Psychiatry - Theses
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The effectiveness of three treatment regimens used in the management of neonatal abstinence syndrome
This study proposed a multifactorial model of development to understand the development of infants during their first 12 months of life who had been born to chemically dependent women. The impact of maternal chemical dependency on pregnancy outcome, factors associated with severity of neonatal abstinence syndrome and effectiveness of three treatments used in the management of neonatal abstinence syndrome was studied in 271 mother-infant pairs, who were managed by the Chemical Dependency Unit, Royal Women’s Hospital, Melbourne between April 1991 and May 1994. The chemically dependent mothers and their infants were grouped on the basis of their primary drug of abuse: viz methadone, heroin, non-opioid and codeine groups. Fifty two infants born to drug-free mothers were recruited from a routine antenatal clinic of the same hospital to serve as a control group. The controls were matched for maternal age, marital status, race socioeconomic status, educational level, alcohol and tobacco consumption. Patterns of maternal drug use were determined by reports from methadone treatment programs, drug rehabilitation centres, medical records, personal interviews and urine toxicologic assays performed on mothers during pregnancy and on their infants during the first 48 hours of life. Urine was assayed for metabolites of methadone, amphetamines, barbiturates, cocaine, opiates, cannabis and benzodiazepines. There were 180 heroin-dependent, one morphine-dependent and one pethidine-dependent pregnant women enrolled in methadone maintenance programs. The methadone group consisted of these 182 methadone-maintained women and their offspring. Thirty five heroin-dependent women and their offspring formed the heroin group. The non-opioid group consisted of 46 chemically dependent women who used multiple drugs but not opioid drugs during their pregnancy and their offspring. There were eight mother-infant pairs in the codeine group. The mothers in this group primarily abused medication containing codeine in pregnancy. (For complete abstract open document)
The history of Yarra Bend Lunatic Asylum, Melbourne
The thesis is in three major sections, plus a brief conclusion. The first section provides essentail background by describing the care of the mentally ill in England and New South Wales (including the Port Phillip district) in the period prior to the establishment of Yarra Bend Lunatic Asylum in 1848. The second section is a chronological history of Yarra Bend, particularly focusing on the period from its inception in 1848 until the Royal Commission of 1884; with some extension to describe the other psychiatric services within Victoria during the same period.The third section discusses at length a number of key issues identified within the chronological history.
A neuroendocrine study of chronic combat-related post-traumatic stress disorder
Descriptions of the development of psychiatric symptoms in response to traumatic experience can be found in literature dating back to some of the earliest writings found. Amongst these symptoms there have always been descriptions consistent with what we would now term Post Traumatic Stress Disorder (PTSD). Tomb (1994) describes how such symptoms historically have been most frequently described in relation to combat experience and are contained in such classical texts as Homer’s Iliad. Recognition that such symptoms also occur in association with non combat related trauma is a relatively recent event. This can be seen in description of response to traumas such as The Boston Coconut Grove Fire (Adler 1943) and the Buffalo Creek Dam collapse (Gleser et al 1981). Combined with the massive number of combat veterans with combat experience related to psychiatric disability following the World Wars, significant impetus appears to have developed for separate classification and understanding of trauma related psychiatric symptoms. Together, these forces led to the creation of the diagnostic category of PTSD for the first time in the American Psychiatric Associations DSMIII (APA 1980). In this series of studies, we are thus aiming to further the understanding of the neurobiology of Post Traumatic Stress Disorder by specifically examining a group of male Australian Vietnam veterans with current PTSD, comparing them to two control Vietnam veteran populations, one group of those veterans who previously met criteria for a diagnosis of PTSD and a third group who never have met criteria for a diagnosis of PTSD. We examined these three groups in a number of ways. Firstly, to further understand aspects of central noradrenergic receptor function we utilised a clonidine growth hormone challenge test. Consistent with previous literature on the HPA axis in PTSD from North American we utilised a modified dexamethasone suppression test to investigate feedback within the HPA axis. Finally, we investigated serotonergic receptor function peripherally with a further study of platelet paroxetine binding and performed the first large study examining central serotonergic receptor function using the d-fenfluamine prolactin challenge test. Before describing the methodology and results of these studies I will review relevant findings to these three systems from studies of animal and human models of stress, clinical populations with PTSD and their treatment and previous experimental analysis of relevant biological variables in subjects with PTSD.
