Comparisons of demographic data of patients with suicide attempts from height.
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",isbn:"978-1-83881-922-4",printIsbn:"978-1-83881-921-7",pdfIsbn:"978-1-83881-923-1",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"dcfc52d92f694b0848977a3c11c13d00",bookSignature:"Dr. Fiaz Ahmad and Prof. Muhammad Sultan",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10454.jpg",keywords:"Agricultural Engineering, Technologies, Application, Sustainable Agriculture, Information Technology in Agriculture, Food Security, Renewable Energies, Precision Farming, Smart Agriculture, Farm Mechanization, Robotics, Post Harvest Technologies",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 25th 2020",dateEndSecondStepPublish:"December 23rd 2020",dateEndThirdStepPublish:"February 21st 2021",dateEndFourthStepPublish:"May 12th 2021",dateEndFifthStepPublish:"July 11th 2021",remainingDaysToSecondStep:"2 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Ahmad is a researcher in the field of agricultural mechanization and agricultural equipment engineering, in-charge of Farm Machinery Design Laboratory at Bahauddin Zakariya University, with expertise in modeling and simulation. He applied for two patents at the national level.",coeditorOneBiosketch:"Renowned researcher with a focus on developing energy-efficient heat- and/or water-driven temperature and humidity control systems for agricultural storage, greenhouse, agricultural livestock and poultry applications including HVAC, desiccant air-conditioning, adsorption, Maisotsenko cycle (M-cycle), and adsorption desalination.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"338219",title:"Dr.",name:"Fiaz",middleName:null,surname:"Ahmad",slug:"fiaz-ahmad",fullName:"Fiaz Ahmad",profilePictureURL:"https://mts.intechopen.com/storage/users/338219/images/system/338219.jpg",biography:"Fiaz Ahmad obtained his Ph.D. (2015) from Nanjing Agriculture University China in the field of Agricultural Bioenvironmental and Energy Engineering and Postdoc (2020) from Jiangsu University China in the field of Plant protection Engineering. He got the Higher Education Commission, Pakistan Scholarship for Ph.D. studies, and Post-Doctoral Fellowship from Jiangsu Government, China. During postdoctoral studies, he worked on the application of unmanned aerial vehicle sprayers for agrochemical applications to control pests and weeds. He passed the B.S. and M.S. degrees in agricultural engineering from the University of Agriculture Faisalabad, Pakistan in 2007. From 2007 to 2008, he was a Lecturer in the Department of Agricultural Engineering, Bahauddin Zakariya University, Multan-Pakistan. Since 2009, he has been an Assistant Professor in the Department of Agricultural Engineering, BZ University Multan, Pakistan. He is the author of 33 journal articles. He also supervised 6 master students and is currently supervising 5 master and 2 Ph.D. students. In addition, Dr. Ahmad completed three university-funded projects. His research interests include the design of agricultural machinery, artificial intelligence, and plant protection environment.",institutionString:"Bahauddin Zakariya University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Bahauddin Zakariya University",institutionURL:null,country:{name:"Pakistan"}}}],coeditorOne:{id:"199381",title:"Prof.",name:"Muhammad",middleName:null,surname:"Sultan",slug:"muhammad-sultan",fullName:"Muhammad Sultan",profilePictureURL:"https://mts.intechopen.com/storage/users/199381/images/system/199381.jpeg",biography:"Muhammad Sultan completed his Ph.D. (2015) and Postdoc (2017) from Kyushu University (Japan) in the field of Energy and Environmental Engineering. He was an awardee of MEXT and JASSO fellowships (from the Japanese Government) during Ph.D. and Postdoc studies, respectively. In 2019, he did Postdoc as a Canadian Queen Elizabeth Advanced Scholar at Simon Fraser University (Canada) in the field of Mechatronic Systems Engineering. He received his Master\\'s in Environmental Engineering (2010) and Bachelor in Agricultural Engineering (2008) with distinctions, from the University of Agriculture, Faisalabad. He worked for Kyushu University International Institute for Carbon-Neutral Energy Research (WPI-I2CNER) for two years. Currently, he is working as an Assistant Professor at the Department of Agricultural Engineering, Bahauddin Zakariya University (Pakistan). He has supervised 10+ M.Eng./Ph.D. students so far and 10+ M.Eng./Ph.D. students are currently working under his supervision. He has published more than 70+ journal articles, 70+ conference articles, and a few magazine articles, with the addition of 2 book chapters and 2 edited/co-edited books. Dr. Sultan is serving as a Leading Guest Editor of a special issue in the Sustainability (MDPI) journal (IF 2.58). In addition, he is appointed as a Regional Editor for the Evergreen Journal of Kyushu University. His research is focused on developing energy-efficient heat- and/or water-driven temperature and humidity control systems for agricultural storage, greenhouse, livestock, and poultry applications. His research keywords include HVAC, desiccant air-conditioning, evaporative cooling, adsorption cooling, energy recovery ventilator, adsorption heat pump, Maisotsenko cycle (M-cycle), wastewater, energy recovery ventilators; adsorption desalination; and agricultural, poultry and livestock applications.",institutionString:"Bahauddin Zakariya University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Bahauddin Zakariya University",institutionURL:null,country:{name:"Pakistan"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"8",title:"Chemistry",slug:"chemistry"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"252211",firstName:"Sara",lastName:"Debeuc",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/252211/images/7239_n.png",email:"sara.d@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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According to the WHO, the yearly mortality due to suicide worldwide is approximately 800,000 people. What is more important is the fact that it affects mainly young people, suicide being the primary cause of death in the age group of 25–34 years [5]. The mean incidence of suicides across Europe in 2013 was of 11.7 deaths per 100,000 people. Low rates, under 8 deaths per 100,000 inhabitants were recorded in Italy, Malta, Cyprus and the United Kingdom. The lowest incidence was observed in Greece (4.8 cases per 100,000 people) [6]. There was a lag between the beginning of the economic crisis in Europe, and the manifestation of its effects on the Greek population. These became evident 3 or 4 years later, in the form of a reduction of household income and an increase in the rate of unemployment [7, 8, 9].
Causes for this mechanism of injury include both accidental falls and deliberate suicide attempts [10]. The latter constitutes a major social problem, with implications for the entire society, but particularly for the affected family. The psychological profile of people committing suicide is complex and unique for each case [11]. Thus, identifying contributing factors that may lead to suicide and establishing strategies for the safekeeping of mental health in communities are of paramount importance.
