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The Psychiatry of Palliative Medicine the Dying Mind 2nd
ed Edition Macleod Digital Instant Download
Author(s): MacLeod, Sandy
ISBN(s): 9781138031517, 1138031518
Edition: 2nd ed
File Details: PDF, 4.03 MB
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Language: english
 The Psychiatry of

The Psychiatry of Palliative Medicine

Palliative Medicine
  
Second Edition

This Second Edition of The Psychiatry of Palliative Medicine remains a practical and
pragmatic distillation of the psychiatry relevant to the terminally ill. Revised throughout
and greatly expanded by the addition of two entirely new chapters, it reviews the major
psychiatric syndromes encountered in palliative care – depression, anxiety, delirium
– and examines psychopharmacological and psychological interventions in detail. It
succinctly considers the psychiatric aspects of pain, sleep, cognitive impairment, terminal
The Psychiatry of
Palliative Medicine
neurodegenerative diseases, sedation, artificial feeding and euthanasia. The dying,
chronically ill psychiatric patient is also discussed.
The author has drawn on his great experience in both consultation–liaison psychiatry
and palliative medicine to produce an essential, evidence-based guide for all healthcare
professionals involved in palliative care. These include consultants and senior nurses, as
well as psychiatrists, especially consultation–liaison psychiatrists, and trainees.
  
‘I find this an immensely sympathetic book, beautifully written. It is a testimony to the Second Edition

  

summation of specialist psychiatric knowledge, broad scholarship and a rich personal practice
in bedside palliation.’ From the Foreword by Ian Maddocks

AD (Sandy) Macleod
    
‘...a relevant, highly readable and reasonably priced book which will be of interest to all,
whether from a psychiatric or palliative care background, who seek to improve the care of
dying patients.’    
International Psychogeriatrics
‘Practical, scientifically based and scholarly, addressing a comprehensive set of common and

Second Edition AD (Sandy) Macleod

important clinical problems in palliative care. The book will doubtlessly be highly valued
by palliative care clinicians for its practical and thorough overview of some of the most
challenging clinical problems they face. Excellent and timely.’
Australian and New Zealand Journal of Psychiatry

    

Counselling for Death and Dying Practical Psychiatry of Old Age
Person-centred dialogues Fourth Edition
Richard Bryant-Jefferies John P Wattis and Stephen Curran

ISBN 978-1-84619-535-8
www.radcliffepublishing.com

Electronic catalogue and

worldwide online ordering facility.
9 781846 195358

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The Psychiatry of Palliative Medicine
 The Psychiatry of
Palliative Medicine
THE DYING MIND
SECOND EDITION

AD (SANDY) MACLEOD
MBChB, FRANZCP, FAChPM
Medical Director
Nurse Maude Hospice, Christchurch, New Zealand
Consultant Psychiatrist
Burwood Hospital, Christchurch, New Zealand
Adjunct Associate Professor
Health Sciences Department, University of Canterbury, New Zealand

Foreword by
IAN MADDOCKS
Emeritus Professor of Palliative Care
Flinders University of South Australia

Radcliffe Publishing
London • New York
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2011 by Sandy Macleod

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Version Date: 20160525

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 Contents

Foreword to the second edition vi

Preface to the second edition viii
About the author ix
Contributor x

1 Psychiatry and palliative medicine 1

2 Adjustment and anxiety 5
3 Psychological issues and dying 23
4 Families and caregivers 39
5 Psychiatry, spirituality and palliative medicine 51
Simon Dein
6 Pain and psychiatry 59
7 Other symptoms and the psyche 85
8 Depression 93
9 Delirium 117
10 Sleep, sedation and coma 139
11 Neoplasms 157
12 Cognitive dysfunction and dementia 173
13 Terminal neurological disorders 187
14 Chronic mental illness and dying 199
15 Euthanasia and psychiatry 209
16 Psychopharmacology 231
 Foreword to the second edition

The need for Palliative Medicine to support specialties other than oncology is
being increasingly recognised, finding expression in articles and monographs
relating to the advanced stages of cardiac, respiratory and neurological diseases,
and resulting in a new range of referrals. Referrals from psychiatry for palliative
assistance are few, since that field of disease management less often involves
predicable imminent death, but, conversely, a partnership with psychiatry is
a significant benefit to palliative medicine. Major discomfort coupled with an
imminence of death challenges the mental and spiritual well-being of affected
individuals and their families. Professor Sandy Macleod’s book, sub-titled The
Dying Mind (a title I prefer), has deservedly been well received, and it is time for
an update with some appropriate revisions.
Because few psychiatrists have shown interest in this field, the task of working
with the mental and spiritual discomforts of the dying mind depends on staff
with limited training in behavioural medicine and psychiatry. The first edition
of this text showed how a pragmatic knowledge of the psychiatric approach and
management options can make a difference. The sensible guidance it offered
has enabled palliative care staff to serve their client patients and families more
adequately. A clear didactic style continues here, and the aphorisms I enjoyed
so much the first time round remain: ‘physical examination of the terminally ill
is predominantly a psychological exercise’; ‘psychologically healthy persons do
their own psychotherapy’; and ‘the nurse is a powerful analgesic’.
A new one is: ‘A normal family does not exist’, and this leads into a chapter on
the tasks and the risks of bringing care to those with whom the patient is close.
Dying is an intense and important time, affecting the dynamic of the family in
major ways. The carer can become ‘the hidden patient’. Staff, also, can become
very involved in their caring role, and risk being idealised by their patients,
but the message here is that ‘burn-out’ has more to do with management and
team hygiene than daily contact with dying persons. Concern for the welfare of
family members often needs to extend beyond the time of death, and Macleod
emphasises the burden of loss: ‘Our losses are never irretrievably forgotten.
Grief is never fully resolved’. Neither an over-pathologising of bereavement nor
discounting it are appropriate.
Another new chapter concerns psychotropic medication essential for palliative

vi
 FOREWORD TO THE SECOND EDITION vii

care. Formularies in most countries now offer extensive options for prescribing
opioids, antidepressants, anxiolytics and antipsychotics. Many practitioners
will have their own list of favourites, but Professor Macleod offers suggestions,
highlighting the need for a basic formulary that avoids the risk of adding one
drug on another when discomforts persist. And there are more of the useful,
simple suggestions that speak of the author as an experienced bedside clinician:
‘Swallow the capsule with the head held forward’.
Concern for the soul was a major incentive for the establishment of the first
hospices by religious foundations. Its secular equivalent for the modern era –
specialist psychiatric care – does not often reach into ‘the spiritual’, and the cure
of souls is pursued with less confidence these days, even by our clergy. For this
edition, Professor Macleod has asked Dr Simon Dein to approach the topic of
spirituality in the secular setting. He affirms the importance of staff being pre-
pared to enter into exchanges with their patients that allow exploration of belief,
hope and religious practice, and urges them to assume a greater confidence. The
interaction of the spiritual unease with mental or physical distress is undoubted,
and spiritual pain will not respond promptly to opioids. Spirituality is not the
same as religiosity, and this is an area too important to be left to the visiting
clergy, though many clergy, through sensitivity and experience, will prove valu-
able members of the palliative team.
The discussion on euthanasia is now expanded with reference to the recent
experiences of those states where physician assistance to die has been author-
ised with various cautions and constraints. The involvement of the psychiatrist
will not solve the thorny issues of futility, competence, depression and fear that
accompany requests for euthanasia, but it has something to offer beyond the
enthusiastic participation of lawyers. Macleod concludes with a sage warning:
‘The euthanasia issue will not vanish from modern society. Medicine and psy-
chiatry need to start contributing to the debate rather than merely dismissing
euthanasia as wrong’.
I conclude as I did in introducing the first edition. We who practice palliative
medicine rarely can restore to our patients the comfort, dignity and function to
which they aspire. Do they lose hope? Embedded in Macleod’s term ‘covenant of
acceptance’ is the offer of a realistic hope, one in which staff, family and patient
may all conspire. I find this an immensely sympathetic book, beautifully written.
It is a testimony to the summation of specialist psychiatric knowledge, broad
scholarship and a rich personal practice in bedside palliation.

