Psychiatry - Theses
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ItemA comparison of homocysteine levels in first episode psychosis patients and age matched controls( 2007)Elevated serum homocysteine concentrations are neurotoxic and are strongly implicated as a risk factor for neuropsychiatric disease (Fabender, Mielke, Bertsch, & Hennerici, 1999; Kim & Pae, 1996; Kruman et al., 2000; Reutens & Sachdev, 2002). This study compares homocysteine levels in early stages psychosis patients and healthy controls. Data from 48 healthy controls were compared with 50 previously diagnosed psychosis patients, 15-25 years, and with a gender ratio males: females 7:3. Patients were outpatients or inpatients at ORYGEN Youth Health, with a diagnosis of first episode of psychosis defined as daily psychotic symptoms lasting longer than a week that could not be explained by other means such as “drug-induced” or “organic”. All subjects were interviewed to collect information relating to family psychotic history. A possible history of psychotic disease in control subjects was tested using the SCID Psych Screening Module, drug use recorded using Alcohol Use Disorders Identification Test (AUDIT) (for alcohol use), The Modified Fagerström Tolerance Questionnaire (mFTQ) (for smoking), Opiate Treatment Index (OTI) (for opiate-type drugs). Dietary and medication histories were also taken. Blood tests were performed to determine serum homocysteine, serum folate, red blood cell folate and serum vitamin B12 levels. An independent sample t test to compare homocysteine levels in patients and controls was performed. Serum homocysteine levels were significantly higher for patients (M = 12.9, S.D. = 3.6) than controls (M = 11.1, S.D. = 2.7) (t(96) = 2.7, p = 0.007, two-tailed). After General Linear Model (GLM) analysis it was found that group (patients or controls), and not serum folate, vitamin B12 and the T allele of MTHFR C677 polymorphism had significant effect on homocysteine levels. Thus a number of factors that may increase homocysteine levels were ruled out. Although it was not possible to obtain a complete data set for some factors (alcohol, smoking and caffeine consumption) (a weakness of the study), strengths included consecutive recruitment, minimisation of selection bias, good matching for age and gender between patients and controls, and the consideration of (serum) folate and (serum) vitamin B12 as potential confounding variables. A number of other studies have found significantly increased homocysteine levels in young patients compared with controls, particularly males. Most related studies favoured the homocysteine-psychosis link. The probability of symptomatic recovery is very high (80-90%) after treatment for first episode psychosis (Robinson et al., 1999) and delayed treatment, but prolonged duration of treatment is associated with poorer response in treatment and worse outcome (Malla & Norman, 2002). This justifies studying homocysteine levels and cognitive function in that first period of psychosis. This research offers evidence for the importance of serum homocysteine levels as showing involvement in the etiology of psychosis. Lowering homocysteine may have a beneficial effect on symptoms and cognitive dysfunction in psychotic illness. Two randomised controlled trials have demonstrated benefit in psychotic illness of giving folate and consequently reducing homocysteine.(Godfrey & Toone, 1990; Levine et al., 2006b). Benefits of taking folate were found in both trials for both cognition and psychotic symptoms. By reducing homocysteine levels early in the illness, some of the excess cardiovascular mortality may be prevented. Secondary prevention of CVD does not appear to influence outcome (Hermann, Herrmann, & Obeid, 2007), so the right time to intervene and reduce risk would appear to be early in the course of psychosis. Additionally, by lowering homocysteine cognitive functioning and psychotic symptoms may be improved (Levine et al., 2006b).
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ItemSemantic change in psychiatric categories: the case of DSM-III( 2007)Psychiatric terminology has undergone a number of significant shifts over time. These have reflected broader social circumstances surrounding mental illness. One of the biggest upheavals was publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, which created a strictly defined categorical system of diagnostic labels. A framework from historical sociolinguistics, proposed by Weinreich, Labov and Herzog (1968), has been used to investigate this change. Three terms were analysed in detail – Schizophrenia, Bipolar Disorder and Panic Disorder – and were found to have very different histories leading up to DSM-III. The Weinreich et al. framework is evaluated for its utility in this type of complex semantic change, and is found to be effective with some minor modifications. Broader effects of language on shaping perceptions of mental illness are also briefly sketched.