The type of injuries incurred after a fall constitute a unique pattern of blunt trauma, with a characteristic distribution of damage (multiple lesions in a variety of body areas) [1, 12, 13]. The most common form of trauma are fractures, followed by other areas, such as the head, the thorax, the abdomen as well as the retroperitoneum, being injured by varied degrees [14]. The quantity and the quality of traumatic load absorbed depend on factors like the height from which the fall occurred, the part of the patient’s body that had the first impact, the surface where the impact occurred and the victim’s age, taking into account the associated comorbidity, and reduced physiologic reserve that advanced age implies [15, 16, 17]. Anticipation and prediction of the exact areas being injured are not possible, because of the multitude of factors involved, and the exact unpredictability of the fall’s kinematic [18, 19].
As aforementioned, one can infer that the differential diagnosis of falls from height from other types of blunt trauma (for example, a road-traffic-collision with expulsion of the occupants from the vehicle) is difficult. Thus, a high index of suspicion must be maintained concerning the initial cause in cases of polytrauma in victims with an unknown history [20]. An array of papers have dealt with injury-related deaths in general, while others have differentiated between unintentional and intentional injury-related deaths [21, 22, 23, 24]. There are few studies though that have looked into patients with intentional or unintentional injuries, due to a fall from height, at a single centre [13, 25].
As noted by research in the past, self-harm due to a fall is a rare phenomenon, being responsible for 4–7% of deaths from suicide in the developed world [26, 27, 28, 29]. On the other hand, studies have shown that psychiatric disorders are a frequent finding in patients suffering trauma [30, 31, 32]. Nevertheless, the connection between mental disorders and specific injury patterns has not been adequately described. Furthermore, the elucidation of patterns of injury incurred after accidental falls and after intentional suicide jumps, might be of help to forensic pathologists while investigating the circumstances of a death after a fall from height.
From January 1990 to October 2012, 64 patients (15 males and 49 females) were studied as a result of falls from height. Fall from height ≥ 3 m is classified as high energy trauma in accordance to ATLS guidelines [33]. The mean patient age was 34 years (range 16–65 years). These 64 cases comprised our series and, for comparison, were divided into those without mental disorders (n = 32, group I) and those with mental disorders (n = 32, group II). Group II cases were further stratified according to their psychiatric diagnosis.
The principles of Advanced Trauma Life Support were followed in the management of all patients. Basic laboratory screening included haemoglobin level, prothrombin time, type and crossmatch and arterial blood gas analysis. Data collected included age, gender, associated trauma, injury severity score (ISS), Glasgow Coma Scale (GCS), haemodynamic status (systolic blood pressure less than 90 mm Hg on arrival), length of intensive care unit (ICU) and hospital stay.
Also, the following trauma variables were analysed: specific intracranial injuries (epidural, subdural and subarachnoid haemorrhage and brain contusion), spinal injuries (cervical, thoracic and lumbar spine), thoracic injuries, specific intra-abdominal injuries (liver, spleen, kidney, and hollow viscus) and specific fractures (pelvis, femur and tibia). The diagnosis of mental disorder was ascertained by psychiatric specialists using the criteria of the International Classification of Disease Ninth Version Clinical Modification (ICD-9CM).
The mean height of fall was 5.4 m (range, 3–25 m). The patients were separated in two groups: group I, without mental disorders (n = 32), and group II, with mental disorders (n = 32). The demographic data, including age, gender, height of fall, ISS, GCS, initial shock (SBP <90 mm Hg), hospital stay (days), ICU stay (days) and deaths are summarized in Table 1. The mean hospital stay was 29 days (range 19–45) and the mean ICU stay was 9 (range, 5–13) (Table 1).
Data | Patients |
---|---|
Age | 35 (18–65) |
Gender (M:F) | 15:49 |
ISS | 20 (12–58) |
GCS | 9 (6–13) |
Haemodynamic status-SBP <90 mmHg | 34 |
Hospital stay (days) | 29 (19–45) |
ICU stay (days) | 9 (5–13) |
Deaths | 13 |
Comparisons of demographic data of patients with suicide attempts from height.
Concerning their background psychiatric disorder in group II, the diagnosis was schizophrenia in 32 patients, depression in 12, drugs or alcohol abuse in 3, personality disorder in one, manic depression in one, another psychiatric condition in one and 14 cases without a specific diagnosis (generally marital or work related).
Patients due to suicide attempts from height comprised of 15 males and 49 females with a mean of age 35 years (range: 18–65 years). Of those, 16 were single, 14 were married and 2 were divorced. Thirty-three patients were employed, 6 were housewives, 7 were unemployed, 3 were students/pupils and 15 had various occupations. As far as religion was concerned, 48 were Christian Orthodox, one Roman Catholic, one Jewish, one Muslim and 13 of other religions.
Regarding their family status: 20 had children, 6 had only their parents, 3 had only their spouse, 2 had a step family, 2 had parents who were divorced, 6 had parents and/or siblings, one had both parents and children and 24 had no family at all.
The falls had occurred from a roof or balcony in 39 cases, from a window in 12, from a bridge in 7 and inside the house in 6. The mean injury severity score (ISS) was 20 (range 12–58) for all victims of fall. Sixteen patients arrived at the emergency department in shock. The most common body region having sustained severe trauma were the fractured extremities and/or spine, followed by the chest, the head and the abdomen for both groups (Table 2).
Fall from | Patients |
---|---|
Roof/balcony | 39 |
Window | 12 |
Bridge | 7 |
Inside the house | 6 |
Associated injuries | |
Abdominal trauma | 4 |
Thoracic trauma | 32 |
Head injuries | 16 |
Extremity fractures | 199 |
Spinal fractures | 32 |
Location where the fall occurred and associated injuries.
Head injuries were revealed by CT scan in 16 patients. The mean GCS was 9 (range 6–13) for both groups. The most common intracranial injury was brain contusion and subarachnoid haemorrhage, followed by subdural hematoma and epidural hematoma. The incidence of subarachnoid haemorrhage in the suicide group was significantly higher than in the accidental group.
Associated abdominal injuries were present in 4 patients. The most common injury was liver laceration, followed by kidney and spleen laceration. One died with an operative finding of a large central retroperitoneal haematoma due to a vena cava rupture. In the remaining 3 patients, ultrasonography showed minimal intraperitoneal blood and these patients were not operated on. Thoracic injuries were present in 32 patients. The most common of these were rib fractures—26 cases. Twelve of these patients had a haemopneumothorax and 6 had a sternum fracture. Conservative treatment with assisted ventilation was necessary in these cases (Table 3).