Ian Maddocks
Emeritus Professor of Palliative Care
Flinders University of South Australia
March 2011
 Preface to the second edition

This is a book for clinicians, written by a clinician practising both psychiatry

and palliative medicine. I hope it may better inform medical and nursing prac-
titioners about the psychiatry of relevance to the terminally ill. The clinical focus
of this book is palliative rather than supportive care. It concerns managing the
terminal phase of life. It is a distillation of clinical knowledge, observation and
experience, the current medical literature (evidence based where available) and
the opinions and biases of the author. Brevity necessitates incomplete considera-
tion of all aspects of the subject. I have therefore concentrated upon those clinical
predicaments that frequently demand a pragmatic knowledge of psychiatry. It
will not be appreciated by all; however, highlighted are some clinical issues and
concepts of management that to date have been rather ignored by palliative
medicine.

Sandy Macleod
March 2011
[email protected]

viii
 About the author

Associate Professor Sandy Macleod graduated from the University of Otago

in 1974. After several years as a general practice locum in New Zealand and the
UK, Dr Macleod completed his specialist training in psychiatry in Dunedin,
New Zealand. Periods of study in Oklahoma City, Boston and London followed.
Since 1985 Dr Macleod has worked as a consultation–liaison psychiatrist/
neuropsychiatrist at Christchurch and Burwood Hospitals, Christchurch, New
Zealand. In 1993, during tenure as visiting psychiatrist to Burwood Hospice,
the illness of the medical officer and the persuasion of the nursing staff enticed
Dr Macleod to commence an additional career in palliative care. Juggling busy
clinical practices in neuropsychiatry and palliative medicine is demanding and
challenging. The pleasures of being able to practise psychiatry within medicine
have been immense. Dr Macleod is an adjunct associate professor in the Health
Sciences Department at the University of Canterbury.
The co-author of a popular regional palliative care handbook, Dr Macleod has
also published over 50 articles, chapters and letters about clinical and historical
topics in psychiatry and palliative medicine.

ix
 Contributor

Simon Dein
Senior Lecturer in Anthropology and Medicine, University College, London
Honorary Consultant Psychiatrist, Princess Alexandra Hospital, Harlow, Essex
Honorary Consultant Palliative Medicine, St Clare Hospice, Hastingwood, Essex

x
 CHAPTER 1

Psychiatry and palliative medicine

It is the special vocation of the doctor to grow familiar with suffering.

John Greenleaf Whittier (1807–92)1

The cardinal goal of medical care is to alleviate suffering. Suffering is an unpleas-

ant and distressing emotional experience that undermines quality of life.2 When
illness confronts the integrity of how we define ourselves, of how we function,
of what roles we perform, and how we perceive ourselves, suffering eventu-
ates. The individual’s personhood is threatened by an event such as disease.3
Illness erodes ‘the self ’, and suffering is the symptom of this damage. Suffering
encompasses physical, psychological, spiritual and philosophical aspects of the
person. Medicine does not have armamentarium to address all the components
of suffering induced by disease. Suffering in advanced cancer patients cannot be
eliminated, but if adequate relief is achieved then coping and personal growth
can occur.4 Multidisciplinary healthcare teams are necessary to tackle this chal-
lenge. Modern medicine, preoccupied by curing rather than caring, focuses on
biology rather than psychology and sociology. The fragmentation of medicine,
made inevitable by the huge clinical and scientific knowledge base, distracts from
the commonalities between the various specialties and subspecialties. Psychiatry
and palliative medicine attend patients who are mentally distressed and dying.
Neither condition is easily amenable to biomedical interventions. These ‘old-
fashioned’ medical specialties practise biopsychosocial medicine with as much
artistry as science. The clinical outcome in psychiatry is ‘good’ palliation of
mental distress. In palliative medicine it is a ‘good death’. The diseases of neither
patient group are curable. The best that can be achieved is symptom control and
maintenance of that control. Quality of (remaining) life is thereby improved and
some suffering relieved.
Dame Cicely Saunders – the founder of the modern hospice movement –
envisioned a field that would encompass the physical, psychological and spiritual

1
2 THE PSYCHIATRY OF PALLIATIVE MEDICINE

dimensions of care. In its earlier years the movement was exquisitely focused
on the physical aspects of symptom management, though there are indications
that this is beginning to change towards a more holistic approach.5 Many of the
distressing symptoms experienced in the ‘deathbed’ are not exclusively physical.
Some are primarily psychological or psychiatric, and some are psychosomatic
or ‘somato-psychic’. Formalising ‘distress’ as the ‘sixth vital sign’ in the assess-
ment of cancer patients may encourage an improved clinical appreciation of the
importance of the mind of the sick.6 As John Donne (1572–1631) commented,
‘That which destroies body and soul, is in neither, but in both together’.7
Terminally ill patients can develop psychiatric illness. The provision of spe-
cialist psychiatric care to the dying is sporadic and inadequate. Psychiatrists
rarely venture off their patch and into palliative care facilities. Despite the interest
and want of a few psychiatrists, this situation is unlikely to change. There are few
psychiatrists interested, trained, and practising both subspecialities. However,
according to Susan Block, professor of psychiatry at Harvard Medical School,
‘there are a lot of frustrated humanists (in psychiatry) who are getting pushed
into just doing psycho-pharmacology, but who really care about the patient’s
existential issues’. 8 But funding psychiatrists to work in palliative care can be a
difficult prospect, despite the obvious need and the opportunities for collabora-
tion. Some fortunate patients are seen through consultation–liaison psychiatric
services to general hospitals. Finlay correctly points out the variability of the
provision of consultation–liaison services throughout the UK.9 The decline of
consultation–liaison psychiatric services worldwide over the last two decades,
because neither mental health nor medical services are willing to fund these
services despite being appreciated and effective, makes the reality of better access
to psychiatry unlikely. A ‘solution’ is that of enhancing the psychiatric skills of
palliative care practitioners and fostering the partnership. In the foundation
period of modern palliative medicine the deficits identified were those of ‘com-
munication skills’. More recently, depression, the psychosocial aspects of pain,
and delirium have been areas of educational endeavour. The claiming of pallia-
tive medicine by physicians’ colleges, and the narrow base of specialist medicine
training, has resulted in very limited exposure to psychiatry by prospective pal-
liative medicine specialists. Palliative care nurses usually possess considerable
experience and intuitive skill in dealing with disturbed patients, but lack a sound
psychiatric knowledge base. As palliative care is slowly expanding outside its tra-
ditional oncology base into neurological, cardiovascular, renal and many other
areas, there is a need to extend expert knowledge. These challenges rely upon a
working familiarity with mental illness and with its management.
The fundamental clinical skill of medicine is acquiring the history of the ill-
ness from the patient. The patient is the one suffering, they know their symptoms
and the doctor’s task is to extract this knowledge and expertly interpret it. The
 PSYCHIATRY AND PALLIATIVE MEDICINE 3

history provides the information on which diagnostic hypotheses are formulated.