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ItemMasculinities in local contexts: structural, individual and cultural interdependencies( 2006-06)Knowledge of the terms sex and gender has important political, health and equity considerations. This thesis investigates the macrostructural assertions of Connell’s social theory of gender which is fundamentally concerned with demonstrating the relational and hierarchical nature of gender. A major criticism of the theory has been its lack of account of the individual and the ways in which gender is performed in local settings. Therefore, investigation primarily concerns whether Connell’s macrostructural theory is explicable in local social contexts. A theoretical critique and reframing of the theory lead to articulating the interdependency between structural, cultural and individual factors. By explicitly stating Connell’s implicit assertions, what becomes evident is that people’s gendered relations are interrelated with beliefs which are held personally and shared culturally. Specifically, a major theoretical impasse is overcome when recognising that the “ideology of supremacy” of a dominative masculinity is necessarily interdependent with the structural relations of power. From here I have suggested that there are particular patterns of these structures and beliefs which can be seen in macrostructural terms, but also in local settings. These hypotheses are reframed into social network terms for an empirical investigation of Connell’s theory in local contexts. To determine whether the predicted hypotheses for Connell’s theory occur at greater than chance levels, a particular type of statistical model for social networks, called exponential random graph (p*) models, is employed. Importantly, such models utilize a methodological approach which specifically acknowledges the interdependency of structural, individual and cultural factors, thus aligning Connell’s theory with the method of investigation. Primarily, Connell’s theory is concerned with differing configurations of masculinity, and for this reason my focus is predominantly on males and their relations with one another. To this end, two general local settings were chosen to explore these issues – secondary schools and all-male elite-level (AFL) sporting teams. Social network models were used to examine the relations between masculinities in six schools and four AFL clubs. Importantly, Connell has suggested that local contexts are likely to differ from one another in the degree to which they support gendered relations of power. Results for schools and clubs vary considerably from one another in the ways in which they provide local level support for Connell’s theory. Significantly though, there are some contexts which do show support for Connell’s theory. That such evidence can be found to endorse specifically defined local-level predictions for Connell’s theory, even when controlling for complex micro-level social structures, and also for other individual level effects, and still produce statistically significant effects supporting these predictions suggests that support is not trivial. There is strong evidence that attitudes towards masculinity can be an important organising principle in the emergence of hierarchy, not universally, but in some contexts. It can be concluded that gender relations tend to operate in ways predicted by Connell’s theory, though local context is particularly important. The specific findings from local social contexts do have wider implications for Connell’s theory, including how hierarchy in gender can be tied to other structures of power, where femininities fit into the theory, a more precise account of hegemony and an exploration of the impact culture has in local settings.
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ItemThe effects of immigration and resettlement on the mental health of South-Asian communities in Melbourne( 2006-02)This research explores the relationship between immigration experiences and psychological well-being within the Indian and Bangladeshi communities in metropolitan Melbourne, Australia. The researcher conducted individual in-depth interviews with thirty-eight adult Australian permanent residents/citizens born in India and Bangladesh with the aim of examining personal post-migration accounts of adjustment, acculturation and coping in a foreign society and the effect on their mental health. Through qualitative analysis, the personal experiences and stories of South-Asian migrants and the psychological consequences of resettlement in Australia are explored. The study investigated coping strategies and psychosocial protective mechanisms and explored factors relevant to both successful and unsuccessful resettlement, and their relationship to psychological well-being. The results indicated that social and emotional disconnection, isolation and alienation, lack of recognition of professional skills, experiences of racism and discrimination, cultural incongruity, feelings of cultural uprooting and inadequate English language competency, all may contribute to psychological distress, difficulties in adjustment to life in Australia and in some cases, repatriation to the country of origin.
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ItemThe creative process: A phenomenological and psychometric investigation of artistic creativity( 2005-08)Although a variety of approaches have been adopted to researching creativity, the phenomenology of creativity has not been well-represented in the literature. This constitutes a significant obstacle to achieving a comprehensive, satisfactory model of the creative process. The current thesis aimed to provide a systematic analysis of the phenomenology of artistic creativity. The thesis also attempted to integrate the analysis of phenomenological aspects of artistic creativity with the more established approaches of creativity-personality and creativity-psychopathology research. Specifically, the research investigated whether the phenomenology of artistic creativity varies in relation to features of personality and psychopathology.
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ItemA prospective study of the relationship between stress, coping and the onset of psychosis in a high risk group( 2005-06)The experience of stress and associated coping responses are often described as playing an important role in the onset of schizophrenia and other psychotic disorders. Despite widespread acceptance of this model, there is little empirical evidence to support such a relationship. This is partly due to a lack of well-designed prospective studies of the onset of psychotic disorders that incorporate different aspects of the stress and coping process. The relatively recent development of validated and reliable criteria for identifying young people at high-risk (UHR) of developing psychosis has enabled the process of onset of psychotic illnesses to be studied more closely than was previously possible. It has also opened the way to the development and evaluation of preventive interventions. This longitudinal study aimed to compare the experiences of stress and coping between a UHR cohort (N = 143) and a group of young people without mental health concerns (HC group, N = 32). In addition, the contribution of stress and coping in the development of acute psychosis in a subgroup of the UHR cohort (UHR-P, n = 18) was also investigated.
