive trials are now needed. Declaration of Interest: None Trial Registration: ISRCTN 30265294, UKCRN 8370. (shrink)

Since Darwin, the idea of psychological continuity between humans and other animals has dominated theory and research in investigating the minds of other species. Indeed, the field of comparative psychology was founded on two assumptions. First, it was assumed that introspection could provide humans with reliable knowledge about the causal connection between specific mental states and specific behaviors. Second, it was assumed that in those cases in which other species exhibited behaviors similar to our own, similar psychological causes were at (...) work. In this paper. we show how this argument by analogy is flowed with respect to the case of second-order mental states. As a test case, we focus on the question of how other species conceive of visual attention, and in particular whether chimpanzees interpret seeing as a mentalistic event involving internal states of perception, attention, and belief. We conclude that chimpanzees do not reason about seeing in this manner, and indeed, there is considerable reason to suppose that they do not harbor representations of mental states in general. We propose a reinterpretation model in which the majority of the rich social behaviors that humans and other primates share in common emerged long before the human lineage evolved the psychological means of interpreting those behaviors in mentalistic terms. Although humans, chimpanzees, and most other species may be said to possess mental states, humans alone may have evolved a cognitive specialization for reasoning about such states. (shrink)

Here we defend the view that one ought to categorize and classify at least some mental disorders as clusters of interrelated dysfunctions of (usually, several) cognitive capacities – that is, the kinds of capacities that are postulated in cognitive science; capacities that are understood as entities that are primarily individuated in cognitive-functional terms (CF-systems); systems that have a set of peculiar properties in their manner of operation when processing information or representations. Usually, some of the mental disorders (...) postulated in psychiatry are clinically heterogeneous with respect to their symptoms, and tend to be comorbid – that is, one disorder is often accompanied by other disorders – for example, schizophrenia often comes with major depression. We argue that describing the manner in which CF-systems operate within themselves and with other CF-systems as well as with stimuli and other kinds of information can best explain why certain mental disorders are very heterogeneous with respect to their symptoms, and why comorbidity is so frequent among these disorders. A consequence is that both within-category heterogeneity and comorbodity are not necessarily indications of defective classifications but are rather a consequence of the actual cognitive functional architecture itself and are therefore to be expected in these cases. (shrink)

Cognitive models propose that both, negative interpretations of ambiguous social situations and ruminative thoughts about social events contribute to the maintenance of social anxiety disorder. It has further been postulated that ruminative thoughts fuel biased negative interpretations, however, evidence is rare. The present study used a multi-method approach to assess ruminative processing following a social interaction and negative interpretation bias in a student sample screened for high and low social anxiety. Results support the hypothesis that group differences in negative (...) interpretations of ambiguous social situations in HSAs vs. LSAs are mediated by higher levels of post-event processing assessed in the questionnaire. Exploratory analyses highlight the potential role of comorbid depressive symptoms. The current findings help to advance the understanding of the association between two cognitive processes involved in social anxiety and stress the importance of ruminative post-event processing. (shrink)

Introduction: Few studies are available on the prevalence and sleep-related factors of dementia with Lewy bodies (DLB) in Chinese older adults, aiming to explore the associations between sleep characteristics and DLB.Methods: A cross-sectional study with 7,528 individuals aged ≥65 years in 106 communities in Northern China was conducted from April 2019 to January 2020. Questionaries (including demographic characteristics, comorbidities, lifestyles, and sleep characteristics) were administered, and neuropsychological assessments and physical examination were conducted in phase I; screening for probable DLB was (...) done in phase II. Logistic regressions were used to assess associations.Results: A total of 919 (12.2%, 919/7,528) participants had dementia, and 101 (1.3%, 101/7,528) participants were diagnosed with DLB. The prevalence of dementia and DLB were slightly higher or equal in women, increased with age, and roughly decreased with nighttime sleep duration. Of the 101 participants, all of them (100.0%) had cognitive impairment, 46 (44.54%) displayed fluctuating cognition, 72 (71.29%) of them showed visual hallucination, 22 (21.78%) individuals reported RBD, and 27.71% showed Parkinsonism. Sleeping for 8 h had combined diagnostic value for DLB (AUC = 0.783, 95%CI: 0.734–0.831, p < 0.001).Conclusions: The current prevalence of DLB is 1.3% in Northern China. Short or long nighttime sleep duration is independently associated with the occurrence of dementia and DLB. (shrink)