The definitive diagnosis is determined from the differential diagnoses with the
assistance of objective information provided by the clinical examination and
the investigations. Acquiring a psychiatric history is little different to any other
medical history. Providing the patient with the opportunity to describe their
symptoms, to reveal their narrative, is the key to good history taking. The inter-
rogative pronoun that ensures a description of ill health is ‘how’. ‘How is your
health affecting you?’, ‘How are you feeling?’, ‘How do you toilet?’, followed by
repeated requests to further describe and elaborate, provides copious informa-
tion, and more efficiently than with closed questions. Allowing the patient the
first half to two-thirds of the interview time for this is appropriate and efficient.
The doctor assumes control for the final portion in order to further clarify any
details and ask specifically about medications, allergies and personal habits. This
interview format applies equally to a full 50-minute psychiatric assessment and a
10-minute general practice consultation. Terminally ill patients are certainly not
an exception. Their symptom load and appreciation of the preciousness of time
encourages productive history taking in a brief period. Often 10–15 minutes
is sufficient. Specific questions need to be asked of the terminally ill concern-
ing fatigue, hallucinations and suicide risk, for these symptoms tend not to be
volunteered.
What constitutes an adequate mental status examination in the dying should
be influenced by what the examiner hopes to confirm. Delirium, depression,
anxiety and cognitive dysfunctions are the common mental health problems of
the dying. Time is limited, for energy and ability to cooperate are compromised.
The bare essentials of a mental status examination in a terminally ill patient
should include estimates of consciousness, orientation, recent memory, simple
calculation and mood. Physical examination of the terminally ill is predomi-
nantly a psychological exercise. While academically it is gratifying to confirm
the historical impression of an enlarged liver or bronchopneumonia, rarely
does this influence a management plan. Most persons have a belief that medical
examination, rather than history, is the key to medical practice. Until physically
examined, even if the examination is only cursory, most don’t consider they
have been properly assessed. The stethoscope and the percussion hammer are
powerful tools of comfort. This is not to suggest that a medical examination
doesn’t provide useful confirmatory information, including for mental illness.
The traditional medical history and examination is a better assessment tool than
the multitude of scales and psychometric measures available.
The practice of clinical psychiatry and medicine in general, requires knowl-
edge of psychology. Personality traits, coping skills, general intellectual function
and current stressors impact upon adjustment to, and living with, termi-
nal illness. Modern psychology is cognitive and behavioural in philosophy.
4 THE PSYCHIATRY OF PALLIATIVE MEDICINE

Psychodynamic conceptualisation is less emphasised. There is a considerable

literature concerning psychology and severe illness. The psychiatric literature is
less robust. The discipline of psychiatry encompasses both organic and psycho-
logical dysfunction. The vast majority endure a sad and unfortunate terminal
illness with courage and stoicism. They manage ‘normally’. For them, psychiatry
has nothing to offer. For those with dual pathology, good psychiatry and good
palliative medicine can enhance the quality of remaining life.

REFERENCES
1 Whittier JG. Quoted in: Strauss MB, editor. Familiar Medical Quotations. Boston: Little,
Brown & Company; 1968. p. 578.
2 Cherny NI, Coyle N, Foley KM. Suffering in the advanced cancer patient: a definition
and taxonomy. J Palliat Care. 1994; 10: 57–70.
3 Cassel EJ. The nature of suffering and the goals of medicine. N Engl J Med. 1982; 306:
639–45.
4 Cherny NI. The treatment of suffering in patients with advanced cancer. In: Cochinov
HM, Breitbart W, editors. Handbook of Psychiatry in Palliative Medicine. Oxford:
Oxford University Press; 2000. pp. 375–96.
5 Chochinov HM. Psychiatry and palliative care: 2 sides of the same coin. Canad J
Psychiatry. 2008; 53: 711–12.
6 Chaturvedi S, Venkateswaran C. New research in psychooncology. Curr Opin Psychiatry.
2008; 21: 206–10.
7 Donne J. Devotions upon Emergent Occasions. Raspa A, editor. Montreal, QC: McGill
Queen’s University Press; 1975.
8 Meier DE, Beresford L. Growing interface between palliative medicine and psychiatry.
J Palliat Med. 2010; 7: 803–6.
9 Finlay I. In: Lloyd-Williams M, editor. Psychosocial Issues in Palliative Care. Oxford:
Oxford University Press; 2003. p. viii.
 CHAPTER 2

Adjustment and anxiety

The human race is the only one that knows it must die, and it knows this
only through its experience. A child brought up alone and transported to a
desert island would have no more idea of death than a cat or a plant.

Voltaire (1694–1778)1

Dying is a personally unique experience and one that we cannot share with
another, nor rehearse with any certainty as to how it will be. Yet we know it will
happen. ‘Never-before-encountered’ psychological challenges are presented to
the terminally ill.2 ‘Can this be death?’ thought the mortally wounded Prince
Andrew in Tolstoy’s War and Peace, moments before his death. For many, until
they are incurably ill, consideration of the psychology and spirituality of death
is not contemplated with seriousness. Adjustments and anxieties are inevitably
created.

ADJUSTMENT DISORDER (OR DISTRESS)

Care more particularly for the individual patient than the special features
of the disease.

William Osler (1849–1919)3

The Diagnostic and Statistical Manual of Mental Disorders (DSM) IV and

International Classification of Diseases (ICD-10) diagnostic criteria for adjust-
ment disorder are imprecise and nebulous.4 Though a relatively commonly used
diagnosis, the relationship of adjustment disorder to other psychiatric disorders
is unclear and there is a lack of research data to support its utility.5 Conceptually,
adjustment disorder may be a subthreshold form of post-traumatic stress disor-
der,5 or merely be a diagnostic creation to satisfy the American health insurers