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ItemSelf-ambivalence in obsessive-compulsive disorder( 2005-01)According to the cognitive model, Obsessive-compulsive disorder (OCD) is maintained by various belief factors such as an inflated sense of responsibility, perfectionism and an overestimation about the importance of thoughts. Despite much support for this hypothesis, there is a lack of understanding about the role of self-concept in the maintenance or treatment of OCD. Guidano and Liotti (1983) suggest that individuals who are ambivalent about their self-worth, personal morality and lovability use perfectionistic and obsessive compulsive behaviours to continuously restore self-esteem. This thesis develops a model of OCD that integrates self-ambivalence in the cognitive model of OCD. (For complete abstract open document)
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ItemWilliams Syndrome: links between brain, cognition, and behaviour( 2005-10)The interrelationships between brain, cognition, and behaviour are complex but can be more clearly characterised by studying disorders with an underlying genetic basis. This thesis examined these interrelationships in the context of Williams syndrome (WS), a neurodevelopmental genetic disorder that affects aspects of cognition, behaviour, and brain structure. The principal aims of this thesis were to evaluate the cognitive, behavioural, and neuroanatomical profile of WS individuals and to explore the relationships between aspects of the cognitive and behavioural profile and the neuroanatomical changes that are evident in WS. Three general hypotheses, and 10 specific hypotheses, were postulated as a means of exploring these aims. The first general hypothesis predicted that WS individuals would demonstrate distinct features within their cognitive and behavioural profile. Specifically, it was predicted that WS individuals would show relative strengths on verbal tasks and significant deficits on visuospatial and mathematical tasks, in contrast to control participants who were predicted to show a more even profile. It was also predicted that WS individuals would show evidence of heightened affect in response to music and demonstrate hypersociability as compared to control participants
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ItemDepot medications and the treatment of schizophrenia in community psychiatry( 2005)Since their introduction in the 1960s, depot antipsychotics have played a substantive role in the pharmacological management of patients with schizophrenia in Australia. During the 1990s, among radical changes to the structure and function of community services in the State of Victoria, a new generation of improved oral antipsychotics was introduced. The latter were anticipated to replace older antipsychotic medications. This thesis examines the impact these changes have had on depot prescribing in community psychiatric settings. It tests the hypothesis that due to widespread concerns over the consequences of non-adherence that frequently accompany the use of all oral antipsychotics, depot agents will maintain a key place in pharmacotherapy. The research is based on Australian data taken from community care teams in Victoria, complemented in one study with data from Western Australia. The prescribing patterns data indicate that between 1998 and 2003 substantial changes in the use of antipsychotics have occurred. The results show a rapid increase in second generation antipsychotics from 38 percent to 78 percent over the five year period of the study. Over the same time, first generation antipsychotics fell from 27 percent to 3 percent of prescriptions. Prescriptions of depot agents also fell, but by a much lesser amount, from 46 percent to 29 percent of prescriptions, a level close to the absolute level of non-adherence proposed in the literature. This supports a further hypothesis that depot antipsychotics use will stabilise at a level close to the absolute level of non-adherence. The findings also indicate that from the perspective of initially distinct prescribing practices in different services, there has been a convergence of prescribing trends towards a common level of use for each group of antipsychotic medications studied. Both depot and newer oral antipsychotics demonstrate a high degree of prescribing stability over time, which is found to be inversely related to the risk of admission for population of patients considered. The clinical application of depots is effected by factors relating to the Service, the range of medications available and, characteristics of the Patient. Four studies were undertaken to explore the likely impact of these influences on community prescribing. The first shows that community treatment orders are used with depot agents more than with other antipsychotics. This supports the hypothesis that involuntary treatment orders facilitate the instigation of depot antipsychotics in reluctant community-treated patients. The second study shows that fewer than 10 percent of patients meet non-adherence criteria of less than 75 percent adherence, that an inverse relationship exists between depot adherence and hospital admission and, a critical level of depot adherence of less than 85 percent is predictive of admission with respect to this population. These findings support the decision of clinicians who prescribe depots with the expectation they will lead to better adherence. The third and fourth studies examine the attitudes of mental health professionals and depot treated patients, respectively. Differences in critical attitudes towards depot antipsychotics between professionals and between services are described. Additionally, patient attitudes to depots, assessed through a pilot satisfaction survey, indicate that only a minority of patients (46 percent) are clearly dissatisfied with their depot medications. This is at odds with the negative attitudes towards depots found among many of the clinical staff. In conclusion, the thesis demonstrates that depot antipsychotics remain an important component of the pharmacotherapy of people with schizophrenia in community psychiatric settings in Victoria. For multi-disciplinary clinical care teams their utility lies in addressing non-adherence, and so preventing relapse and rehospitalisation, and the subsequent, often widespread, costs that ensue.
