Canadian respiratory therapists who considered leaving their clinical position experienced elevated moral distress and adverse psychological and functional outcomes during the COVID-19 pandemic. / Détresse morale et conséquences psychologiques et fonctionnelles négatives chez les thérapeutes respiratoires canadiens ayant envisagé de quitter leur poste clinique pendant la pandémie de COVID-19.

INTRODUCTION: Respiratory therapists (RTs) faced morally distressing situations throughout the COVID-19 pandemic, including working with limited resources and facilitating video calls for families of dying patients. Moral distress is associated with a host of adverse psychological and functional outcomes (e.g. depression, anxiety, symptoms of posttraumatic stress disorder [PTSD] and functional impairment) and consideration of position departure. The purpose of this study was to understand the impact of moral distress and its associated psychological and functional outcomes on consideration to leave a clinical position among Canadian RTs during the COVID-19 pandemic. METHODS: Canadian RTs (N = 213) completed an online survey between February and June 2021. Basic demographic information (e.g. age, sex, gender) and psychometrically validated measures of moral distress, depression, anxiety, stress, PTSD, dissociation, functional impairment, resilience and adverse childhood experiences were collected. RESULTS: One in four RTs reported considering leaving their position. RTs considering leaving reported elevated levels of moral distress and adverse psychological and functional outcomes compared to RTs not considering leaving. Over half (54.5%) of those considering leaving scored above the cut-off for potential diagnosis of PTSD. Previous consideration to leave a position and having left a position in the past each significantly increased the odds of currently considering leaving, along with system-related moral distress and symptoms of PTSD, but the contribution of these latter factors was small. CONCLUSIONS: Canadian RTs considering leaving their position reported elevated levels of distress and adverse psychological and functional outcomes, yet these individual-level factors appear unlikely to be the primary factors underlying RTs' consideration to leave, because their effects were small. Further research is required to identify broader, organizational factors that may contribute to consideration of position departure among Canadian RTs.

Coping, Supports and Moral Injury: Spiritual Well-Being and Organizational Support Are Associated with Reduced Moral Injury in Canadian Healthcare Providers during the COVID-19 Pandemic.

Healthcare providers (HCPs) have described the onset of shame- and trust-violation-related moral injuries (MI) throughout the COVID-19 pandemic. Previous research suggests that HCPs may turn to various coping methods and supports, such as spirituality/religiosity, substance use, friends/family or organizational support, to manage workplace stress. It remains unknown, however, if similar coping methods and supports are associated with MI among this population. We explored associations between MI (including the shame and trust-violation presentations individually) and coping methods and supports. Canadian HCPs completed an online survey about their mental health and experiences during the COVID-19 pandemic, including demographic indices (e.g., sex, age, mental health history) and measures of MI, organizational support, social support, spiritual well-being, self-compassion, alcohol use, cannabis use and childhood adversity. Three hierarchical multiple linear regressions were conducted to assess the associations between coping methods/supports and (i) MI, (ii) shame-related MI and (iii) trust-violation-related MI, when controlling for age, mental health history and childhood adversity. One hundred and seventy-six (N = 176) HCPs were included in the data analysis. Spiritual well-being and organizational support were each significantly associated with reduced total MI (p's < 0.001), shame-related MI (p = 0.03 and p = 0.02, respectively) and trust-violation-related MI (p's < 0.001). Notably, comparison of the standardized beta coefficients suggests that the association between trust-violation-related MI and both spiritual well-being and organizational support was more than twice as great as the associations between these variables and shame-related MI, emphasizing the importance of these supports and the trust-violation outcomes particularly. Mental health history (p = 0.02) and self-compassion (p = 0.01) were additionally related to shame-related MI only. Our findings indicate that heightened levels of spiritual well-being and organizational support were associated with reduced MI among HCPs during the COVID-19 pandemic. Rather than placing sole responsibility for mental health outcomes on HCPs individually, organizations can instead play a significant role in mitigating MI among staff by implementing evidence-informed organizational policies and interventions and by considering how supports for spiritual well-being may be implemented into existing models of care where relevant for employees.

Characterizing the mental health and functioning of Canadian respiratory therapists during the COVID-19 pandemic.