5
6 THE PSYCHIATRY OF PALLIATIVE MEDICINE

and permit financial return to health professions. By DSM definition, within

1–3 months of a triggering event, emotional disturbance (marked distress in
excess of expected) and behavioural changes (impairment of social/occupational
functioning) occur, which are not able to be diagnosed as another mental disor-
der. Anxiety, depressed mood and conduct aberrations are often the prominent
symptoms, yet not of the intensity or persistence to meet the specific diagnostic
criteria for these conditions. Adjustment disorder refers to someone who is
distressed and ‘not coping’, having recently experienced a stressor, such as a
malignant diagnosis, a treatment complication or the awareness of impending
death. If the identified stressor is a ‘traumatic event’ (according to DSM-IV cri-
terion A) a post-traumatic diagnosis is preferred.5
Adjustment disorder is reported in 32% of cancer patients, and 35% of cancer
sufferers are clinically significantly distressed.6 These would appear to be surpris-
ingly low figures, for at stages it is probable that all cancer patients struggle with
their emotions and coping. ‘Distress’ is not defined in the medical literature.
Rather than attempting to differentiate adjustment difficulties from sadness,
sorrow, grief, subclinical anxiety, depression and Axis-1 DSM-IV diagnoses, it
may be more useful to use the term ‘distress’. Distress rather than the medical
condition of adjustment disorder would avoid psychiatric stigmatisation and
acknowledge an expected and normal reaction to an unsettling life event. Risk
factors including low ego strength, passive or avoidant coping style, inadequate
or inappropriate information, lack of social support, communication problems,
treatment-related stressors, number of unresolved concerns and level of partner’s
distress have been identified.7 Lack of coping flexibility may well predispose
persons to difficulties problem-solving and adjusting to the new problems a
malignant illness presents.8 It is difficult to conceive a greater stressor than that of
a terminal illness, irrespective of the resilience and resourcefulness of the patient.
Indeed, those few persons who respond to such illnesses without a behavioural or
emotional flinch are probably more likely to suffer significant psychopathology.

Management
There is no empirical research providing information on the most effective
treatment of adjustment disorder or its natural course.9 Adjustment disorder
is by definition a self-limiting disorder once the stressor is removed,5 however
this is unlikely in cancer patients and the distress suffered may be so severe that
treatment strategies need to be offered.5 Possessing appropriate and adequate
information, most individuals with the support of their family and social
network adjust and adapt. The innate resourcefulness of most is remarkable.
Information and empathic (not sympathetic) support provided by the attending
medical and nursing staff is surely helpful. Too much complex information, often
provided in the modern climate of non-paternalistic medicine, risks enhancing
 ADJUSTMENT AND ANXIETY 7

distress and indecision of the individual. A fundamental and reassuring task of

the health professional is, ironically, to reinforce the normality of distress. Some
health professions, particularly psychiatrists, often have little to offer for they are
inclined to somewhat trivialise distress or convert it into a medical condition
that they think they know how to treat.
Self-help groups may have a role and for some, individual and/or group psy-
chotherapy may be of benefit. Psychodynamic interventions based on a trusting
relationship and the relating of earlier experience to the current one is the most
effective form of psychotherapy for adjustment disorder.10 Cognitive–behav-
ioural approaches are, however, more commonly practised these days. While
there is undoubtedly a role for specialist psychotherapists with those struggling
profoundly with adjustment distress, the therapeutic costs of making normality
into pathology need to be carefully ascertained. The ideal assistance is that pro-
vided by the patient’s natural support network. Nursing staff are the best-placed
professionals to provide support, however, specialist counsellors also have a role,
perhaps an increasing one.
Very short-term and intermittent hypnotic use may be helpful during the
crisis period. Insomnia may perpetuate a vicious cycle of distress and fatigue,
each amplifying the other. Arresting this cycle can be most beneficial. There is no
evidence that antidepressant or antipsychotic medications ameliorate distress. In
some communities and cultures alcohol is used. Alcohol is an effective remedy
for initial insomnia, until tolerance develops, but it disturbs the sleep architec-
ture and dreams, and fitful awakenings tend to negate the advantage of ease of
falling off to sleep. Habitual use and physical dependence can be initiated by an
adjustment crisis. Drugs are best avoided; adjustment distress is a psychological
process and requires, and is eased by, psychological interventions.
The passage of life is a procession of adjustments to minor and major events.
Sadness and distress invariably occur. Such experiences can initiate psychologi-
cal growth and maturation. Pathological interpretations of adjustment or distress
reactions are rarely therapeutic. Distress and cancer are naturally associated.
This doesn’t mean psychotherapy is not helpful. The illness may be a therapeutic
opportunity for both patient and family to sort not only the current, but also
older, troubles.

FRIGHT, FEAR AND ANXIETY

Objects of fear are of two kinds – the reasonable (death and surgical opera-
tions) and the unreasonable (thunder, darkness, ghosts, speaking in public,
sailing, riding, certain animals, particularly cats, rats, insects and the like).

Benjamin Rush (1746–1813)11

8 THE PSYCHIATRY OF PALLIATIVE MEDICINE

A sudden, unexpected sensory stimulus may result in fright, a pre-emotional,

innate, reflexive reaction characterised by a startle response. This ‘clears the
neural slate’ of competing behaviours allowing for rapid motor readiness to react
to the stressor. Hopefully, frights are unusual and avoidable in palliative care.
Fear is a universal and briefly unpleasant emotional response caused by
anticipation or awareness of danger. Some fear stimuli are innate, such as pain,
bleeding, physical proximity, confined spaces, unpleasant odours, nasty tastes
and snakes. Many fears are learned, often as a consequence of an aversive expo-
sure. These may include fears of dying, death, being buried alive, needles and
unpleasant medical treatments such as chemotherapy and radiotherapy. Fear
is a common, probably universal, complication of severe medical illness. Fear
initiates a behaviour reaction – aggressive defence (‘fight’), avoidance (‘flight’),
immobility (‘freezing’) or appeasement (‘submission’). Associated are symptoms
of physiological and psychological arousal, the latter usually rising subsequent
to the immediate survival behavioural response.
It was not until the eighteenth century, and particularly the era of Freud
in the late nineteenth century, that the concept of anxiety was introduced to
medicine, though philosophers such as Spinoza, Pascal and Kierkegaard had
previously considered the rationality of human responses to challenge or conflict.
Kierkegaard (1813–55) first differentiated fear and anxiety suggesting that in fear
one moves away from the feared object, whereas the anxious person maintains
an ambivalent yet persisting relationship with the conflictual situation.12 Anxiety
is prompted by generalised, non-specific threats and cues. It is objectless, the
threat is to the ‘self ’, to one’s existence. It is a sustained and irrational response.
The reaction, though understandable, is grossly exaggerated. Whereas in fear the
neural processes are automatic or reflexive, in anxiety cognitive processes are
involved in evaluating and responding to the threat, which may be externally or
internally derived. The dissolution of the self is the perceived peril of the anxious
person.
Fright, fear and anxiety are adaptive, indeed creative, responses to danger.
However, if severe and protracted they cause suffering, which should be man-
aged. Approximately 8% of patients with advanced cancer, particularly younger
women, suffer an anxiety disorder, most commonly generalised as anxiety or
panic disorder.13 In those with terminal illness, as a realistic appraisal of health
status becomes apparent, the prevalence is higher, approximately 14%.14 Left
untreated, anxiety is associated with increased pain, increased desire for has-
tened death, and increased disability. Modern psychiatry has been lazy in its
lack of differentiating fear and anxiety, using anxiety as the preferred term. The
prevalence of fear in palliative patients has not been determined. Few would
be expected to avoid some moments of fear during the course of their illness.
Though the physiological, emotional and cognitive symptoms of fear and anxiety
 ADJUSTMENT AND ANXIETY 9

are similar, they are distinct responses to differing types of stimuli. They are
demanding of different management strategies.