BackgroundPublic Safety Personnel are routinely exposed to human suffering and need to make quick, morally challenging decisions. Such decisions can affect their psychological wellbeing. Participating in or observing an event or situation that conflicts with personal values can potentially lead to the development of moral injury. Common stressors associated with moral injury include betrayal, inability to prevent death or harm, and ethical dilemmas. Potentially psychologically traumatic event exposures and post-traumatic stress disorder can be comorbid with moral injury; however, moral injury (...) extends beyond fear to include spiritual, cognitive, emotional or existential struggles, which can produce feelings of severe shame, guilt, and anger.ObjectiveThis scoping review was designed to identify the extant empirical research regarding the construct of moral injury, its associated constructs, and how it relates to moral distress in firefighters, paramedics, and police officers.MethodsA systematic literature search of peer-reviewed research was conducted using databases MEDLINE, EMBASE, APA PsychInfo, CINHAL PLUS, Web of Science, SCOPUS, and Google Scholar. Included studies were selected based on the inclusion criteria before being manually extracted and independently screened by two reviewers.ResultsThe initial database search returned 777 articles, 506 of which remained after removal of duplicates. Following review of titles, abstracts, and full texts, 32 studies were included in the current review. Participants in the articles were primarily police officers, with fewer articles focusing on paramedics and firefighters. There were two studies that included mixed populations. Most studies were qualitative and focused on four topics: values, ethical decision-making, organizational betrayal, and spirituality.ConclusionPublic safety organizations appear to recognize the experience of moral distress or moral injury among public safety personnel that results from disconnects between personal core values, formal and informal organizational values, vocational duties, and expectations. Further research is needed to better understand moral distress or moral injury specific to public safety personnel and inform training and treatment in support of public safety personnel mental health. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Surrender Versus Control:How Best Not to DrinkMark D. Rego (bio)Keywordsaddiction, Alcoholics Anonymous, will, St. AugustineI recall as a teenager noticing that some people modified nouns in, what sounded to me, a peculiar way. A friend's mother who was taking an automotive repair course said, " We're going to learn to fix the brakes next week." The same folks would also use the possessive for common nouns in phrases like: (...) "I'll be ready after I take my shower." Although not incorrect, I believe this type of usage reflected a different attitude about brakes, showers, and other things. These tended to be more hands-on people and thus, in my understanding at least, had a more particular relationship with things in their world than others for whom objects were examples of types of things.This brief vignette serves as an introduction to my qualified enthusiasm for the project taken up by Allison Mitchell in her paper, "Taking Mentality Seriously: A Philosophical Inquiry into the Language of Addiction and Recovery" (Mitchell, 2006). Indeed, as a practicing psychiatrist I would be hard pressed not to endorse the use of language as a key to deeper aspects of experience.My following remarks are mostly contra Mitchell's hypothesis, but before beginning I name one more reason I think this project is worthwhile. In spite of much research and recitations of the motto "treatment works," we do not presently have a reliable treatment for addiction. The linguistic portrait painted by Mitchell allows us to view our treatments in vivo and reflect upon what we see. (For the purpose of this commentary, I consider alcoholism and Alcoholics Anonymous [AA] as a general example of addiction and treatment.)Medication treatment remains almost inconsequential except when applied for comorbid psychiatric disorders rather than the primary addiction. Even then it rarely serves to undo some form of self-medication, but instead only offers an important leg up in battling the addiction.Research and much experience has shown AA to be the single best treatment for alcoholism (Vaillant and Hiller-Sturmhofel 1996). Some investigators have proposed underlying mechanisms for its efficacy (some, like "creating dependency" run very counter to Mitchell) (Vaillant 2005). AA's success is highly dependent upon attendance (McCrady et al. 2004), which can of course be a marker for getting better in the first place and not solely a cause of improvement (i.e., people who are doing better attend more meetings not vice- versa). Even within AA, the dropout rate is quite high (Martin et al. 1996). Workers in this area [End Page 223] have raised questions about AA's approach and have proposed other avenues to sobriety, including interpersonal, cognitive–behavioral, and relapse prevention programs (Witkiewitz and Marlatt 2005, 2004; O'Dwyer 2006). Lamentably, some very large studies failed to show any effective ability to match up alcoholics with a particular treatment modality (Church 2004; Read 2004).Given the lack of clarity with which we still work, I think an approach like Mitchell's is a welcome call for serious reflection. The limitations of a linguistic analysis place an unfortunate constriction on implications to be drawn.Mitchell's chief concern is that the language of recovery, as reflected in twelve-step programs, betrays and even fosters a degree of passivity, which leaves the addict without an adequate sense of agency and autonomy with which to combat addiction. From a more philosophical perspective, Mitchell believes this is due to an incomplete philosophical materialism; one that lacks "mentality" (i.e., the sense that part of our physical being is made up of mental activities such as emotions, motivations, beliefs, etc.). This attitude is manifest in a "pretheoretic conception of the self" that leaves the addict with a dearth of self-awareness as a mental agent of action and change.In place of the standard recovery model in use today, Mitchell suggests cultivating a sense of self that values and fosters engaged agency that is both capable of self-control and responsive to external obligations.A Few ConcernsFirst, I will offer a few concerns about premises at work within the paper. Then, I outline an attempt to make sense of the... (shrink)