Introduction: Healthcare professionals (HCPs) appear to be at increased risk for negative psychological outcomes [e.g. depression, anxiety, post-traumatic stress disorder (PTSD), moral distress] and associated impacts on functioning throughout the COVID-19 pandemic. HCPs working on designated COVID-19 units may be further impacted than their colleagues not on these units given added demands of patient care and risk of contracting COVID-19. Little is known, however, about the mental health and functioning of specific professional groups beyond nurses and physicians, including respiratory therapists (RTs), over the course of the pandemic. Accordingly, the purpose of the present study was to characterize the mental health and functioning of Canadian RTs and compare profiles between RTs working on and off designated COVID-19 units.Methods: Canadian RTs completed an online survey between February and June 2021, including demographic information (e.g. age, sex, gender,) and measures of depression, anxiety, stress, PTSD, moral distress and functional impairment. Descriptive statistics, correlation analyses and between-groups comparisons were conducted to characterize RTs and compare profiles between those on and off COVID-19 units.Results: Two hundred and eighteen (N = 218) RTs participated in this study. The estimated response rate was relatively low (6.2%) Approximately half of the sample endorsed clinically relevant symptoms of depression (52%), anxiety (51%) and stress (54%) and one in three (33%) screened positively for potential PTSD. All symptoms correlated positively with functional impairment (p's < .05). RTs working on COVID-19 units reported significantly greater patient-related moral distress compared to those not on these units (p < .05).Conclusion: Moral distress and symptoms of depression, anxiety, stress and PTSD were prevalent among Canadian RTs and were associated with functional impacts. These results must be interpreted with caution given a low response rate, yet raise concern regarding the long-term impacts of pandemic service among RTs.

Research on RTs' mental health prior to and during the COVID-19 pandemic is scant, especially in comparison to other HCPs.RTs in the present study reported experiencing moral distress and clinically significant symptoms of depression, anxiety and PTSD, with associated functional impairment.One in three RTs screened positive for likely PTSD on the PCL-5.There is a need to provide RTs with adequate mental health supports and to understand the long-term impacts of pandemic service among RTs.

Associations between trauma and substance use among healthcare workers and public safety personnel during the SARS-CoV-2 (COVID-19) pandemic: the mediating roles of dissociation and emotion dysregulation.

BACKGROUND: Given the highly stressful environment surrounding the SARS-CoV-2 pandemic, healthcare workers (HCW) and public safety personnel (PSP) are at an elevated risk for adverse psychological outcomes, including posttraumatic stress disorder (PTSD) and alcohol/substance use problems. As such, the study aimed to identify associations between PTSD severity, related dissociation and emotion dysregulation symptoms, and alcohol/substance use problems among HCWs and PSP. METHODS: A subset of data (N = 498; HCWs = 299; PSP = 199) was extracted from a larger study examining psychological variables among Canadian HCWs and PSP during the pandemic. Structural equation modelling assessed associations between PTSD symptoms and alcohol/substance use-related problems with dissociation and emotion dysregulation as mediators. RESULTS: Among HCWs, dissociation fully mediated the relation between PTSD and alcohol-related problems (indirect effect ß = .133, p = .03) and emotion dysregulation partially mediated the relation between PTSD and substance-related problems (indirect effect ß = .151, p = .046). In PSP, emotion dysregulation fully mediated the relation between PTSD and alcohol-related problems (indirect effects ß = .184, p = .005). For substance-related problems among PSP, neither emotion dysregulation nor dissociation (ps >.05) had any effects. CONCLUSION: To our knowledge, this is the first study examining associations between PTSD severity and alcohol/substance use-related problems via mediating impacts of emotion dysregulation and dissociation among HCWs and PSP during the SARS-CoV-2 pandemic. These findings highlight dissociation and emotion dysregulation as important therapeutic targets for structured interventions aimed at reducing the burden of PTSD and/or SUD among Canadian HCWs or PSP suffering from the adverse mental health impacts of the SARS-CoV-2 pandemic.

Among healthcare workers, dissociation mediated relation between posttraumatic stress disorder (PTSD) severity and alcohol-related problems and emotion dysregulation mediated relation between PTSD severity and substance-related problems.Among public safety personnel, emotion dysregulation mediated relation between PTSD severity and alcohol-related problems. Neither dissociation nor emotion dysregulation mediated relation between PTSD severity and substance-related problems.Results underscore dissociation and emotion dysregulation as potential key therapeutic targets for intervention for healthcare workers and public safety personnel struggling with PTSD and comorbid alcohol/substance use-related problems.

The Hidden Crisis: Understanding Potentially Morally Injurious Events Experienced by Healthcare Providers during COVID-19 in Canada.