ANXIETY STATES
Acute situational anxiety and panic attacks
The receiving of ‘bad news’, the discomforts and the humiliations of medical
procedures, and the dawning awareness of illness progression are but a few of
the predicaments precipitating acute anxiety in the terminally ill. It may also be
precipitated by the withdrawal of active treatment rendering the patient ‘unpro-
tected’ or ‘abandoned’.15 The psychological adaptation from curative to palliative
care is an anxious phase. The prevalence of pure anxiety symptoms in cancer
patients is not established, for often mood symptoms coexist and panic attacks
are presumed to be ‘normal’. Lewis, in the 1930s, proposed a continuum between
anxiety and depression and believed they could not be usefully distinguished,16
an opinion that to this day has not been convincingly refuted.17 In practice, ‘nerv-
ous’ patients are frequently encountered (see Box 2.1). If the anxiety response is
very severe and abrupt, it is referred to as a panic attack. Anxiety fades sponta-
neously and is extinguished, but is easily reactivated by lesser stimuli for some
period of time. Somatic symptoms activate the central discomfort, and vice versa,
thus a self-perpetuating cycle can be initiated.

BOX 2.1 Symptoms of anxiety

Psychological: apprehension, panic, inappropriate fear, foreboding, dread,

tension, intrusive thoughts of death, catastrophic thoughts, depersonalisation,
derealisation, irritability, initial insomnia, impaired concentration, slowed thinking.

Physiological/somatic:
● gastrointestinal: dry mouth, diarrhoea, indigestion (‘butterflies’), anorexia,

nausea, dysphagia (‘globus hystericus’)

● cardiovascular: palpitations, chest ache, tachycardia

● respiratory: hyperventilation (‘air hunger’), yawning, sighing

● nervous system: headaches, dizziness, tremor, paraesthesia, shakiness,

muscle twitching, restlessness

● genitourinary: urgency, impotence

● dermatological: sweating, rash.

Most people at some crisis during their life, such as before an examination or
after a frightening occurrence, will have experienced a panic attack. In situa-
tions of profound and real danger, panic is rare: rather a sense of calmness and
Other documents randomly have
different content
1
As I gaed in yon greenwood-side,
I heard a fair maid singing;
Her voice was sweet, she sang sae complete
That all the woods were ringing.

2
‘O I’m the Duke o Athole’s nurse,
My post is well becoming;
But I woud gie a’ my half-year’s fee
For ae sight o my leman.’

3
‘Ye say, ye’re the Duke o Athole’s nurse,
Your post is well becoming;
Keep well, keep well your half-year’s fee,
Ye’se hae twa sights o your leman.’

4
He leand him ower his saddle-bow
And cannilie kissd his dearie:
‘Ohon and alake! anither has my heart,
And I darena mair come near thee.’

5
‘Ohon and alake! if anither hae your heart,
These words hae fairly undone me;
But let us set a time, tryst to meet again,
Then in gude friends you will twine me.

6
‘Ye will do you down to yon tavern-house
And drink till the day be dawing,
And, as sure as I ance had a love for you,
I’ll come there and clear your lawing.

7
‘Ye’ll spare not the wine, altho it be fine,
Nae Malago, tho it be rarely,
But ye’ll aye drink the bonnie lassie’s health
That’s to clear your lawing fairly.’

8
Then he’s done him down to yon tavern-house
And drank till day was dawing,
And aye he drank the bonny lassie’s health
That was coming to clear his lawing.

9
And aye as he birled, and aye as he drank,
The gude beer and the brandy,
He spar’d not the wine, altho it was fine,
The sack nor the sugar candy.

10
‘It’s a wonder to me,’ the knight he did say,
‘My bonnie lassie’s sae delaying;
She promisd, as sure as she loved me ance,
She woud be here by the dawing.’

11
He’s done him to a shott-window,
A little before the dawing,
And there he spied her nine brothers bauld,
Were coming to betray him.

12
‘Where shall I rin? where shall I gang?
Or where shall I gang hide me?
She that was to meet me in friendship this day
Has sent nine men to slay me!’

13
He’s gane to the landlady o the house,
 Says, ‘O can you supply me?
For she that was to meet me in friendship this day
Has sent nine men to slay me.’

14
She gae him a suit o her ain female claise
And set him to the baking;
The bird never sang mair sweet on the bush
Nor the knight sung at the baking.

15
As they came in at the ha-door,
Sae loudly as they rappit!
And when they came upon the floor,
Sae loudly as they chappit!

16
‘O had ye a stranger here last night,
Who drank till the day was dawing?
Come show us the chamber where he lyes in,
We’ll shortly clear his lawing.’

17
‘I had nae stranger here last night
That drank till the day was dawing;
But ane that took a pint, and paid it ere he went,
And there’s naething to clear o his lawing.’

18
A lad amang the rest, being o a merry mood,
To the young knight fell a-talking;
The wife took her foot and gae him a kick,
Says, Be busy, ye jilt, at your baking.

19
They stabbed the house baith but and ben,
The curtains they spared nae riving,
And for a’ that they did search and ca,
For a kiss o the knight they were striving.

E. a.
1 . nurse altered to nurice.
1

3 . drink the bonnie out, originally.

3

4 . drank struck out for sang.

1

7 . and struck out before gin.

2

8 . callit changed in pencil to were calling.

2

b.
The printed copy seems to have been made up
from a and Kinloch’s other versions.
1. Preceded by these two lines, taken from D:

As I cam in by Athol’s yetts,

I heard a fair maid singing.

2
1 . And I wat it weel does set me.
3 . ye’ll omitted. 3 . drink the lass’ health.
2 3

3 . That’s coming to pay the. (This stanza occurs

4

in Motherwell’s Note-Book, p. 46, where it is

credited to a MS.)
After 3:
 He hied him doun to yon change-house,
And he drank till the day was dawing,
And at ilka pint’s end he drank the lass’ health
That was coming to pay for his lawing.

1
4 . and aye.
2
6 . see gin she war.
3
6 . There he saw the duke and a’ his merry men.
6 . the hill. 7 . doun omitted.
4 1

3
7 . She buskit: woman’s.
2
8 . they war calling.
3
8 . Had ye a young man here yestreen.
After 8:

‘He drank but ae pint, and he paid it or he went,

And ye’ve na mair to do wi the lawing.’
They searchit the house a’ round and round,
And they spared na the curtains to tear them,

While the landlady stood upo the stair-head,

Crying, ‘Maid, be busy at your baking!’
They gaed as they cam, and left a’ undone,
And left the bonnie maid at her baking.