Given research and public interest for conditions related to an extended lifespan, we addressed the questions of what matters and what matters most for subsequent survival past age 80. The data was drawn from the population-based and multidisciplinary Swedish OCTO Twin Study, in which a sample consisting of identical and same-sex fraternal twin pairs, followed from age 80 until death, provided detailed data on health, physical functioning, life style, personality, and sociodemographic conditions. Information concerning date of birth and death were (...) obtained from population census register. We estimated heritability using an ACE model and evaluated the role of multiple predictors for the mortality-related hazard rate using Cox regression. Our findings confirmed a low heritability of 12%. As expected, longer survival was associated with being a female, an apolipoprotein E e4 allele non-carrier, and a non-smoker. Several diseases were found to be associated with shorter survival as well as certain health conditions. Stronger grip and better lung function, as well as better vision, and better cognitive function was related to longer survival. Social embeddedness, better self-evaluated health, and life-satisfaction were also significantly associated with longer survival. After controlling for the impact of comorbidity, functional markers, and personality-related predictors, we found that sex, cerebrovascular diseases, compromised cognitive functioning, self-related health, and life-satisfaction remained as strong predictors. Cancer was only associated with the mortality hazard when accounting for other co-morbidities. The survival estimates were mostly in anticipated directions and contained effect sizes within the expected range. Noteworthy, we found that some of the so-called “soft-markers” remained strong predictors, despite a control for other factors. For example, self-evaluation of health and ratings of life-satisfaction provide additional and valuable information. (shrink)

Current psychiatric classification adopts a disorder-focused diagnostic approach, as exemplified within ICD-11 and DSM-V. Although this approach has improved reliability of categorization, its validity and utility has been questioned. Limitations include high comorbidity between supposedly distinct disorders; heterogeneity within diagnoses; limited treatment efficacy; and similarities across disorders in aetiology, latent symptom structure, and underlying biology. There is also evidence of transdiagnostic cognitive-behavioural processes. An alternative approach is therefore to focus on fundamental underlying mechanisms of psychopathology rather than observed (...) symptom clusters. This article considers the possible benefits, hurdles, and steps towards implementation of this transdiagnostic mechanistic approach, using the example of repetitive negative thought. (shrink)