BACKGROUND: Healthcare providers (HCPs) may be at elevated risk for moral injury due to increased exposure to potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic. Identifying PMIEs experienced during the COVID-19 pandemic is a critical first step for understanding moral injury in HCPs. Accordingly, the purpose of the present study was to gain a deeper understanding of the work-related PMIEs experienced by HCPs in Canada during the pandemic. METHODS: Canadian HCPs completed an online survey between February and December 2021 about mental health and functioning, including demographics and the Moral Injury Outcome Scale (MIOS). We conducted a qualitative thematic analysis of PMIEs described extemporaneously by HCPs in the open-text field of the MIOS. RESULTS: One-hundred and twenty-four (N = 124) HCPs were included in analysis. Eight PMIE-related themes were identified, comprising patients dying alone; provision of futile care; professional opinion being ignored; witnessing patient harm; bullying, violence and divided opinions; resources and personal protective equipment; increased workload and decreased staffing; and conflicting values. CONCLUSIONS: Understanding broad categories of PMIES experienced by Canadian HCPs during the COVID-19 pandemic provides an opportunity to enhance cultural competency surrounding their experiences which will aid the development of targeted prevention and intervention approaches.

A Qualitative Approach to Understanding Canadian Healthcare Workers' Use of Coping Strategies during the COVID-19 Pandemic.

Throughout the COVID-19 pandemic, healthcare workers (HCWs) have been exposed to highly stressful situations, including increased workloads and exposure to mortality, thus posing a risk for adverse psychological outcomes, including acute stress, moral injury, and depression or anxiety symptoms. Although several reports have sought to identify the types of coping strategies used by HCWs over the course of the pandemic (e.g., physical activity, religion/spirituality, meditation, and alcohol), it remains unclear which factors may influence HCWs' choice of these coping strategies. Accordingly, using a qualitative approach, the purpose of the present study was to gain a deeper understanding of the factors influencing HCWs' choice of coping strategies during the COVID-19 pandemic in Canada. Fifty-one HCWs participated in virtual, semi-structured interviews between February and June 2021. Interview transcripts were analysed through an inductive thematic approach, yielding two primary themes. First, HCWs described an ongoing shift in their approach to coping depending on their mental "bandwidth", ranging from "quick fix" to more "intentional effort" strategies to engage in proactive strategies to improve mental health. Second, many HCWs identified various barriers to desired coping strategies during the pandemic, including the preponderance of pandemic- and other circumstantial-related barriers. The findings from this study offer a unique understanding of the factors influencing HCWs' choice of coping strategies under novel and increased stress. This knowledge will be central to developing appropriate forms of support and resources to equip HCWs throughout and after the pandemic period, and in mitigating the potential adverse mental health impacts of this period of prolonged stress and potential trauma.

Examining the 4-D Model in Persons Enrolled in the Top DD Internet Intervention.

The 4-dimensional (4-D) model of trauma-related dissociation differentiates between dissociative experiences involving trauma-related altered states of consciousness and symptoms of distress that do not appear to involve alterations in normal waking consciousness across four phenomenological dimensions (i.e., our experience of time, thought, body, and emotions). The current study evaluated hypotheses associated with the 4-D model using analyses of variance and correlation analyses in individuals with a primary diagnosis of a trauma-related dissociative disorder who were participating in the TOP DD internet study involving a combination of in-person psychotherapy and an online psychoeducational program (n = 111). Intrusive memories of traumatic events were more frequently endorsed than flashbacks, but emotional numbing was more frequently endorsed than other forms of affect dysregulation. Negative thoughts and emotion dysregulation were more strongly intercorrelated than were voice hearing and emotional numbing. Distress symptoms were more strongly associated with PTSD symptoms and difficulties in emotion regulation, whereas experiences of depersonalization were more strongly associated with dissociative self-states. Greater reduction in distress symptoms was also seen in comparison with trauma-related altered states of consciousness over the course of the combined psychotherapy and internet-based psychoeducational intervention. Overall, results continue to suggest that measures of distress and dissociative experiences can be distinguished by measures of symptom frequency, co-occurrence, and convergence with other measures of distress vs. dissociation albeit that results varied across the four phenomenological dimensions that were surveyed.

The reasons dissociative disorder patients self-injure.