F. b.
“Some alterations made from the way it was
sung” by the editor’s maternal grandfather.
2
4 . And kindly said, My dearie.
3
6 . as you ance had a love for me.
4
11 . That were.
2
12 . Where shall I gang to hide me.
4
14 . Than the.
 213

SIR JAMES THE ROSE

‘Sir James the Rose.’ a. From a stall-tract of about

1780, Abbotsford library. b. Motherwell’s
Minstrelsy, p. 321. c. Sir James the Rose’s
Garland, one of a volume of the like from Heber’s
library. d. Motherwell’s MS., p. 281; from the
recitation of Mrs Gentles, of Paisley. e. Herd’s
MSS, I, 82. f. The same, II, 42. g. ‘Sir James the
Rose,’ Pinkerton’s Scottish Tragic Ballads, 1781, p.
61.

b, says Motherwell, “is given as it occurs in early

stall-prints, and as it is to be obtained from the
recitations of elderly people.” Most of the variations
are derived from d. c may have been printed earlier
than a, but is astonishingly faulty. d, well
remembered from print, is what Motherwell meant
by “the recitations of elderly people.” e was obtained
by Herd, probably from recitation, as early as 1776,
but must have been learned from print. f is e with a
few missing lines supplied. g, says Pinkerton, “is
given from a modern edition in one sheet 12mo,” but
was beyond question considerably manipulated by
the editor. All the important variations are certainly
his work.
The copy in Buchan’s Gleanings, p. 9, is g.
Whitelaw, in his Book of Scotish Ballads, p. 39, has
combined b and g.
Half a dozen lines preserved by Burns, Cromek’s
Select Scotish Songs, II, 196 (see the preface to No
212), seem to belong to this ballad.
‘Sir James the Ross, A Historical Ballad’
(sometimes called ‘The Buchanshire Tragedy’), was
composed by the youthful Michael Bruce ([+] 1767)
upon the story of the popular ballad, and has
perhaps enjoyed more favor with “the general” than
[93]
the original. ‘Elfrida and Sir James of Perth,’ Caw’s
Poetical Museum, 1784, p. 290 (probably taken, as
most of the pieces are by the collector said to be,
from some periodical publication), looks more like an
imitation of Bruce’s ballad than of its prototype. It is
in fact a stark plagiarism.
Sir James the Rose has killed a squire, and men
are out to take him. A nurse at the house of Marr is
his leman, and he resorts to her in the hope that she
may befriend him. She advises him to go to an ale-
house for the night, promising to meet him there in
the morning; he says he will do so, but, perhaps
from distrust, which proves to be well grounded,
prefers to wrap himself in his plaid and sleep under
the sky. The party sent out to take him question the
nurse, who at first makes a deceptive answer, then
gives them a direction to his hiding-place. They find
James the Rose asleep and take away his arms; he
wakes and begs for mercy, and is told that he shall
have such as he has given. He appeals to his servant
to stay by him till death, and then to take his body to
Loch Largan (Loughargan), for which service the
man shall have his clothes and valuables. The
avengers cut out his heart and take it to his leman at
the house of Marr; she raves over her treachery, and
is ‘born away’ bodily, to be seen no more.
e, f, it may be by accident, lack the vulgar passage
18, 19, which may be a later addition, for nothing is
said of a man being in attendance when Sir James
goes to his lair. The leader of the band that takes Sir
James the Rose is Sir James the Graham, Sir James
Graham, in c, e, f; a simple error, evidently. No
motive is furnished in a-f for the woman’s betraying
her leman. g makes her offer information on
condition of getting a proper reward, and she is
promised Sir James’s purse and brechan, but in the
end is tendered his bleeding heart and his bleeding
tartan, whatever that may be other than his brechan.
This must be one of Pinkerton’s improvements. The
moral tag, st. 24, is dropped, or wanting, in c, e, f,
g.
The topography of traditional ballads frequently
presents difficulties, both because it is liable to be
changed, wholly, or, what is more embarrassing,
partially, to suit a locality to which a ballad has been
transported, and again because unfamiliar names,
when not exchanged, are exposed to corruption.
Some of the places, also, have not a dignity which
entitles them to notice in gazetteers. The first point,
in the case before us, would be to settle the
whereabouts of the House of Marr, in the vicinity of
which the scene is laid. This I am unable to do.
There is a Ballechin in Logierait Parish, Perthshire.
[94]
There is said to be a Baleichan in Forfarshire. It is
not easy to see why the heir of either of these places
(Buleighan and the rest may stand for either) should
wish to have his body taken to Loch Largon in
Invernesshire, if Loch Largon means Loch Laggan, as
[95]
seems likely.

Translated by Knortz, Schottische Balladen, p. 79,

after Aytoun.
1
O heard ye of Sir James the Rose,
The young heir of Buleighen?
For he has killd a gallant squire,
An ‘s friends are out to take him.

2
Now he’s gone to the House of Marr,
Where the nourrice was his leman;
To see his dear he did repair,
Thinking she would befriend him.

3
‘Where are you going, Sir James?’ she says,
‘Or where now are you riding?’
‘O I am bound to a foreign land,
For now I’m under hiding.

4
‘Where shall I go? Where shall I run?
Where shall I go to hide me?
For I have killd a gallant squire,
And they’re seeking to slay me.’

5
‘O go ye down to yon ale-house,
And I’ll pay there your lawing;
And, if I be a woman true,
I’ll meet you in the dawing.’

6
‘I’ll not go down to yon ale-house,
For you to pay my lawing;
There’s forty shillings for one supper,
I’ll stay in ‘t till the dawing.’

7
He’s turnd him right and round about
And rowd him in his brechan,
And he has gone to take a sleep,
In the lowlands of Buleighen.

8
He was not well gone out of sight,
Nor was he past Milstrethen,
Till four and twenty belted knights
Came riding oer the Leathen.

9
‘O have you seen Sir James the Rose,
The young heir of Buleighen?
For he has killd a gallant squire,
And we’re sent out to take him.’

10
‘O I have seen Sir James,’ she says,
‘For he past here on Monday;
If the steed be swift that he rides on,
He’s past the gates of London.’

11
But as they were going away,
Then she calld out behind them;
‘If you do seek Sir James,’ she says,
‘I’ll tell you where you’ll find him.

12
‘You’ll seek the bank above the mill,
In the lowlands of Buleighen,
And there you’ll find Sir James the Rose,
Lying sleeping in his brechan.

13
‘You must not wake him out of sleep,
 Nor yet must you affright him,
Till you run a dart quite thro his heart,
And thro the body pierce him.’

14
They sought the bank above the mill,
In the lowlands of Buleighan,
And there they found Sir James the Rose,
A sleeping in his brechan.

15
Then out bespoke Sir John the Græme,
Who had the charge a keeping;
‘It’s neer be said, dear gentlemen,
We’ll kill him when he’s sleeping.’

16
They seizd his broadsword and his targe,
And closely him surrounded;
But when he wak’d out of his sleep,
His senses were confounded.

17
‘O pardon, pardon, gentlemen!
Have mercy now upon me!’
‘Such as you gave, such you shall have,
And so we’ll fall upon thee.’

18
‘Donald my man, wait me upon,
And I’ll give you my brechan,
And, if you stay here till I die,
You’ll get my trews of tartan.

19
‘There is fifty pounds in my pocket,
Besides my trews and brechan;
You’ll get my watch and diamond ring;
And take me to Loch Largon.’

20
Now they have taken out his heart
And stuck it on a spear,
Then took it to the House of Marr,
And gave it to his dear.

21
But when she saw his bleeding heart
She was like one distracted;
She smote her breast, and wrung her hands,
Crying, ‘What now have I acted!

22
‘Sir James the Rose, now for thy sake
O but my heart’s a breaking!
Curst be the day I did thee betray,
Thou brave knight of Buleighen.’