Background: Frailty is a common syndrome among older adults and patients with several comorbidities. Grip strength is a representative parameter of frailty because it is a valid indicator of current and long-term physical conditions in the general population and patients with severe mental illnesses. Physical and cognitive capacities of people with SMIs are usually impaired; however, their relationship with frailty or social functioning have not been studied to date. The current study aimed to determine if GS is a valid (...) predictor of changes in cognitive performance and social functioning in patients with type-2 diabetes mellitus and SMIs. Methods: Assessments of social functioning, cognitive performance, and GS were conducted in 30 outpatients with type 2 diabetes mellitus, 35 with major depressive disorder, 42 with bipolar disorder, 30 with schizophrenia, and 28 healthy controls, twice during 1-year, follow-up period. Descriptive analyses were conducted using a one-way analysis of variance for continuous variables and the chi-squared test for categorical variables. Differences between groups for the motor, cognitive, and social variables at T1 and T2 were assessed using a one-way analysis of covariance, with sex and age as co-variates. To test the predictive capacity of GS at baseline to explain the variance in cognitive performance and social functioning at T2, a linear regression analysis was performed. Results: Predictive relationships were found among GS when implicated with clinical, cognitive, and social variables. These relationships explained changes in cognitive performance after one year of follow-up; the variability percentage was 67.7%, in patients with type-2 diabetes mellitus and 89.1% in patients with schizophrenia. Baseline GS along with other variables, also predicted changes in social functioning in major depressive disorder, bipolar disorder, and schizophrenia, with variability percentages of 67.3, 36, and 59%, respectively. Conclusion: GS combined with other variables significantly predicted changes in cognitive performance and social functioning in people with SMIs or type-2 diabetes mellitus. Interventions aimed to improve the overall physical conditions of patients who have poor GS could be a therapeutic option that confers positive effects on cognitive performance and social functioning. (shrink)

Immanuel Kant’s theory of imagination is a surprisingly fruitful nexus of explanation for the prima facie disparate characteristics of autism spectrum disorder (ASD), especially the sub-spectrum best characterized by the Sensory Integration (SI) and Intense World (IW) theories of ASD. According to the psychological theories that underpin these approaches to autism, upstream effects of sensory processing atypicalities explain a cascade of downstream effects that have been characterized in the diagnostic triad, e.g., poor sensory integration contributes to weak central coherence, which (...) in turn contributes to difficulty participating in a back and forth conversation. To see why Kant’s theory of imagination might be useful, consider that ASD is neither a sensory disorder nor an intellectual disorder per se. Cognitive dysfunction is a common comorbidity of ASD, not a characteristic of it. If we exclude sense and intellect, what’s left? According to Kant, imagination is a synthesizing faculty that mediates between sense and understanding. It does so by transforming intuition from the canonic and vital senses. The uses of imagination include our spatially formative, temporally associative, and communicatively affinitive production, where affinitive production includes sympathy and fantasy. Imagination is thus the faculty of sensory integration, embodied subjectivity, empathy, mindreading, and social cooperation. The wide range of how autism presents and how it is experienced can thus be understood in terms of the atypical development of specific functions of imagination. Kant’s theory of imagination provides a new perspective on how to organize our understanding of autism at the psychological level, one that makes sense of how some of the disparate characteristic phenomena of autism are systematically related and which might lead to novel predictions, research targets, or intervention recommendations. (shrink)

Treatment-resistant symptoms complicate the clinical course of schizophrenia, and a large proportion of patients do not reach functional recovery. In consequence, polypharmacy is frequently used in treatment-refractory cases, addressing psychotic positive, negative and cognitive symptoms, treatment-emergent side effects caused by antipsychotics and comorbid depressive or obsessive-compulsive symptoms. To a large extent, such strategies are not covered by pharmacological guidelines which strongly suggest antipsychotic monotherapy. Add-on strategies comprise combinations of several antipsychotic agents and augmentations with mood stabilizers; moreover, antidepressants and (...) experimental substances are applied. Based on the accumulated evidence of clinical trials and meta-analyses, combinations of clozapine with certain second-generation antipsychotic agents and the augmentation of antipsychotics with antidepressants seem recommendable, while the augmentation with mood stabilizers cannot be considered superior to placebo. Forthcoming investigations will have to focus on innovative pharmacological agents, the clinical spectrum of cognitive deficits and the implementation of cognitive behavioral therapy. (shrink)