Background: Most individuals with dissociative disorders (DDs) report engaging in self-injury. Objective: The present study aimed to understand the reasons for self-injury among a clinical sample of 156 DD patients enrolled in the TOP DD Network study. Method: Participants answered questions about self-injury, including a prompt asking how often they are aware of the reasons they have urges to self-injure, as well as a prompt asking them to list three reasons they self-injure. Results: Six themes of reasons for self-injury, each with subthemes, were identified in the qualitative data: (1) Trauma-related Cues, (2) Emotion Dysregulation, (3) Stressors, (4) Psychiatric and Physical Health Symptoms, (5) Dissociative Experiences, and (6) Ineffective Coping Attempts. Participants reported that they were able to identify their reasons for self-injuring sometimes (60.26%) or almost always (28.85%), with only 3.20% unable to identify any reasons for their self-injury. Conclusion: Results suggest that the vast majority of DD patients (92.31%) reported being at least partially unaware of what leads them to have self-injury urges, and many individuals with DDs experience some reasons for self-injury that are different from those with other disorders. The treatment implications of these findings are discussed.

Antecedentes:La mayoría de los individuos con trastornos disociativos (DDs por sus siglas en inglés) informan realizarse autolesiones. Objetivo: El presente estudio tuvo como objetivo el comprender las razones de las autolesiones en una muestra clínica de 156 pacientes con DD enroladas en el estudio TOP DD Network.Método:Los participantes respondieron a preguntas sobre las autolesiones, incluyendo una pregunta sobre la frecuencia con la que son conscientes de las razones por las que se autolesionan, así como una pregunta que les pedía que enumeraran tres razones por las que se autolesionan.Resultados:En los datos cualitativos se identificaron seis temas de motivos de autolesión, cada uno con subtemas: (1) Claves relacionadas con el trauma, (2) Desregulación emocional, (3) Estresores, (4) Síntomas psiquiátricos y de salud física, (5) Experiencias disociativas y (6) Intentos de afrontamiento ineficaces. Los participantes informaron que pudieron identificar sus razones para autolesionarse a veces (60,26%) o casi siempre (28,85%), y solo el 3,20% no pudo identificar las razones de sus autolesiones.Conclusiones:Los resultados sugieren que la gran mayoría de los pacientes con DD (92.31%) informaron no ser, al menos parcialmente, conscientes de lo que los lleva a tener deseos de autolesionarse y muchos individuos con DDs experimentan algunas razones de autolesión que son distintas de las que padecen otros trastornos. Se discuten las implicaciones de estos hallazgos en el tratamiento.

An examination of the relations between emotion dysregulation, dissociation, and self-injury among dissociative disorder patients.

Background: Dissociative disorder (DD) patients report high rates of self-injury. Previous studies have found dissociation and self-injury to be related to emotional distress. To the best of our knowledge, however, the link between emotion dysregulation and self-injury has not yet been examined within a DD population. Objective: The present study investigated relations between emotion dysregulation, dissociation, and self-injury in DD patients, and explored patterns of emotion dysregulation difficulties among DD patients with and without recent histories of self-injury. Method: We utilized linear and logistic regressions and t-test statistical methods to examine data from 235 patient-clinician dyads enrolled in the TOP DD Network Study. Results: Analyses revealed emotion dysregulation was associated with heightened dissociative symptoms and greater endorsement of self-injury in the past six months. Further, patients with a history of self-injury in the past six months reported more severe emotion dysregulation and dissociation than those without recent self-injury. As a group, DD patients reported the greatest difficulty engaging in goal-directed activities when distressed, followed by lack of emotional awareness and nonacceptance of emotional experiences. DD patients demonstrated similar patterns of emotion dysregulation difficulties irrespective of recent self-injury status. Conclusions: Results support recommendations to strengthen emotion regulation skills as a means to decrease symptoms of dissociation and self-injury in DD patients.

Antecedentes: Los pacientes con trastorno disociativo (DD en sus siglas en inglés) reportan altas tasas de autolesiones. Estudios anteriores han encontrado que la disociación y las autolesiones están relacionadas con el sufrimiento emocional. Sin embargo, hasta donde sabemos, la relación entre la desregulación emocional y las autolesiones aún no se ha examinado en una población con DD.Objetivo: El presente estudio investigó las relaciones entre la desregulación emocional, la disociación y la autolesión en pacientes con DD, y exploró los patrones de las dificultades de desregulación emocional entre los pacientes con DD con y sin historias recientes de autolesión.Método: Se utilizaron regresiones lineales y logísticas y métodos estadísticos de prueba t para examinar los datos de 235 díadas paciente-médico inscritas en el Estudio TOP DD Network.Resultados: Los análisis revelaron que la desregulación emocional se asoció con un aumento de los síntomas disociativos y una mayor tendencia a la autolesión en los últimos seis meses. Además, los pacientes con un historial de autolesiones en los últimos seis meses informaron de una desregulación emocional y una disociación más graves que los que no se habían autolesionado recientemente. Como grupo, los pacientes con DD informaron de la mayor dificultad para participar en actividades dirigidas a objetivos cuando estaban angustiados, seguidos por la falta de conciencia emocional y la no aceptación de las experiencias emocionales. Los pacientes con DD demostraron patrones similares de dificultades de desregulación emocional, independientemente del estado de autolesión reciente.Conclusiones: Los resultados apoyan las recomendaciones de fortalecer las habilidades de regulación de las emociones como medio para disminuir los síntomas de disociación y autolesión en pacientes con DD.