Patients | |
Skull, thorax and upper extremities | |
Skull | 16 (25%) |
Shoulder | 4 (6.2%) |
Scapula | 6 (9.3%) |
Sternum | 6 (9.3%) |
Ribs | 26 (40.6%) |
Humerus | 8 (12.5%) |
Elbow joint | 8 (12.5%) |
Distal radius | 7 (10.9%) |
Hand | 4 (6.2%) |
Spinal fractures | 32 (50%) |
Pelvis | 27 (42.1%) |
Lower extremities | |
Acetabulum | 9 (14%) |
Femoral neck | 38 (59.3%) |
Femur | 18 (28.1%) |
Knee joint | 17 (26.5%) |
Tibia | 19 (29.6%) |
Ankle joint | 36 (56.2%) |
Calcaneum | 34 (53.1%) |
The distribution of fractures in percentage across body region for the two groups of patients.
Upper extremity fractures were found in 37 patients, while pelvic and lower extremity fractures were found in 198 cases. Spinal fractures were noted in 32 patients. As far as the level of injury was concerned, in 16 cases, it was in the lumbar level, in 9 cases in the cervical, in 5 cases in thoracic and in 2 cases the sacral vertebrae were concerned. Regarding the neurologic deficit, in 23 cases, the injury was incomplete (14 with ASIA C and 9 with ASIA D), and in 9 cases, it was complete (4 with ASIA A and 5 with ASIA B). Further details with our data of 32 patients with spinal cord injury as a result of deliberate self-harm have been published previously [34]. It seems that the neurological complications of spinal injuries were correlated with the increase of the height from which the fall occurred.
Patients with psychiatric disorders were more frequently shocked on arrival at the emergency department than those in the accidental group, the most common reason for death being head injury. Fatalities were more common when patients fell from greater heights (over 4 m), or when their head hit a hard surface, such as concrete.
The final causes of inpatients’ death were: head injury in 8 cases, multiple organ failure in 3 cases, pneumonia in one case and cardiac complications in another one. The majority of patients who died of organ failure had sustained significant head injury. In one case, death occurred after a second suicide attempt 2 years later.
Each patient underwent a psychiatric evaluation by a consulting psychiatrist as soon as his condition and cooperation permitted. The assessment comprised of an interview. Regarding the type of treatment for the spinal fracture—dislocations, instrumentation devices included titanium rods, transpedicular screws, sacral bars and bone grafting in all patients. No new suicide attempt was recorded during the hospital stay.
All patients were discharged from hospital approximately 6–8 weeks after the operation with a custom-made thermoplastic thoracolumbar or lumbosacral orthosis for another 8 weeks and instructions for physical therapy and rehabilitation programs. The mean follow-up was 6 years (12 months to 10 years range). At follow-up, 27 patients were available for evaluation due to the death of 5 patients, 1–3 years post initial injury, because of suicide in one case (patient 7 of group II) and medical complications in 4 cases [renal failure in 3 cases (patients 8, 14 and 30 in group II) and pneumonia in one (patient 21)]. In the remaining patients, new unsuccessful attempts were recorded in 2 cases (7%) due to psychiatric disorders, 1–3 years after the first attempt (patients 10 and 24). All survivors received psychiatric follow-up. The overall mortality was significantly higher in those patients who fell from more than 10 m.
Suicides and suicide attempts constitute a major concern for public health services, with implications for both families and society [35]. Trauma incurred due to falls from height poses a great burden on health services due to its severity. This is particularly important if we take into account the fact that this is a largely preventable mechanism of injury. Prior knowledge of the possible traumatic patterns incurred after a fall from height can prove helpful in the initial evaluation of this group of patients. From an epidemiologic point of view, trauma due to falls may occur across all age groups, but it is the two extremes, the very young and elderly, which are particularly susceptible to it [36].
In this study, we have considered two groups of patients. Group I represented patients with no mental disorders and group II with mental disorders. It is quite difficult to identify someone who is prone to committing suicide. In addition, the observed number of suicides and suicide attempts being committed at a younger age (i.e. adolescence) has been a cause of concern worldwide and particularly in Europe [37]. The male-female ratio of suicide attempts varies across age groups. Thus, in the younger age group (15–24 years old), it is 1:1.9; and in the middle age group (45–54 years old) it is 1:1.7. This ratio further decreases for those older than 55 years to 1:1.4 [38]. In this study, the male-female ratio was 1:3. The female sex was associated with an increased likelihood of death due to a higher amount of energy involved in their attempted fall.
According to other studies [39, 40], young males tend to repeat suicide attempts more frequently than females and the methods used by them lead to an increased mortality. A suicide attempt in the past is a red flag for a possible attempt in the future; so, there is a strong correlation between suicide attempts and deaths from suicide both regionally and nationally, and particularly in young males [41]. Also, there is a strong correlation between repeated attempts and completed suicide, especially in the group of males who have used a violent method [42, 43].
The study by Dickson et al. had the aim of establishing a correlation between mortality and various factors, such as the patients’ injury severity score (ISS), the height from which the fall took place, the patient’s intention and the body regions that were injured. In addition, the height of the fall strongly correlated with the patient’s ISS and was an important predictor of mortality [44]. Head and/or chest injuries, if due to a fall from height, were strongly associated with an increased incidence of death. According to the authors, this mechanism of injury should be a triage priority when tasking ambulances. In addition, the best way of treating these injuries is their prevention. No other significant predictors of mortality were found in this study.
In the case series by Kent and Pearce, 282 suicide attempts were studied, 13 of which were completed. Of those, 8 happened at home, all patients were older than 49 years; and in 7 out of 8 deaths, ladders were implicated [45]. The retrospective study by Petratos et al. analysed in detail the musculoskeletal traumatic pattern resulting from falls from height, and focused particularly on the correlation between specific fracture patterns and the height from which the fall happened, as well as on the causation of the fall (suicide attempt vs. accident). According to their findings, with an increase in the height from which the fall occurred, the frequency of limb, thoracic and pelvic fractures also increased. Such a correlation was not evident for head injuries. Nevertheless, the anatomical regions having sustained fractures (including the cranium) varied in accordance with the height of the fall. Thus, we can infer a mechanism of injury that is varying proportionately to the height of the fall. There was no significant difference between the patients who attempted suicide and those who fell by accident as far as the number of fractures incurred or the regions having been injured were concerned. Nevertheless, with regard to our results that have been published previously, patients who attempted suicide had a significantly greater number of bilateral lower limb fractures than their accidental fall counterpart. In addition, logistic regression analysis shows a significant correlation between the cause of the fall and the presence of lower limb fractures. According to the authors, further research is necessary in order to establish a correlation between incurred traumatic pattern, the height of the fall and the patient’s intention [46].