Aim: This study explores priority dilemmas in dialysis treatment and care offered elderly patients within the Norwegian public healthcare system.Background: Inadequate healthcare due to advanced age is frequently reported in Norway. The Norwegian guidelines for healthcare priorities state that age alone is not a relevant criterion. However, chronological age, if it affects the risk or effect of medical treatment, can be a legitimate criterion.Method: A qualitative approach is used. Data were collected through semistructured interviews and analysed through hermeneutical content analysis. (...) The informants were five physicians and four nurses from dialysis wards.Findings: Pressing priority dilemmas centre around decision-making concerning withholding and withdrawal of dialysis treatment. Advanced age is rarely an absolute or sole priority criterion. It seems, however, that advanced age appears to be a more subtle criterion in relation with, for example, comorbidity, functional status and cognitive impairment. Nurses primarily prioritise specialised dialysis care and not comprehensive nursing care. The complex needs of elderly patients are therefore often not always met.Conclusions: Clinical priorities should be made more transparent in order to secure legitimate and fair resource allocation in dialysis treatment and care. Difficult decisions concerning withholding or withdrawal of dialysis ought to be openly discussed within the healthcare team as well as with patients and significant others. The biomedical focus and limitations on comprehensive care during dialysis should be debated. (shrink)

Hip fractures are common and serious injuries in the geriatric population. Obtaining informed consent for surgery in geriatric patients can be difficult due to the high prevalence of comorbid cognitive impairment. Given that virtually all patients with hip fractures eventually undergo surgery, and given that delays in surgery are associated with increased mortality, we argue that there are select instances in which it may be ethically permissible, and indeed clinically preferable, to initiate surgical treatment in cognitively impaired patients under (...) the doctrine of presumed consent. In this paper, we examine the boundaries of the license granted by presumed consent and use the example of geriatric hip fracture to build an ethical framework for understanding the doctrine of presumed consent. The license to act under presumed consent requires three factors: patient incapacity, clinical urgency and clarity on the correct course of action. All three can apply to geriatric hip fracture. The typical patient frequently lacks capacity. Delays in initiating surgical treatment are associated with markedly increased mortality rates. Last, there appears to be consensus that surgery is the preferred treatment. Nonetheless, because there is a window of safe delay during which treating physicians can stabilize the patient, address reversible causes of cognitive impairment and identify surrogate decision makers, presumed consent should be invoked only as a method of last resort. A medical situation need not be characterized by risk of imminent and certain death for presumed consent to be relevant. Rather, there are two distinct windows that must be considered: the time interval in which action may be delayed without danger, and the time interval needed to obtain a better form of consent. Presumed consent is appropriate only when the latter exceeds the former. (shrink)