The utility of the Structured Inventory of Malingered Symptomatology for distinguishing individuals with Dissociative Identity Disorder (DID) from DID simulators and healthy controls.

Background: Individuals with dissociative identity disorder (DID) have complex symptoms consistent with severe traumatic reactions. Clinicians and forensic assessors are challenged by distinguishing symptom exaggeration and feigning from genuine symptoms among these individuals. This task may be aided by administering validity measures. Objective: This study aimed to document how individuals with DID score on the Structured Inventory of Malingered Symptomatology (SIMS). The second objective was to compare coached DID simulators and healthy controls to DID patients on the SIMS's total score and subscales. The third objective was to examine the utility rates of the SIMS in distinguishing simulated DID from clinically diagnosed DID. Method: We compared SIMS data gathered from participants from two Dutch sites, one Swiss site and one U.S. site. Sixty-three DID patients were compared to 77 coached DID simulators and 64 healthy controls on the SIMS. A multivariate analysis compared the groups on the SIMS total scores and subscales, and post-hoc Games Howell tests and univariate ANOVAs examined differences between the groups. Utility statistics assessed the accuracy of the SIMS in distinguishing clinical from simulated DID. Results: DID simulators scored significantly higher than DID individuals and healthy controls on every SIMS subscale as well as the total score. The majority (85.7%) of the individuals with DID scored above the cut-off, which is typically interpreted as indicative of possible symptom exaggeration. DID individuals scored higher than the healthy controls on every subscale except Low Intelligence, even after controlling for dissociation. The subscales and items most frequently endorsed by the DID group are consistent with symptoms associated with complex trauma exposure and dissociative reactions. The SIMS total score had a sensitivity of 96% but an unacceptably low specificity of 14%. Conclusions: The findings indicate that the instrument is not accurate in assessing potential symptom exaggeration or feigning in DID.

Antecedentes: Los individuos con trastorno de identidad disociativo (TID) tienen síntomas complejos consistentes con reacciones traumáticas severas. Los clínicos y evaluadores forenses se enfrentan al reto de distinguir la exageración de los síntomas y la simulación de los síntomas genuinos entre estos individuos. Esta tarea puede verse facilitada por la administración de medidas de validez.Objetivo: Este estudio tuvo como objetivo documentar la puntuación de los individuos con TID en el Inventario Estructurado de Sintomatología Simulada (SIMS). El segundo objetivo era comparar los simuladores de TID entrenados y los controles sanos con los pacientes de TID en la puntuación total y las subescalas del SIMS. El tercer objetivo fue examinar los índices de utilidad del SIMS para distinguir el TID simulado del TID diagnosticado clínicamente.Método: Se compararon los datos de la SIMS obtenidos de participantes de dos centros holandeses, un centro suizo y un centro estadounidense. Se compararon 63 pacientes de TID con 77 simuladores de TID entrenados y 64 controles sanos en el SIMS. Un análisis multivariante comparó los grupos en las puntuaciones totales y subescalas de la SIMS, y las pruebas post-hoc de Games Howell y los ANOVAs univariantes examinaron las diferencias entre los grupos. Las estadísticas de utilidad evaluaron la precisión de la SIMS para distinguir el TID clínico del simulado.Resultados: Los simuladores de TID obtuvieron puntuaciones significativamente más altas que los individuos con TID y los controles sanos en cada subescala del SIMS, así como en la puntuación total. La mayoría (85,7%) de los individuos con TID puntuaron por encima del punto de corte, que suele interpretarse como indicativo de una posible exageración de los síntomas. Los individuos con TID puntuaron más alto que los controles sanos en todas las subescalas excepto en Inteligencia baja, incluso después de controlar la disociación. Las subescalas y los ítems más frecuentemente respaldados por el grupo de TID son consistentes con los síntomas asociados con la exposición al trauma complejo y las reacciones disociativas. La puntuación total del SIMS tuvo una sensibilidad del 96% pero una especificidad inaceptablemente baja del 14%.Conclusiones: Los resultados indican que el instrumento no es preciso para evaluar la potencial exageración o simulación de los síntomas en el TID.