Choi et al. in his recent study attempted to differentiate the characteristics of traumatic pattern between intentional and non-intentional falls [47]. In addition, he attempted to determine prognostic factors for suicide attempt-related injury and promote adequate measures for the prevention and management of such injuries. In this study, 8992 patients with an accidental fall (non-intentional group) and 144 patients who committed a suicide attempt (intentional group) were included. Falls from a height greater than 4 metres were more frequently encountered in the intentional group. Death prior to patient’s arrival in the accident and emergency department occurred in 54.9% of the cases of suicide attempt. Patients within the intentional group, having sustained increased traumatic load, had fallen from higher, were older and were more likely to be of lower educational level (high-school graduates, instead of college). Due to the fact that injuries sustained after an intentional fall were more likely to have a reserved outcome, the authors highlighted the importance of prevention. Such measures include telephone support and counselling lines, the installation of signs advising against suicide in high risk areas for an intentional fall, such as bridges, along with suggestions for government-coordinated programs aiming for the education of the public and the improvement of social conditions generally and the support of the community and family in particular.
The reasons behind a suicide attempt are multifactorial, hard to quantify and unique in every case. Nevertheless, the study of multiple suicide attempts puts into evidence some risk factors that would lead to such a decision. These are common across all age groups and include: the presence of mental illness, either currently or in the past, a history of alcohol or drug dependence, as well as the presence of depression [10]. Epidemiologically, one out of five persons who have attempted suicide will try once more within a year, and 10% of them will succeed in the end. Drug ingestion is the most common mechanism for a suicide attempt. Violent mechanisms such as hanging, falls from height and use of weapons are not common [48]. The persons who have attempted suicide by falling from height usually become polytrauma patients. The types of injuries incurred are two: deceleration injuries due to inertial phenomena, usually at viscera with vascular pedicles, and direct impact injuries [49].
The severity of fractures incurred will depend on factors like the area over which the impact is applied [50]. The smaller the area of spread of the impact, the greater the local load. Therefore, patients landing on their legs tend to suffer more severe injuries than those who have landed on their flanks, or prone, or supine [51]. Patients due to accidental falls mostly suffered spinal fractures and upper extremities fractures in an attempt to protect themselves. Patients due to suicidal high falls attempts suffered mostly of lower limb fractures, pelvis, spinal fractures and head injuries. Distal radius and hand was the most common affected region in upper extremities in patients with non-intentional falls, in an attempt to protect mainly the head and grab something stable to prevent further fall. In patients with intentional falls, kinetic energy is absorbed mainly by the lower limbs, pelvis, spine and head, leading to characteristic fracture patterns [52]. The most common cause for death is head injury [51, 53, 54] and this is accordance to our results. Turk and Tsokos reviewed 68 medicolegal autopsy cases (22 females, 46 males, age range 13–89 years) of fatal falls from height from 1997 to 2001 [55]. The cause of instant death was head trauma in 24 (35%), internal blood loss in 9 (13%) and polytrauma in 30 (44%) cases. Other causes of death, when the individuals survived the trauma for a longer period, included septic multiple organ dysfunction syndrome and pulmonary embolism. In general, suicides were from greater heights than accidents (mean height 22.7 m for suicides and 10.8 m for accidents, respectively). Strikingly, severe head injuries predominantly occurred in falls from heights below 10 m (84%) and above 25 m (90%). Head trauma was the cause of death in 11 of the 19 cases that were from 9 m or less (58%). Of all cases, 51 (75%) died within a few minutes. A survival time of several hours up to 1 day was observed in 8 cases. Nine patients survived for several days (up to 16 days). Five of them fell from heights below 10 m. Patients with intentional fall from height have a higher early mortality than patients due to accidental fall from height [56].
The easiest way to underline the suspicion that the mode is suicide is if a suicide note is found at the jumping site; this is, however, closer to being the exception than the rule. Analysing the distance of the body from the site of descent may sometimes also help us determine the manner of death. The distance of the body from the site of descent includes the falling height and the horizontal distance. The falling height in suicide was statistically higher than that in accident [57, 58]. For similar heights, Wischhusen et al. have demonstrated that in passive falls, the horizontal distance is usually farther than jumps [59]. From a mechanical point of view, during a fall from height, potential (dynamic) energy is converted into kinetic and this leads to fractures upon impact. Another important factor of the severity of injuries is the height of fall, as the kinetic energy is increasing due to acceleration during the fall and is maximum at the time of impact [60]. In suicide falls, kinetic energy is absorbed mainly by the lower limbs, pelvis and spine, leading to characteristic fracture patterns. In accidental falls, patients most probably extend their arms and flex their hips, which lead to a damping effect that protects the spine [61]. Hence, the most important determinant of survival after a free fall is the position of the body at the time of impact [49]. There were only 3 patients (cases 1, 22 and 31) in group II who have sustained solely upper extremity fractures. The most common body position at the time of impact is with the patient standing and landing with the lower extremities first. This usually leads to calcaneal or pilon fractures, as well as thoracolumbar fractures. If the impact takes place with the patient seated, then higher thoracic or cervical injuries are more likely to happen, which are associated with a higher rate of mortality. Finally, an unpredictable fracture pattern takes place when the victim suffers multiple secondary impacts, in various postures, after bouncing from the primary impact. The amount of injury incurred will depend on the rate of dissipation and absorption of energy, through the patient’s body.
According to the paper by Teh et al., there is a difference to the traumatic pattern incurred by jumpers compared to fallers [13]. Namely, the jumpers tend to impact their dominant lower limb first, as well as sustaining right sided thoracic injuries in the process. We did not confirm the above-mentioned findings in our study. The severity of spinal cord injuries was more important in the suicide than the accidental group [52]. This was in accordance with studies performed in the past, which also showed the early neurologic involvement in such cases. As far as prognosis of spinal cord injury is concerned, complete injuries will be unaltered both in level and extent in a year’s time. On the other hand, incomplete injuries may show signs of improvement for a period of 2 years after the impact [62]. Our results regarding prognosis for ambulation in ASIA A patients and for functionality in ASIA C patients are in accordance with current knowledge [63].
Anderson et al. performed a retrospective study, regarding the rehabilitation outcome of patients with spinal cord injury, as a result of deliberate self-harm (DSH) [29]. According to them, spinal fractures in the DSH group were mainly the result of falls from height. Underlying causes were revealed, such as psychiatric disorders and substance abuse, necessitating formal psychiatric review. There was no difference in short-term rehabilitation results between the DSH and accidental spinal cord injury group. In addition, DSH seemed to impact the length of stay only in patients with a spinal fracture, but without cord injury.