The aim of this study was to investigate the level of posttraumatic growth of cancer patients post-treatment in the context of selected sociodemographic characteristics, clinical markers, and psychological variables (positive and negative emotions, anxiety and depressive symptoms, gratitude, forgiveness, hope, importance of the spiritual aspect of life and the practice of religious faith). The study sample consisted of 110 patients post-treatment aged 22-79 years and with an average time since the completion of the last treatment ranging from 5 to 396 (...) months. The Posttraumatic Growth Inventory, the Positive and Negative Affect Schedule, screening methods to measure anxiety (General Anxiety Dis- order-7) and depression (Patient Health Questionnaire-9), and questionnaires to measure dispositional gratitude (Gratitude Questionnaire GQ-6), dispositional hope (Adult Dispositional Hope Scale), and forgiveness (Heartland Forgiveness Scale) were used to measure the psychological variables. There were no differences in the level of posttraumatic growth in terms of sociodemographic characteristics and clinical markers. Partner status, employment status, presence of recurrence, and comorbidities did not differentiate its level either. The rate of posttraumatic growth was related to the experience of positive emotions, gratitude, the importance of the spiritual aspect of life, and the practice of religious faith. In the regression model that explained 21.90% of the variance in posttraumatic growth, only the level of positive emotions was a significant predictor. The results of the present research point suggest that the level of posttraumatic growth is associated with several areas of emotional experience and cognitive adjustment of cancer patients post-treatment. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Deflating Psychiatric ClassificationClaudio E. M. Banzato (bio)Keywordsnosography, comorbidity, utility, pragmatismSystems of classification bring order into the world. They are a key part of the informational working infrastructure of the world we inhabit (Bowker and Star 1999). Thus, much of the human interaction hinges on these ordering—pattern identifying and creating—systems. Formal or informal, standardized or ad hoc, visible or invisible, enforced or optional, there are a myriad of classifications (...) we necessarily live by.Typically, classifications convey representations of states of affairs to make interventions on them feasible and, to some extent, predictable. In other words, classificatory systems and schemes try to confer intelligibility to the world. By succeeding in such task, they may provide rational grounds to human operation on reality (toward the most diverse ends). This account fully applies to medical classifications, which struggle to sort out all kinds of diseases, ailments, complaints, and sufferings that can possibly be targeted by medical interventions. This means classifications are instrumental to the ends pursued by medicine, quintessential modificatory activity. In sum, classifications are cognitive tools devised to build up knowledge by making relevant distinctions, which may prove helpful to guide human action.By working well, classifications eventually tend to become invisible. They end up looking just natural, as if they were carved by nature itself. But indeed purpose is the touchstone here. Even if a given class of objects fully qualifies as a 'natural kind' and necessary and sufficient criteria for class membership can be definitely established, it does not entail that it constitutes the best way to classify these objects irrespective of the context. Peter Zachar (2002) offers a compelling example from natural sciences, the utmost practical importance of distinguishing between hydrogen and its isotopes (hydrogen, deuterium, and tritium). In this case, the classificatory thrust stretches beyond the shared atomic number. In his words, "A crucial factor in recognizing them as distinct is that they are used in distinct activities and practices. We get a better neutron bounce with heavy water or D2O. Deciding what aspects of internal structure are important therefore cannot be isolated from external factors." (p. 220)In contemporary psychiatry, diagnostic classification has been center stage for several reasons. But before addressing them, however, a brief historical detour is necessary. Back in the nineteenth century, putting forward a new classification of mental diseases was taken somewhat as a token of psychiatric proficiency according to the witty remark by the French physician and publicist Philippe Buchez: "Upon believing that they have [End Page 23] completed their studies, rhetoricians will compose a tragedy and alienists a classification" (Berrios 1999, 152). By the middle of the twentieth century, many psychiatric classifications (based on diverse principles and underlying theoretical orientations) were still used across the world. The British psychiatrist Erwin Stengel (1959), in his influential report on classification of mental disorders, pointed out that the issue of difficulty of communication was then the order of the day for psychiatry, because it was widely perceived as one of the most serious obstacles to the progress in the field.The broad, worldwide survey carried out by Stengel made it clear that classifications of all shapes were used in different contexts, but they were seldom appealing outside the boundaries of the respective centers that generated them. Such diversity of classifications reflected not only different functions or purposes they were meant to serve, but also the role played by the history of a given problem within a particular medical tradition and cultural background. Thus, Stengel's aims for an acceptable statistical international classification were relatively modest: it should simply ground epidemiological work.Stengel's stance on classification was frankly pragmatic and utilitarian. He understood well the difficulties posed by the 'disease entity' assumption in psychiatry and asked the straight question: "Firstly, what do we classify in this field? Are we classifying diseases or people?", to which he offered a compromised answer: "It may be said that the material the psychiatrist has to classify consists neither of diseases nor of people but of a variety of disorders or reactions, a material which does not readily lend itself to classification" (Stengel 1959, 612). For him, the pursued agreement on the... (shrink)