Dissociative Identity Disorder: Diagnostic Accuracy and DSM-5 Criteria Change Implications.

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) revised the diagnostic criteria for dissociative identity disorder (DID) to more accurately reflect the symptom profile of DID patients. No study has examined how this change affects clinical diagnosis of DID. The present study examined clinician reports of patient symptoms in relation to DSM-IV-TR and DSM-5 DID diagnostic criteria. Data were analyzed from 169 clinicians who participated in the Treatment of Patients with Dissociative Disorders Network Study with a patient they assigned a DID diagnosis. Clinicians evaluated their patients with respect to DSM-IV-TR and DSM-5 DID diagnostic criteria. Researchers determined a clinician-assigned DID diagnosis as "accurate" when the patient's reported dissociative symptoms matched DSM-IV-TR and/or DSM-5 criteria for DID. Most of the clinicians (95.27%) accurately diagnosed DID. Of those accurately diagnosed, 83.85% of patients met DSM-IV-TR and DSM-5 DID criteria, 9.94% only met DSM-IV-TR DID criteria, and 6.21% only met DSM-5 DID criteria. Further examination of responses suggested that possible idiomatic responses to the negative wording of the DSM-5 exclusionary criteria might have accounted for the DSM-IV-TR appearing to fit for a greater number of cases in this study. Changes in the DSM criteria for DID did not substantially change the frequency or accuracy of assigned DID diagnoses, but the removal of the requirement in DSM-5 that self-states regularly take control of an individual's behavior slightly increased the number of individuals meeting criteria for DID.

Healthcare Workers and COVID-19-Related Moral Injury: An Interpersonally-Focused Approach Informed by PTSD.

The COVID-19 pandemic has resulted in a still-unfolding series of novel, potentially traumatic moral and ethical challenges that place many healthcare workers at risk of developing moral injury. Moral injury is a type of psychological response that may arise when one transgresses or witnesses another transgress deeply held moral values, or when one feels that an individual or institution that has a duty to provide care has failed to do so. Despite knowledge of this widespread exposure, to date, empirical data are scarce as to how to prevent and, where necessary, treat COVID-19-related moral injury in healthcare workers. Given the relation between moral injury and post-traumatic stress disorder (PTSD), we point here to social and interpersonal factors as critical moderators of PTSD symptomology and consider how this knowledge may translate to interventions for COVID-19-related moral injury. Specifically, we first review alterations in social cognitive functioning observed among individuals with PTSD that may give rise to interpersonal difficulties. Drawing on Nietlisbach and Maercker's 2009 work on interpersonal factors relevant to survivors of trauma with PTSD, we then review the role of perceived social support, social acknowledgment and social exclusion in relation to potential areas of targeted intervention for COVID-19-related moral injury in healthcare workers. Finally, building on existing literature (e.g., Phoenix Australia-Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence-PTSD, 2020) we conclude with individual and organizational considerations to bolster against the development of moral injury in healthcare workers during the pandemic.

The economic burden of dissociative disorders: A qualitative systematic review of empirical studies.

OBJECTIVE: Dissociative disorders (DDs) are associated with intensive, long-term treatment, suicidality, recurrent hospitalizations, and high rates of disability. However, little is known about the specifics of the economic burden associated with DDs. This worldwide, systematic review examines the results of studies in adults on direct and indirect costs associated with DDs. METHOD: We searched 6 databases and the reference lists of articles. We also approached researchers to identify unpublished studies. No language restrictions were imposed. RESULTS: A total of 1,002 records met the search criteria, of which 29 papers were selected for full-text inspection. Ultimately, of these, we reviewed four empirical studies. We provide a narrative discussion of study findings. Our findings suggest that DDs are costly to society, and that there is a reduction in service utilization and associated costs over time with diagnosing of and specialized treatment for DDs. However, the overall quality of the economic evaluations was low; several types of DDs, comorbid conditions, and costs were not included; and men were underrepresented. Due to the heterogeneity among studies, we could not perform a meta-analysis. CONCLUSIONS: Due to the heterogeneity and low quality of the identified economic evaluations, no firm conclusions about the economic burden of DDs alone can be drawn. Higher quality research, including a detailed description of the study design, population, and primary outcome measures used, utilizing appropriate clinical alternatives and including major comorbidities, is urgently needed to more rigorously assess the economic impact of DDs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

An Online Educational Program for Individuals With Dissociative Disorders and Their Clinicians: 1-Year and 2-Year Follow-Up.