According to the literature, there are three studies on the subject of acute spinal cord injury following a suicide attempt that stand apart. The first is by Stanford et al. In his paper, 56 cases were followed over a period of 30 years (1970–2000). Fifty five cases were due to a fall from height and one open injury, through the use of a gun. Follow-up of 8 years on average was available for 47 cases (84%). The vertebral levels most frequently injured were C5 and L1. About 23 patients suffered from a complete spinal cord injury and 32 had a severe traumatic load (ISS > 15). The psychiatric background of these patients included personality disorder in 27, schizophrenia in 16, depression in 14 and substance abuse/dependence in 20. Of these patients, 4 were successful in subsequent suicide attempts [28].
The following two studies on this subject are from the UK [26] and Denmark [27]. Both of those are observational and retrospective, with a long follow-up. According to the latter, there is an increasing incidence of suicide attempts and associated spinal cord injury from 1965 to 1987. Approximately one third of the patients who attempted suicide suffered from schizophrenia. According to other papers [64, 65], schizophrenia is strongly correlated with falls from height (from bridges in particular). There were 7 patients in our study who have sustained a fall from a bridge. Damage control surgery principles are followed initially for the treatment of life-threatening injuries and for both limb and spinal trauma [66]. The primary goals of fracture fixation are timely mobilization and safe transfer to psychiatric services. Conservative treatment measures are not usually recommended for this group of patients.
Our findings are in accordance with relevant bibliography [67, 68], regarding the psychiatric background of patients who attempt suicide by falling from height. The spectrum of conditions encountered encompasses bipolar disorder, substance dependence and abuse, personality disorder and schizophrenia.
From an epidemiological point of view, schizophrenia is encountered in 5–10% of cases of suicide attempt. These patients may have well planned their suicide or even suffered from an active self-harm ideation. From the above-mentioned, we gather that management of these patients from a trauma point of view must take into consideration their psychiatric needs. The latter may cause significant disturbance in the delivery of medical care [69]. Most of the patients in this study had a positive response following adequate psychiatric intervention. Hence, we gather that prevention and early identification of persons at risk for a suicide attempt with the use of appropriate screening tools by health care professionals are invaluable.
Education of medical and nursing staff regarding the demands and particularities of care of this population, suffering from both spinal cord injury and psychiatric disorders, cannot be overemphasized. Regular follow-up with multidisciplinary team input and future research are necessary for the provision of high-quality care to this population.
According to the literature, it has been difficult to obtain comparable international data on suicide attempts, owing to disparities in definitions, survey designs and study methods, because the combination of free falls and mental disorders produces a unique group of patients. It has been our experience that psychiatric conditions, and especially the suicidal risk, should be evaluated and treated as early as possible during the orthopaedic or surgical hospitalization. Management requires both psychopharmacological therapy and psychotherapy. It has to be directed towards the achievement of symptomatic relief and, if possible, towards the remission of the primary psychiatric disorder.
The management of these patients in the orthopaedic or surgical ward is difficult, because of restlessness, non-cooperation of the patient and the problem of staff inexperienced in handling the psychiatric patient. When prolonged orthopaedic and rehabilitation management are necessary, it is suggested that the patient be transferred to a psychiatric hospital while continuing the necessary orthopaedic treatment. The outcome data provide critical information concerning those individuals who have attempted suicide and suggests future methods for the identification of suicidal factors.
The authors declare that they have no conflicts of interest.
Consciousness is a complex term to tackle objectively due to its broad epistemological spectrum. From a clinical view, consciousness has been neurophysiologically and behaviorally parameterized for its assessment [1, 2]. It is a central nervous process (reduccionism) that multiple neural long-range connections control (conexionism) and that is teleonomically goal directed. This neurofunctional point of view converges with theories about the emergence of new features in complex systems [3]. Various authors propose that high brain connectivity between distinct and distant neural groups is an elemental characteristic for the emergence of consciousness [3, 4, 5]. In this respect, consciousness is a neurophysiological phenomenon regulated by different brain networks that create qualia, the subjective experience of consciousness [6, 7, 8, 9, 10, 11].
\nConsciousness should be interpreted as a physiological state of the central nervous system that changes over time and space. This functional mutability allows high-order cognitive functions to take place [6, 12, 13] to produce an overt and/or covert behavior that can be measured via direct observation or neuroimage [14, 15, 16]. All of these intermingled processes are supported via various brain networks that integrate endogenous and exogenous information with the intention of responding effectively to organic and psychological demands [6, 8, 11, 17, 18]. In this regard, acquired brain damage can impair the regular activity of brain networks, disorganizing cognition and behavior (mild, moderate, or severe brain damage), or even inhibiting the experience of consciousness (disorder of consciousness) [14, 19, 20, 21]. Therefore, from a clinical view, the structural and neurophysiological integrity of the neural substrate that underlies consciousness will determine the functional behavior of individuals [6, 22, 23]. Thus, consciousness can be described as a basal, dynamic, and transitive brain state that supports the high-order cognitive processing of information to produce suitable behaviors for environmental demands [24].
\nA huge number of theories seem to agree on many assumptions about consciousness, although they diverge regarding the descriptive approach. Some of them, such as the Global Neural Workspace Theory, focus on its neurophysiological components [11]. Meanwhile, others, such as the Global Workspace Theory, focus on its cognitive components [25]. In addition, the Integrated Information Theory focuses on its computational components [8, 26, 27]; the Temporo-Spatial Theory of Consciousness focuses on its inner space and time characteristics [6]; and the PFC-feedback System [28] focuses on its feedforward and feedback components. Crick and Koch introduced one of the first approaches to the study of consciousness [9]. Their approach posits that the experience of consciousness will be determined based on the long-range connectivity between the front and back parts of the brain. All of these authors and theories have shed light on the phenomena of consciousness and have probably contributed to the very first theoretical foundations for the study of consciousness objectively:
Consciousness depends on bioelectrical and biochemical brain activity.
Some neurophysiological processes are required to experience consciousness as awareness (i.e., the object or event has to trigger a P300 wave on the cortex).
These neurophysiological processes are regulated via various neural groups that process information in a rapid, automatic, and stereotypical manner (back brain), as well as via other neural groups that process information in a slow and voluntary manner (front brain).
Consciousness needs long-range connectivity between distinct and distant brain areas.
These long-range connections (probably in beta bands) assemble distinct and distant neural groups into extended neural networks that regulate various physiological and phenomenological dimensions that are necessary for the experience of consciousness.