23
Then up she rose, and forth she goes,
All in that fatal hour,
And bodily was born away,
And never was seen more.

24
But where she went was never kend,
And so, to end the matter,
A traitor’s end, you may depend,
Can be expect’d no better.

a.
 From “A collection of Popular Ballads and Tales,”
in six volumes, “formed by me,” says Sir W.
Scott, “when a boy, from the baskets of the
travelling pedlars.... It contains most of the
pieces that were popular about thirty years
since.” (“1810.”) Vol. IV, No 21. In stanzas of
eight lines.
b.
1 . Buleighan, and always.
2

3
2 . To seek (d).
2
5 . there pay.
3
5 . maiden true (d).
1
11 . As they rode on, man after man.
2
11 . she cried.
3
11 . James the Rose.
1
12 . Seek ye the bank abune.
3
13 . you drive (d).
4
13 . through his (d).
1
14 . abune (d).
4
14 . Lying sleeping (d).
1
15 . Up then spake (d).
 3
15 . It shall (d).
4
15 . We killed: when a (d).
3
16 . And (d).
4
17 . we fall (d).
1
20 . they’ve taen out his bleeding heart (d).
3
21 . wrung her hands and tore her hair (d).
4
21 . Oh, what have I.
1
22 . It’s for your sake, Sir J. the R. (d).
2
22 . That my poor heart’s (d).
3
23 . She bodily.
4
24 . Can never be no.
c.
1
1 . Did you hear.
2
1 . That young.
2 4 2
1 , 7 , 9 . Belichan.
1 . For wanting.
3

4
1 . Who was sent out.
2 . Now wanting.
1

2
2 . nurse she was his layman.
 2
3 . where are you a.
3
3 . I am going to some land.
4
3 . For I am.
1
4 . Where must: I turn.
2
4 . I run.
3 3
4 , 9 . esquire.
4
4 . And my friends are out to take me.
1
5 . Go you.
2
5 . There you’ll stay till the dawning.
4
5 . I’ll come and pay your lawing.
6 . down wanting.
1

2
6 . To stay unto the dawning.
3
6 . Now if you be a woman true.
4
6 . [D] o (?) come and pay the lawning.
1
7 . himself quite round.
3
7 . he is.
1
8 . not quite out.
8 . Wanting.
2

4
8 . ore Beligham.
 1
9 . did you see.
2
9 . That.
9 . For wanting.
3

4
9 . Who was sent.
1
10 . Oh yes, I seed S. J. the R.
2
10 . He passed by here.
3
10 . His steed was: rid.
4
10 . And past.
1
11 . Just as.
2
11 . They thought no more upon him.
3
11 . Oh if you want S. J. the R.
2
12 . And the: Belighan.
12 . And wanting.
3

13 as 14.
1
13 . him from his.
13 . you wanting.
2

3
13 . But in his breast must run a dart.
14 as 13.
2
14 . And lowlands.
 4
14 . Lying sleeping.
1
15 . up bespoke Sir James the Graham.
2
15 . charge in.
3
15 . Let it neer: gentleman.
4
15 . We killd a man a sleeping.
1
16 . They have taken from him his sword and
target.
3
16 . wakened out of sleep.
4
16 . was.
17 . O wanting.
1

2
17 . And now have mercy on.
3
17 . Which as.
4
17 . And so shall fall upon you.
2
18 . Until I be a dead man.
3
18 . You’ll get my hose, likewise my shoes.
4
18 . Likewise my Highland brichan.
19 . Wanting.
1,2

19 with 20 : 20 with 21 : 21 with 22 :

3,4 1,2 3,4 1,2 3,4 3,4

22 wanting.
1,2

3
19 . You shall have my.
 4
19 . If you’ll carry me to Loughargan.
1
20 . tane out his bleeding heart.
2
20 . And fetched it on a spear man.
3
20 . And locked it to the Marr.
4 2
20 . A present to. 21 . She ran.
3
21 . She wrung her hands and smote her breast.
4
21 . Oh what have I done, what have I acted.
3
22 . day I you betrayd.
4
22 . of Brichan.
23 . Then wanting.
1

2
23 . And in.
3
23 . Her body by.
23 . never was heard tell of: more wanting.
4

24. Wanting.
d.
1 . Buleichan, and always.
2

4
1 . And his.
2 . Now wanting.
1

3
2 . To seek.
3. Wanting.
4
4 . They’re seeking for to.
2
5 . there I’ll pay.
3
5 . a maiden.
1
6 . no gae.
3
6 . thirty shillings for your.
4
6 . And stay until the.
1
8 . He had.
2
8 . And past the Mill strethan.
1
10 . S. J. the Rose.
11 . But wanting.
1

2
11 . She cried out.
3
11 . S. J. the Rose.
1
12 . Search the.
3
13 . you drive.
4
13 . through his.
1
14 . They searched: abune.
4
14 . Lying sleeping.
1
15 . Up then spoke.
 3
15 . It shall.
4
15 . We killed him when a.
3
16 . And.
4
17 . we fall.
19 . There is wanting.
1

1
20 . They’ve taen out his bleeding.
3
20 . And they’ve gone to.
4
20 . And gien.
21 . But wanting.
1

3
21 . She wrung her hands and tore her hair.
4
21 . Crying, Now what.
1
22 . It’s for your sake, S. J. the R.
2
22 . That my poor heart’s.
23 . Then wanting.
1

2
23 . And in.
23 . Bodily: She prefixed later.
3

1
24 . kent.
4
24 . Cannot expect no.
e, f.
e. Another song of Sir James the Ross; this
following Bruce’s ballad, which has the title (p.
73) Sir James the Rose or de Ross. f. Another
song of Sir James de Ross.
1
1 . O did ye na ken Sir.
1 . e. Ballachen, and always.
2

2 4 2
f. 1 , 7 , 9 , Ballachen;
2
12 . Ballichan;
2
14 . Ballichin;
4
22 . Ballichen.
4
1 . e. And they seeking, f. And they’re seeking.
1
2 . He’s hy’d him: Moor.
2 , 3. e. Wanting.
2–4

2
3 . f. O where away are.
3
3 . f. to some.
1
4 . O where.
2
4 . O whither shall I hide me.
4
4 . to kill.
1
5 . e. gan ye. f. gang you.
2
5 . I will pay your.
 3
5 . And gin there be.
1
6 . gang.
3
6 . shillings in my purse.
4
6 . We’l stake it in the.
1
7 . He turnd.
3
7 . is gone.
2
8 . Mill Strechin.
3
8 . Ere.
4
8 . the Rechin.
1
9 . O saw ye.
1
10 . O yes, I saw S. J. the R.
10 . And gif: swift he: on wanting.
3

4
10 . He’s near.
1
11 . They were not well gane out o sight.
2
11 . Ere she.
3
11 . O gin ye seek S. J. the R.
4
11 . ye where to.
1
12 . Ye’ll search the bush aboon the know.
1
13 . him from his sleep.
 2
13 . Neither man you
1
14 . the bush aboon the know.
4
14 . Lying sleeping.
1
15 . O then spake up Sir James Graham.
3
15 . Let it not be.
4
15 . We killd: while.
1
16 . They’ve tane his broadsword from his side.
16 . him they have for closely him.
2

16 . o for of his.
3

2
17 . O pardon me, I pray ye.
8
17 . ye gae, such shall ye hae.
4
17 . There is no pardon for ye.
18, 19. Wanting.
1
20 . they’ve tane out his bleeding heart.
2
20 . f. stickt it.
3
20 . Then carried, e. Mure, f. Moor.
4
20 . And shewd.
21 . But wanting.
1