Individuals with dissociative disorders (DDs) are underrecognized, underserved, and often severely psychiatrically ill, characterized by marked dissociative and posttraumatic stress disorder (PTSD) symptoms with significant disability. Patients with DD have high rates of nonsuicidal self-injury (NSSI) and suicide attempts. Despite this, there is a dearth of training about DDs. We report the outcome of a web-based psychoeducational intervention for an international sample of 111 patients diagnosed with dissociative identity disorder (DID) or other complex DDs. The Treatment of Patients with Dissociative Disorders Network (TOP DD Network) program was designed to investigate whether, over the course of a web-based psychoeducational program, DD patients would exhibit improved functioning and decreased symptoms, including among patients typically excluded from treatment studies for safety reasons. Using video, written, and behavioral practice exercises, the TOP DD Network program provided therapists and patients with education about DDs as well as skills for improving emotion regulation, managing safety issues, and decreasing symptoms. Participation was associated with reductions in dissociation and PTSD symptoms, improved emotion regulation, and higher adaptive capacities, with overall sample |d|s = 0.44-0.90, as well as reduced NSSI. The improvements in NSSI among the most self-injurious patients were particularly striking. Although all patient groups showed significant improvements, individuals with higher levels of dissociation demonstrated greater and faster improvement compared to those lower in dissociation |d|s = 0.54-1.04 vs. |d|s  = 0.24-0.75, respectively. These findings support dissemination of DD treatment training and initiation of treatment studies with randomized controlled designs.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Un programa educativo online para personas con trastornos disociativos y sus médicos: Seguimiento de uno y dos años INTERVENCIÓN ONLINE PARA TRASTORNOS DISOCIATIVOS Las personas con trastornos disociativos (TDs) se encuentran sub-reconocidas, con pocos servicios y, a menudo, con enfermedades psiquiátricas graves, caracterizadas por marcados síntomas disociativos y de trastorno de estrés postraumático (TEPT) con discapacidad significativa. Los pacientes con TD tienen altas tasas de autolesión no suicida (ALNS) e intentos de suicidio. A pesar de esto, hay una escasez de entrenamiento sobre los TDs. Reportamos el resultado de una intervención psicoeducativa basado en la web para una muestra internacional de 111 pacientes diagnosticados con trastorno de identidad disociativa (TID) u otros TDs complejos. El programa de la Red de Tratamiento de Pacientes con Trastornos Disociativos (TOP DD Network, en su denominación en inglés) se diseñó para investigar si, en el transcurso de un programa psicoeducativo basado en la web, los pacientes con TD exhibirían un mejor funcionamiento y reducción de síntomas, incluso en los pacientes que generalmente han sido excluidos de los estudios de tratamiento por razones de seguridad. Mediante el uso de videos, ejercicios de escritura y prácticas conductuales, el programa TOP DD Network brindó a los terapeutas y los pacientes educación sobre los TDs y las habilidades para mejorar la regulación de las emociones, manejar los problemas de seguridad, y disminuir los síntomas. La participación se asoció con reducciones en los síntomas de disociación y de TEPT, mejor regulación de las emociones y mayores capacidades de adaptación, muestra total ds = .44-.90, así como reducción de ALNS. Las mejoras en ALNS entre los pacientes más auto-agresivos fueron particularmente sorprendentes. Aunque todos los grupos de pacientes mostraron mejoras significativas, los individuos con niveles más altos de disociación demostraron una mejoría mayor y más rápida en comparación con los más bajos en disociación |d|s = .54-1.04 vs. |d|s = .24-.75, respectivamente. Estos hallazgos apoyan la diseminación de la capacitación en el tratamiento del TD y el inicio de estudios de tratamiento con diseños controlados aleatorios.

Assessing therapeutic change in patients with severe dissociative disorders: the progress in treatment questionnaire, therapist and patient measures.