One of the main neural models that are emerging currently about neural processing is the “predictive coding model” [29, 30]. This model posits that neural processing occurs within feedforward and feedback loops between upper and lower brain structures and slices. Lower structures/slices send predictions to upper structures and these structures send back error predictions to adjust neural processes to make the ongoing behavior efficient [29, 30, 31, 32, 33]. Llinás has already suggested that consciousness could be more related to a close-loop neural network than to the emergent consequence of a sensory input [34]. In this sense, a functional and preserved consciousness could depend on the predictive codification between inferior (brainstem and thalamus) and superior brain structures (cortex), where the prefrontal cortex (PFC) receives “end-of-the-line” bottom-up predictions and sends top-down error predictions to the thalamus to adjust new top-down projections [24, 35, 36, 37, 38, 39, 40].
\nDespite all of the theories and experimental evidence about the neural networks involved in consciousness, no global theoretical framework exists to describe how these neural networks operate to produce and maintain consciousness. The present chapter will introduce a neurofunctional model that organizes the interaction and functioning of the neural networks into three neurofunctional loops: (1) the Brainstem-Thalamic neural loop (B-T neural loop), (2) the Thalamo-Cortical neural loop (T-C neural loop), and (3) the Cortico-Cortical neural loop (C-C Neural Loop). Each of these loops are formed via differentiated and semi-independent neural structures that are involved in specific aspects of the phenomenological consciousness.
\nThe brainstem plays a key role in the regulation of consciousness due to the control that it exerts to the Ascending Reticular Activating System (ARAS) and therefore to wakefulness (wakefulness and awareness are the two clinical dimensions typically related to consciousness) [41, 42]. The ARAS is composed of myriad brainstem nuclei (dorsal raphe locus coeruleus, median raphe, pedunculopontine, and parabrachial nuclei), with connections to the thalamus, hypothalamus, and basal forebrain [42, 43, 44, 45, 46, 47, 48], and even with the prefrontal areas [49] and the precuneus (Pcu) [50]. The lower dorsal ARAS connects the pontine reticular formation to the intralaminar thalamic nuclei (ILN), the lower ventral ARAS connects the pontine reticular formation to the hypothalamus, and the upper ARAS connects the intralaminar thalamic nuclei to the cerebral cortex [51, 52, 53, 54]. Whereas hypothalamic-basal forebrain pathways regulate sleep-wakefulness cycles [48, 55, 56], the ILN, as part of the non-specific thalamic nuclei, can block thalamocortical rhythms and therefore the emergence of arousal and awareness [22, 57, 58, 59, 60]. Baars [18] called this circuit the Extended Reticular-Thalamic Activating System, which he considered to be the principal neural assembly in the experience of consciousness.
\nA significant amount of evidence points out that reciprocal interactions between the thalamus and cortex are a fundamental component of the proper functioning of the thalamo-cortical system [61], which is related to consciousness [62]. This thalamo-cortico-thalamic connectivity starts to develop in the late prenatal and early postnatal stages [61, 63, 64], and the efficient deployment of these developmental processes will determine the functional state of the thalamo-cortical system in the adult stage [65]. The thalamus has been proposed as the main neural structure of the thalamo-cortical system, as it operates as a regulator of cortical functional connectivity, whereby it is involved in the ongoing cognitive processes [66, 67, 68, 69, 70]. The thalamus can be divided into three nuclear groups: first-order thalamic relay nuclei, higher-order thalamic relay nuclei, or non-specific thalamic nuclei. First-order thalamic nuclei send afferent projections to the primary sensory cortical areas, whereas higher-order nuclei receive projections from the primary sensory cortical areas and send these projections back to the higher visual cortical areas forming the cortico-thalamo-cortico circuits. Finally, nonspecific thalamic nuclei are those that receive projections from the ARAS and send diffuse projections throughout the brain [71, 72, 73]. The nonspecific thalamic nuclei are composed of three main nuclear groups: the thalamic reticular nucleus (TRN), the ILN, and the midline thalamic nuclei (MTN). The TRN-ILN-MTN thalamic axis has been related to consciousness [22, 62, 74] with strong implications in the distribution of neural information throughout the brain [24].
\nThe functional extent of each nonspecific thalamic nuclei is related to the control and regulation of a specific cognitive domain [24] . The TRN is one of the main neural nodes that regulates the activity of the thalamus and therefore the activity of the entire thalamo-cortical system [75, 76, 77]. The TRN receives afferent glutamatergic projections from the entire brain, and in turn, it sends only efferent GABAergic projections to the thalamus, thus regulating thalamo-cortical and cortico-cortical activity [28, 78, 79]. On a morphological level, the TRN is divided into sensory and motor regions [80]. Whereas the sensory region modulates attentional processes via connections with the prefrontal cortex [38], the motor region is involved in limbic and motor processes due to high connectivity with the ILN-NMT, the ventrolateral, and the anterior thalamic nuclei [81, 82, 83, 84, 85]. Various authors have referred to the involvement of the TRN in the attentional processes as the “attention spotlight” and “attentional door” that regulate the flow of information between the thalamus and the cortex [35, 86, 87]. The capacity to control neural information throughout the brain is due to the inhibition that it exerts to the thalamic nuclei [37, 76, 86]. This inhibition mechanism underlying the “attention spotlight” selects the information needed to face psychological and physiological demands while suppressing those that are not relevant. Some authors suggest that the TRN is involved in the content of consciousness by controlling selective attentional processes and the thalamus activity [28, 86]. According to Crick [35], the short-term synaptic plasticity of the TRN could influence first-order thalamic relay nuclei in the formation of temporal connections between brain areas related to the content of consciousness [35]. Hence, this capacity to modulate the content of consciousness could be mediated by the control of attentional processes [88, 89, 90].
\nOn the other hand, the functions of the ILN and the MTN are functionally differentiated, but their activity are highly dependent [91, 92, 93, 94, 95]. Regarding consciousness, both nuclei (due to its multiple connections with the ARAS) activate the excitability of the cerebral cortex to maintain vigilance and arousal [42, 58, 59, 60, 76, 91]. For instance, the ILN send and receive projections from the prefrontal, motor, and parietal cortices. Meanwhile, the MTN is connected to the medial prefrontal cortex (mPFC) and the hippocampus (HPC). These diffuse connections spread to the cortex, thus allowing the synchronization of brain activity through the adjustment of the brain waves’ phases. Thus, distinct and distant neural groups assemble into cortico-cortical networks to facilitate the flow of neural information [91]. In addition, The ILN and MTN are also involved in the regulation of the striatal-thalamocortical circuits [96] due to the multiple efferent inhibitory connections that receive from the TRN, the basal ganglia, and the reticular formation of the ARAS [97, 98, 99]. These connections with the striatum, the brainstem, and the cortex highlight the relevance of the ILN and the MTN in the motor, somatic, and visceral functions, which are essential for controlling arousal, perception, and even emotion expression [100].