Severe obesity has been associated with reduced performance on tests of verbal memory in bariatric surgery candidates. There is also some evidence that bariatric surgery leads to improved verbal memory, yet these findings need further elucidation. Little is known regarding postoperative memory changes in the visual domain and how patients subjectively experience their everyday memory after surgery. The aim of the current study was to repeat and extend prior findings on postoperative memory by investigating visual, verbal, and self-reported everyday memory (...) following surgery, and to examine whether weight loss and somatic comorbidity predict memory performance. The study was a prospective, observational study in which participants underwent cognitive testing at baseline, 1 and 2 years after bariatric surgery. Repeated measures analyses of variance revealed significantly poorer visual and verbal memory performance at the 1-year follow-up, with performance subsequently returning to baseline levels after 2 years. Verbal learning and self-reported everyday memory did not show significant postoperative changes. Memory performance at 1 year was not significantly predicted by weight loss, changes in C-reactive protein levels or postoperative somatic comorbidity. The study demonstrated poorer visual and verbal memory performance at 1-year follow-up that returned to baseline levels after 2 years. These findings are in contrast to most previous studies and require further replication, however, the results indicate that postoperative memory improvements following bariatric surgery are not universal. Findings suggest that treatment providers should also be aware of patients potentially having poorer memory at 1 year following surgery. (shrink)

In a previous study we examined reading, spelling, and maths skills in an unselected group of 129 Italian children attending fifth grade by testing various cognitive predictors; results showed a high degree of predictors’ selectivity for each of these three behaviors. In the present study, we focused on the specificity of the predictors by performing cross-analyses on the same dataset; i.e., we predicted spelling and maths skills based on reading predictors, reading based on maths predictors and so on. Results (...) indicated that some predictors, such as the Orthographic Decision and the Arithmetic Facts tests, predicted reading, spelling and maths skills in similar ways, while others predicted different behaviors but only for a specific parameter, such as fluency but not accuracy, and still others were specific for a single behavior. To interpret these results, we propose a novel model of learning skills separately considering factors in terms of competence, performance and acquisition. Reading, spelling and calculation skills would depend on the development of discrete and different abstract competences. By contrast, overlap among behaviors would be accounted for by defective acquisition in automatized responses to individual “instances”; this latter skill is item specific but domain independent. Finally, performance factors implied in task’s characteristics may contribute to the partial association among learning skills. It is proposed that this new model may provide a useful base for interpreting the diffuse presence of comorbidities among learning disorders. (shrink)

Chronic pain affects a large part of the population causing functional disability, being often associated with coexisting psychological disorders, such as depression and anxiety, besides cognitive deficits, and sleep disturbance. The world elderly population has been growing over the last decades and the negative consequences of chronic pain for these individuals represent a current clinical challenge. The main painful complaints in the elderly are related to neurodegenerative and musculoskeletal conditions, peripheral vascular diseases, arthritis, and osteoarthritis, contributing toward poorly life (...) quality, social isolation, impaired physical activity, and dependence to carry out daily activities. Organ dysfunction and other existing diseases can significantly affect the perception and responses to chronic pain in this group. It has been proposed that elderly people have an altered pain experience, with changes in pain processing mechanisms, which might be associated with the degeneration of circuits that modulate the descending inhibitory pathways of pain. Aging has also been linked to an increase in the pain threshold, a decline of painful sensations, and a decrease in pain tolerance. Still, elderly patients with chronic pain show an increased risk for dementia and cognitive impairment. The present review article is aimed to provide the state-of-art of pre-clinical and clinical research about chronic pain in elderly, emphasizing the altered mechanisms, comorbidities, challenges, and potential therapeutic alternatives. (shrink)

With the world's population aging, hospitals are facing pressure to adequately meet the needs of a growing number of frail older patients. For this population, comorbidities combined with a limited ability to face stressful situations contribute to frailty whereby a small injury or illness can lead to significant loss of function. It is widely recognized that hospitalized older patients are more vulnerable to physical or cognitive functional decline and require increased assistance in activities of daily living (Creditor 1993; Sager (...) et al. 1996; Mahoney, Sager, and Jalaluddin 1998; Kortebein et al. 2008; English and PaddonJones 2010; Covinsky, Pierluissi, and Johnston 2011; Zisberg et al. 2011;... (shrink)