Background: Treatment research for dissociative identity disorder (DID) and closely related severe dissociative disorders (DD) is rare, and has been made more difficult by the lack of a reliable, valid measure for assessing treatment progress in these populations. Objective: This paper presents psychometric data for therapist and patient report measures developed to evaluate therapeutic progress and outcomes for individuals with DID and other DD: the Progress in Treatment Questionnaire - Therapist (PITQ-t; a therapist report measure) and the Progress in Treatment Questionnaire - Patient (PITQ-p; a patient self-report measure). Method: We examined the data of 177 patient-therapist pairs (total N = 354) participating in the TOP DD Network Study, an online psychoeducation programme aimed at helping patients with DD establish safety, regulate emotions, and manage dissociative and posttraumatic symptoms. Results: The PITQ-t and PITQ-p demonstrated good internal consistency and evidence of moderate convergent validity in relation to established measures of emotional dysregulation, dissociation, posttraumatic stress disorder, and psychological quality of life, which are characteristic difficulties for DD patients. The measures also demonstrated significant relationships in the hypothesized directions with positive emotions, social relations, and self-harm and dangerous behaviours. The patient-completed PITQ-p, which may be used as an ongoing assessment measure to guide treatment planning, demonstrated evidence of stronger relationships with established symptom measures than the PITQ-t. Conclusions: The PITQ-t and PITQ-p merit use, additional research, and refinement in relation to the assessment of therapeutic progress with patients with DD.

Planteamiento: La investigación del tratamiento para el trastorno de identidad disociativo (TID) y los trastornos disociativos (TD) graves que están estrechamente relacionados es poco frecuente y se ha dificultado por la falta de una medida fiable y válida para evaluar el progreso del tratamiento en estas poblaciones. Objetivo: Este artículo presenta los datos psicométricos de las medidas de informes de terapeutas y pacientes desarrolladas para evaluar el progreso terapéutico y los resultados en personas con TID y otros TD: El Cuestionario del progreso del tratamiento - terapeuta (PITQ-t, siglas en inglés de Progress in Treatment Questionnaire - Therapist; una medición mediante informe del terapeuta) y el Cuestionario del progreso del tratamiento - paciente (PITQ-p, siglas en inglés de Progress in Treatment Questionnaire - Patient; una medición mediante autoinforme del paciente). Método: Se examinaron los datos de 177 pares de pacientes-terapeutas (N total = 354) que participaron en el TOP DD Network Study, un programa de psicoeducación online destinado a ayudar a los pacientes con TD a establecer seguridad, regular emociones y manejar síntomas disociativos y postraumáticos. Resultados: El PITQ-t y PITQ-p demostraron buena consistencia interna y evidencia de una validez convergente moderada en relación a las medidas establecidas de desregulación emocional, disociación, trastorno por estrés postraumático y calidad de vida psicológica - dificultades características en pacientes con TD. Las medidas también demostraron relaciones significativas en el sentido establecido por la hipótesis en cuanto a emociones positivas, relaciones sociales, y conductas autolesivas y peligrosas. El PITQ-p completado por el paciente, que puede usarse como una medida de evaluación continua para guiar la planificación del tratamiento, evidenció relaciones más fuertes con las medidas establecidas de los síntomas que el PITQ-t. Conclusiones: El PITQ-t y PITQ-p justifican su uso, investigación adicional y refinamiento en relación con la evaluación del progreso terapéutico con pacientes con TD.

Assessing the predictive ability of the transtheoretical model's heavy episodic drinking constructs among a population of underage students.

The current study examined the ability of the transtheoretical model (TTM) to describe and predict alcohol consumption-related behaviors. Data from 321 first-year students were collected on the first day of classes and the week before finals. Three structural models consistent with the TTM were evaluated and tested. The three models fit the data well and indicated that stage of change was a good predictor of alcohol consumption-related behaviors, current and future, and change in alcohol consumption-related behaviors. These results suggest that interventions aimed at first-year students that concentrate on stage of change and the cons of alcohol use may be effective.

Creative consensus on interpretations of qualitative data: the Ward method.

The Ward method (1987) offers an iterative approach to consensus building that encourages the development and consideration of each contributor's unique perspectives. Collaborators begin by orienting to the method and project-specific goals and then engage in an iterative process, cycling between individual creative work and group meetings. Meetings serve as opportunities to share ideas within a noncritical atmosphere. Paradoxically, much of the work of reaching consensus occurs while collaborators are working independently; across iterations, versions tend to converge as collaborators adapt and adopt what they like of one another's ideas. This article, which was itself written using the Ward method, describes the method, its strengths, and challenges associated with its use.