\nSpecifically, the ILN have been associated with the regulation of cortical activity and the restoration of consciousness [22, 68, 101, 102]. The anterior region of the ILN react to motor inputs [103, 104], whereas the posterior region organizes motor, limbic, and associative information [60, 97, 105, 106]. Projections to limbic structures and sensori-motor areas suggest the relevance of the integration of the affective and motor functions that underly propositional behaviors [107]. In addition, they are involved in tasks that require the focalization of attention and the selection of actions for unexpected events [108, 109]. Kinomura and colleagues pointed out that arousal and attention require the simultaneous activation of the reticular formation of the midbrain and the ILN [110]. This evidence places the ILN as the basic neural nodes for the integration of brain functions, such as arousal, attention, and motor control, to trigger high-level cognitive performance [86, 104, 110, 111, 112, 113]. This functional characteristic of the ILN in the regulation of the arousal has been employed for deep brain stimulation in cases of minimally conscious state. Schiff [22, 114] showed that stimulating the ILN in minimally conscious state patients could improve their motor behavior, but without showing any sign of “real” consciousness [22, 114, 115]. Therefore, although the ILN seems to be involved in consciousness, it cannot produce a constant and fluent stream of consciousness by itself.
\nFinally, the MTN have been reported as the main “gateway” of information to the HPC and the limbic system, with a high dependence on the individual’s arousal levels [116, 117, 118, 119]. Concretely, the nucleus reuniens and rhomboid of the MTN jointly with the mPFC and the HPC form a specialized neural circuit that contribute to learning and to the cognitive flexibility [120], probably due to its relationship with the working memory [116, 117]. This circuit constituted by the MTN-HPC-mPFC could be modified via the functional state of the TRN [121] and also affect the content of consciousness [122]. Other authors propose that the circuit formed via the orbital and mPFC, the amygdala, the hypothalamus, and the MTN could also be involved in the visceral and emotional control of human behavior [123, 124, 125, 126, 127, 128]. The MTN directly influences the arousal and attentional processes through its involvement in emotional regulation [129]. Thence, it is implicated in the emotional adjustment of behavior in a continuously changing environment [130]. According to these authors, the MTN could mediate the selection of the most suitable behavior depending on the emotional tone inputs received in a specific moment [118, 130]. This evidence places the MTN as a remarkable interface between the diverse structures of the limbic system to integrate memory, emotion, and cognition [100, 119, 129, 131].
\nAll of this evidence points out that the TRN-ILN-MTX thalamic axis and its connections throughout the brain are essential components for being conscious and aware of our surroundings due to the axis’s capacity to place the T-C neural loop in an optimal functional state [24, 35]. In this sense, it is important to distinguish between “be aware” and the “formation of consciousness.” Being aware of something means that our cognitive systems are prepared to receive and manipulate the content of consciousness, but the formation of the content of consciousness depends on other neural processes. The content of consciousness is formed mainly in the posterior cortex [132, 133] through cortico-thalamo-cortico circuits, which facilitate connections among various sensory cortical areas in the “content-specific Neural Correlates of Consciousness (NCC)” [70, 133, 134, 135, 136]. Regardless of the content-specific NCC, when it comes to accessing consciousness, some neurophysiological requirements, such as a late P300 wave, are needed to ignite a global brain activation that will trigger awareness [137]. The conscious perception of the content of consciousness is the end of the concatenation of neurophysiological events that propagate from the back to the front cortex [6, 138]. It would be like a competition among various neural coalitions to access consciousness, and once a winning coalition exists (the first to break neurophysiological requirements), a specific representation or the content of consciousness can be perceived as generating a genuine experience of consciousness [137]. Afterward, this content of consciousness is controlled by high-order cognitive functions and is incorporated into plans, desires, and/or thoughts [6, 139].
\nOnce the content of consciousness is created in the back brain [132, 133], various cortico-cortical networks consciously manipulate the information [140]. One of the main cortico-cortical networks, which is broadly documented, is the Default Mode Network (DMN) [141, 142, 143, 144]. This network is formed by the anterior and posterior cingulate cortex, the mPFC, the orbital PFC, the medial temporal lobe (parahippocampal cortex and HPC), the retrosplenial cortex, and the inferior parietal lobe [145] . The DMN is a rest neural network, whose activity is maximum when the subject is awake and the cognitive demand is low (low-level processing of exogenous information) [146]. Moreover, the DMN is characterized by a high metabolism during rest states [147, 148, 149, 150], a progressive deactivation when more cognitive resources are needed to process information [147], and a high connectivity with other cortico-cortical networks to exchange information [140, 143, 151]. Traditionally, the DMN has been related to internal processes, such as self-reference thoughts and mind-wandering [152, 153, 154], although some studies currently link its activity to extrinsic processes, such as certain attentional processes [155] and the recall of memories [156, 157, 158, 159]. Recently, it has been posed that the DMN could also be involved in the integration of spatial, self-reference, and temporal information, thus generating episodic memories [160]. These authors suggest that, henceforth, the DMN is mostly activated in all of the cognitive processes [160].
\nOne of the key points for understanding the role of the DMN in consciousness is to conceive it as a cognitive system that modulate cortico-cortical activity through its mediation in the transfer of information from resting states or task-negative networks to cognitively active states or task-positive networks [140, 147, 156, 161, 162, 163, 164]. When a subject is resting (with the low-level processing of exogenous information), the DMN controls cortical activity with the posterior cingulate cortex (PCC) and the precuneus (Pcu) as their main neural nodes. However, as long as elaborated processing is required and the load of the working memory increases, the physiological burden of the DMN decreases in favor of task-positive networks: the fronto-parietal central executive network (FPN), the dorsal attention network (DAN), and the salience network (SN). The FPN includes the dorsolateral PFC, the mPFC, the anterior insula (aINS), the Pcu, and the interior parietal lobe [140, 165, 166, 167]. On the other hand, the DAN is formed by the frontal eye field and the intraparietal sulcus [168], and the SN by the aINS, the dorsal anterior cingulate cortex, the amygdala, the ventral striatum, and the ventral tegmental area of the mesencephalon [169]. All of these networks share overlapping regions whereby they can exchange neural information depending on the ongoing cognitive activity [147, 149, 150, 170, 171, 172, 173] . The outcome of the continuous interactions among the cortico-cortical networks will define the functional conscious state of the individual [163].