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ItemWar experiences: the emotional health and wellbeing of Polish elderly immigrants( 2007)Background: Large numbers of Polish refugees arrived in Australia following the end of the Second World War as displaced people, unable to return to their homeland. All had experienced loss of their homeland and many lost loved ones, endured hardship and suffering. Now this group constitutes a significant proportion of the Polish-Australian aged community. The main aim of this thesis is to describe, from a life-span perspective, the relationship between major life events, including war experiences, and psychological and physical health now and in the past. Attention is focused on the factors associated with the longevity of the trauma response. Method: A mixed methods approach was employed using quantitative and qualitative methods along with a detailed historical account of the war and resettlement contexts. The quantitative component involved the recruitment and interview of a convenience sample of 72 Polish elderly migrants from Polish Senior Citizen's clubs across the Melbourne Metropolitan area. Participants who gave informed consent completed a detailed questionnaire and interview about their current physical health, social networks, psychological health, quality of life, posttrauma growth, war-related experiences, traumatic events, migration, and post war life events. Categorical and continuous variables were analysed using a combination of parametric and nonparametric statistics. The qualitative component involved a narrative interview with a subset of 18 people about the war years and early life in Australia. In addition, detailed field notes were compiled from the quantitative questions with the remaining 54 people supplementing their responses with stories and accounts while filling out the questionnaires. This produced a rich source of data that was analysed thematically. Results: Fifty-three per cent of participants were women. Most were aged 75 or older (71%). Just over half were married and a third were living alone. The majority had children (90%). Twenty-one per cent described their physical health and seven per cent their emotional health as poor. During the war, 42% were in Germany as forced labourers, 26% had been exiled to the former Soviet Union, 15% had participated in the Armed Forces, 11% were civilians in Poland and 5% were Concentration Camp Survivors. Every person interviewed had experienced at least two traumatic events during the war. The most commonly reported events were the loss of home and belongings (81%), lack of food and water (79%), bombardment (78%) and forced separation from family (74%). People who had survived the concentration camps and ex-service men experienced the highest number of traumatic events. Number of traumatic events during the war was correlated with life-time PTSD symptoms (r=0.46 p=0.01), current PTSD symptoms (r=0.36) and physical health conditions (r=0.37 p=0.01) but was not associated with current quality of life. Negative worldview was associated with PTSD (lifetime and current), physical health conditions and impact of illness. Trait anxiety and years of residency were associated with depression, anxiety, PTSD (lifetime and current) scores and physical health conditions. Negative worldview, Trait anxiety and years of residency were all independent predictors of psychological distress accounting for 51% of the variance in psychological distress. During their-lifetime, 75% of people identified a period of fear, anxiety and panic, 47% of participants reported feeling depressed, while 7% met criteria for PTSD. In the last six months, 33% reported clinically significant anxiety symptoms, 3% had moderate-severe depressive symptoms and 3% met criteria for current PTSD. Coping strategies mentioned most frequently were use of religion (54%) talking to family and friends (32%) and avoiding any reminders (18%) although none of these strategies were associated with emotional or physical health. Thematic analysis revealed that Polish elderly described their accounts of trauma and physical deprivation in the context of individual, familial and community suffering. Individuals described a range of emotional responses to trauma such as fear, grief and humiliation. These emotions were also experienced by family and community. Survival mechanisms such as acts of defiance, using one’s own skills and having hope were described at an individual level. Family was identified as an important survival resource - a central component to this theme was that of the ‘strong mother’ fending for her children. Community was another resource identified by study participants such as the ‘acts of kindness by strangers’ that often made the difference between life and death. The theme of community and family suffering meant that the individual was not alone in trauma but surrounded by others in a similar situation. Community structures were an important part of the recovery and healing that took place after the war. The cohesive nature of Polonia (Poles abroad) may explain why people who did not return to Poland and migrated to Australia in the late 1940’s and 1950’s had lower rates of psychological distress compared with those who returned to communist Poland and only arrived relatively recently. Conclusions: More than 60 years on from the end of the Second World War Polish elderly people were still affected by these events in some way and that in a small number of cases these events were associated with current emotional and physical health. The main determinant of current emotional and physical health was the type of main experience people endured, the number of traumatic events experienced, having a negative world-view, fewer years of residency and higher Trait-Anxiety scores. The thematic analysis revealed that there is a complex relationship between individuals, families and communities in how they experienced trauma and its aftermath and the resources and mechanisms they used in order to survive.