2
21 . She rav’d.
 3
21 . And cried, Alake, a weel (well) a day.
4
21 . Alas what have.
2
22 . My heart it is a.
3
22 . Wae to the day I thee betrayd.
4
22 . Thou bold.
2
23 . In that unhappy hour.
4
23 . neer was heard of more.
24. Wanting.
g.
1 . Buleighan, and always.
2

4
1 . Whase friends.
1
2 . has gane.
2
2 . Whar nane might seek to find him.
4
2 . Weining.
1
3 . said.
2
3 . O whar awa are ye.
3
3 . I maun be bound.
4
3 . And now.
2
4 . I rin to lay.
 4
4 . And his friends seek.
1
5 . yon laigh.
2
5 . I sall pay there.
3
5 . And as I am your leman trew.
4
5 . at the.
6. Wanting.
1
7 . He turnd.
2
7 . And laid him doun to.
3
8 . Whan.
4
9 . sent to.
1
10 . Yea, I: said.
2
10 . He past by here.
3
10 . Gin.
4
10 . the Hichts of Lundie.
1
11 . as wi speid they rade awa.
2
11 . She leudly cryd.
3
11 . Gin ye’ll gie me a worthy meid.
4
11 . whar to.
12.
‘O tell, fair maid, and, on our band,
Ye’se get his purse and brechan:’
‘He’s in the bank aboon the mill,
In the lawlands o Buleighan.’

13, 14. Wanting.

1
15 . out and spak.
3
15 . said, my stalwart feres.
4
15 . We killd him whan a.
3,4
16 .
O pardon, mercy, gentlemen!
He then fou loudly sounded.
3,4
17 –19.
‘Sic as ye gae sic ye sall hae,
Nae grace we shaw to thee can.’
‘Donald my man, wait till I fa,
And ye shall hae my brechan;
Ye’ll get my purse, thouch fou o gowd,
To tak me to Loch Lagan.’

1
20 . Syne they tuke out his bleeding heart.
2
20 . And set.
 4
20 . And shawd.

21.
We cold nae gie Sir James’s purse,
We cold nae gie his brechan,
But ye sall ha his bleeding heart,
Bot and his bleeding tartan.

1
22 . O for.
2
22 . My heart is now.
3
22 . day I wrocht thy wae.
4
22 . brave heir.
2,3
23 . And in that hour o tein, She wanderd to
the dowie glen.
4
23 . never mair was sein.
24. Wanting.
 214

THE BRAES O YARROW

A. ‘The Braes of Yarrow,’ communicated to Percy by

Dr Robertson, Principal of Edinburgh.
B. ‘The Braes o Yarrow,’ Murison MS., p. 105.
C. ‘The Dowie Downs o Yarrow,’ Motherwell’s MS.,
p. 334; Motherwell’s Minstrelsy, p. 252.
D. ‘The Bonny Braes of Yarrow,’ communicated to
Percy by Robert Lambe, of Norham, 1768.
E. a. ‘The Dowy Houms o Yarrow,’ “Scotch Ballads,
Materials for Border Minstrelsy,” Abbotsford. b.
‘The Dowie Dens of Yarrow,’ Scott’s Minstrelsy III,
72, 1803, III, 143, 1833.
F. ‘The Dowie Dens o Yarrow,’ “Scotch Ballads,
Materials for Border Minstrelsy,” Abbotsford.
G. ‘The Dowie Dens of Yarrow,’ “Scotch Ballads,
Materials for Border Minstrelsy,” Abbotsford.
H. ‘The Dowie Dens of Yarrow,’ Campbell MSS, II,
55.
I. ‘Braes of Yarrow,’ Buchan’s MSS, II, 161;
Buchan’s Ballads of the North of Scotland, II, 203;
Dixon, Scottish Traditional Versions of Ancient
Ballads, p. 68, Percy Society, vol. xvii.
J. ‘The Dowie Glens of Yarrow,’ “Scotch Ballads,
Materials for Border Minstrelsy,” Abbotsford.
K. ‘The Dowie Den in Yarrow,’ Campbell MSS, I, 8.
L. ‘The Dowie Dens,’ Blackwood’s Magazine,
CXLVII, 741, June, 1890.
M. ‘Dowie Banks of Yarrow,’ “Scotch Ballads,
Materials for Border Minstrelsy,” Abbotsford.
N. ‘The Yetts of Gowrie,’ “Scotch Ballads, Materials
for Border Minstrelsy,” Abbotsford.
O. Herd’s MSS, I, 35, II, 181; Herd’s Ancient and
Modern Scottish Songs, 1776, I, 145; four
stanzas.
P. Cromek’s Select Scotish Songs, 1810, II, 196;
two stanzas.
 First published in Minstrelsy of the Scottish Border,
1803 (E b). Scott remarks that he “found it easy to
collect a variety of copies, but very difficult indeed to
select from them such a collated edition as might in
any degree suit the taste of ‘these more light and
giddy-paced times.’” The copy principally used was E
a. St. 12 of Scott, which suited the taste of the last
century, but does not suit with a popular ballad, is
from O, and also st. 13, and there are traces of F, G,
M, but 5–7 have lines which do not occur in any
version that I have seen.
A had been somewhat edited before it was
communicated to Percy; the places were, however,
indicated by commas. Several copies besides O,
already referred to, have slight passages that never
came from the unsophisticated people; as J 2, in
which a page “runs with sorrow,” for rhyme and
3 3,4
without reason, L 2 , and L 12 , which is manifestly
[96]
taken from Logan’s Braes of Yarrow. N has been
[97]
interpolated with artificial nonsense, and is an
almost worthless copy; the last stanza may defy
competition for silliness.
M 1, 3, and N 4, 6, 7, belong to ‘The Duke of
Athole’s Nurse.’ So also does one half of a fragment
sent by Burns in a letter to William Tytler, Cromek’s
Select Scotish Songs, 1810, II, 194–8, which,
however, has two stanzas of this ballad (P) and two
of ‘Rare Willie’s drowned in Yarrow,’ No 215.
The fragment in Ritson’s Scotish Songs, 1794, I,
lxvii, is O.
Herd’s MSS, I, 36, II, 182, have the following
couplets, evidently from a piece treating the story of
this ballad:
O when I look east my heart is sair,
But when I look west it’s mair and mair,
For there I see the braes of Yarrow,
And there I lost for ay my marrow.

The groups A-I and J-P are distinguished by the

circumstance, of no importance to the story, that the
hero and heroine in the former are man and wife, in
the other unmarried lovers. In all the versions
(leaving out of account the fragments O, P) the
family of the woman are at variance with the man.
Her brothers think him an unfit match for their sister,
[98]
A 8, B 2. In C 2 the brothers have taken offence
because their sister was not regarded as his equal by
her husband, which is perhaps too much of a
refinement for ballads, and may be a perversion. She
was worth stealing in C as in B. The dispute in two
or three copies appears to take the form who is the
flower, or rose, of Yarrow, that is the best man, C 8,
9, 17, B 1, 12, D 1, 14; but this matter is muddled,
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