\nThe FPN, DAN, and SN play a key role in conscious behavior due to its capacity to operate jointly and synchronically in a highly coordinated and temporally accurate manner [140, 165, 174]. For instance, the DAN has been related to focalized attention and working memory, whereas the SN has been related to social communication, social behavior, and self-consciousness [171, 175, 176, 177, 178] . When all of these task-positive networks are operating, the DMN needs to deactivate [179, 180, 181] to facilitate the transition from low-energy cognitive states to high-energy cognitive states [147]. In these high-energy cognitive states, the mPFC takes control of the global brain activity at the expense of the PCC and the Pcu [170, 182]. Therefore, the alteration of structural and functional connectivity “within and between cortico-cortical networks” could cause the individual to experience a broad spectrum of neuropsychiatric and neurocognitive disorders [162, 163, 180, 183, 184].
\nThe FPN and SN, especially in the prefrontal regions, regulate the cognitive processes involved in the achievement of conscious goals through the regulation of the physiological equilibrium between the DMN and the rest of the cortico-cortical networks (cognitive control) [140, 165, 166, 167, 185, 186]. Some studies point out that the mPFC and aINS regulate physiological equilibrium among brain networks [178, 187]. For instance, Crone and colleagues compared the activation/deactivation of the DMN in vegetative states (currently known as “unresponsive wakefulness state”), minimally conscious states, and individuals with preserved and functional consciousness (control subjects) [182]. They suggested that although the deactivation of the DMN was normal in control subjects, the same deactivation was significantly diminished in overlapped areas between the DMN and the FPN in a minimally conscious state, and it was absent in unresponsive wakefulness state patients. In other words, the cohesive and functional integrity between the DMN and the task-positive networks is a crucial factor in the transition between rest states (those with a low cognitive burden) to high-demand cognitive states (those with a high cognitive burden) [147]. Our team conducted an investigation whereby we compared cortical connectivity between minimally conscious states and severe neurocognitive disorders [4]. Our results revealed how the degree of connectivity between the anterior and the posterior cortex in the beta band was essential for maintaining a preserved consciousness. In this investigation, patients with minimally conscious states showed a low connectivity between the posterior and the anterior cortex, which could explain why their consciousness fluctuates over time [4]. In contrast, subjects with preserved consciousness showed a high connectivity between the anterior and the posterior cortex, whereby they can operate continuously without the absence of consciousness [4]. In this sense, in a case study, an unresponsive conscious patient emerged to a minimally conscious state when connectivity between the anterior and the posterior cortex increased [188]. Thus, the integration of the posterior and the anterior cortex into long-distance cortico-cortical networks is one of the principal prerequisites for maintaining functional consciousness [9, 182, 189, 190].
\n\n
The nFMC is a theoretical and referential framework from which the study of consciousness can be tackled in all of its operative dimensions: neurophysiological, clinical, neuropharmacological, and phenomenological.
Consciousness is a global neural process that keeps the individual in an optimal and continuous functional state, thus allowing qualia and high-order processes to take place to drive behavior.
The nFMC divides global neural activity into three large systems, or functional loops, that are morphologically differentiated (although they share overlapped areas) and have semi-independent neurophysiological processes: the B-T neural loop, T-C neural loop, and C-C neural loop (see Figure 1).
Cognitive, behavioral, and emotional expression due to brain damage will depend on the location and extension of the lesion within the neural loop, thus leading to clinical outcomes that they may vary from a mild cognitive impairment to a disorder of consciousness, such as a coma, minimally conscious state, or unresponsive wakefulness state.
Each neural loop is activated hierarchically and sequentially by its preceding level, thus extending a representation of the neural processes that took place in the lower level, as well as integrating and transforming this neural representation into new information.
The nFMC is in accordance with predictive coding models that present brain activity as a system in which lower brain structures project predictions/signals via bottom–up processing, and where higher cortical areas send prediction errors back via top-down processes.
Neural processes (both automatic and controlled) related to consciousness (such as P300, brain rhythms, and neurotransmitter discharges) can be localized within either of the neural loops or in their reciprocal interactions.
The nFMC is complementary and comprises several assumptions considered in previous theories and investigations of consciousness:
Consciousness can be deemed a Global Neural Workspace in which distinct neural networks compete to access consciousness [11, 25, 192].
Consciousness is the result of functional units or complexes that integrate information and that are activated or deactivated depending on the ongoing sensorial/visceral necessities [8, 26, 27].
Consciousness is a neurophysiological continuum commanded by inner spatio-temporal brain laws [6].
Regarding the neural mechanisms or processes involved in the formation of the content of consciousness, the nFMC aligns with models and evidence that posit that the contents of consciousness are formed in the back brain via cortico-thalamo-cortical connections [70, 132, 133, 134, 135, 136]. In addition, the nFMC recognizes that PFC top-down connections could modulate the selection and even the formation of the content of consciousness [28].
Consciousness is the phenomenological quality of human existence that arises from a hierarchical, parallel, and serial activation of long-distance brain networks [7], which operate as neural loops that “inform” upper and lower levels about their own operations [29, 30]. These loops receive input from lower levels (which contains new information/predictions) and input from upper levels (error predictions). The loop will integrate all of this new information, updating its own functional state and, consequently, also the functional state of the rest of the loops and the brain [29, 30, 31, 32, 191]. ARAS: Ascending reticular activating system; TNN: Task-negative networks; TPN: Task-positive networks.
Human behavior has to be understood as a global brain activity dominated by complex and hierarchical neural processes that cannot be divided and explained by isolated functional units. Consciousness is the “operating system” running underneath the “interface” of overt and covert human behavior, and it is dominated by the interactions of various neural levels composed of differentiated and semi-independent neural networks. Thence, the nFMC gathers reliable knowledge generated in the study on neural correlates of consciousness, providing a novel theoretical and referential framework that will help clinicians, researchers, and even students to localize the neural processes of interest within a global brain activity model. A further proposal should extend the structures and connectivity involved within and between each neural loop introduced in the nFMC.
\nThe authors have no conflict of interest to declare.
"I work with IntechOpen for a number of reasons: their professionalism, their mission in support of Open Access publishing, and the quality of their peer-reviewed publications, but also because they believe in equality. Throughout the world, we are seeing progress in attracting, retaining, and promoting women in STEMM. IntechOpen are certainly supporting this work globally by empowering all scientists and ensuring that women are encouraged and enabled to publish and take leading roles within the scientific community." Dr. Catrin Rutland, University of Nottingham, UK
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