Linguistic politeness in middle childhood: its social functions, and relationships to behaviour and development
This research compared Brown and Levinson’s “face saving” account of linguistic politeness with the everyday or social normative account in the context of children’s requesting skills. The research also explored the relationship between children’s politeness skills and their behavioural adjustment. The subjects comprised four groups of ten-and-a-half year old children: a comparison group without behaviour problems, a hostile-aggressive group; an anxious-fearful group; and a comorbid group. All the children were selected from the Australian Temperament Project subject population based on parents’ ratings of the children on the hostile-aggressive and anxious-fearful subscales of the Rutter Child Behaviour Questionnaire. Study 1 found that all the groups of children discriminated between others on the power and distance dimensions in ways consistent with social norms, e.g. adults are judged as more powerful than children. Study 1 also showed that the hostile-aggressive and comorbid groups were significantly less likely to discriminate between others on these dimensions compared to the comparison group. Study 2 showed that for all the children studied politeness as a normative way of speaking was marked by use of please whereas face saving politeness was marked by the use of question directives and hints compared to other request forms. Further, Study 2 showed that there were no differences between children with and without behaviour problems in their use of please to mark different ways of asking.
Outpatient commitment: is it effective?
Outpatient Commitment (OPC) is a legal procedure that allows for involuntary psychiatric treatment in the community. Legislation for OPC first emerged in the 1970s in the USA in an attempt to provide a legal remedy for the problems posed by ideological reforms to institutional psychiatry and mental health law. OPC in particular attempts to address the difficulties presented by persons with chronic relapsing forms of serious mental illness and poor compliance with outpatient treatment - persons whose disadvantage is now particularly visible in the streets of our large cities. OPC sits awkwardly between the developing and expanding frameworks of community mental health services and mental health law. It potentially overlaps with guardianship laws, enduring medical power of attorney and court orders. Despite the growing provision for OPC and its increasing frequency of use in North America, the Antipodes, and most recently on the boarders of the European continent, there remains little understanding of the conceptual mechanisms involved in its application. Even less is known about the group of patients who might respond best to its implementation. Without taking stock of its potential adverse effects, societies run the risk of enthusiastically embracing this rather crude legal mechanism of persuasion, instead of exploring or supporting the development of potentially more effective and sophisticated clinical interventions to address the problem of non-compliance with outpatient psychiatric treatment. Given the current limitations of clinical interventions for serious mental illness and treatment non-compliance, OPC may provide a very useful role in enhancing the efficacy of these interventions/treatments through its effects on the way a treatment service is provided as well as on the patient's treatment adherence. With this aim in mind, many different forms of OPC have now emerged. However, without adequate research evidence, it is not possible to advocate strongly for the development of one form of OPC legislation over another. Nor is it possible to argue for its use in preference to other legal mechanisms of treatment orders e.g., guardianship orders. The final decision about which form of OPC legislation is chosen appears to have relatively little to do with any empirical evidence of clinical efficacy but more to do with historical and legal concerns. This thesis attempts to go some way to further bridge the gap between evidence based psychiatry and the application of mental health law with respect to Outpatient Commitment. Chapters 1 and 2 describe a brief account of the historical context within which OPC has emerged both internationally and in Australia. Chapter 3 provides a review of clinical outcome studies in the USA and elsewhere, concluding that on simple clinical measures of outcome, OPC appears to be associated with significant benefits. It is of note that all these studies have considerable limitations, and none provide a useful comparison of patients' objective clinical ratings with patients' subjective ratings of the "persuasiveness" or "coerciveness" of OPC. Chapters 4 and 5 of this thesis outline the results of a retrospective controlled study of the clinical outcome of all patients on a form of OPC in a sector of metropolitan Melbourne, Victoria, Australia, between 1987-1992. The characteristics of the patients selected has already been reported in a previous study which describes the sample as being mainly those with chronic relapsing forms of psychotic illness complicated by a history of violence and noncompliance with outpatient treatment. In Chapter 4, the results of an analysis of the clinical outcome of this group of patients suggests that the majority of these patients benefit from the application of OPC. In Chapter 5, the results of the control group comparison also indicate that though these OPC patients have evidence of higher levels of morbidity than other involuntary patients discharged directly into the community, OPC patients improve relatively better while on OPC orders. However, a minority of OPC patients do not seem to benefit or even deteriorate with the application of OPC. The study attempts to identify the characteristics that might predict better or worse clinical outcomes associated with OPC. It is important to note that the study, because of its retrospective design, suffers from limitations similar to those evident in other studies and, in particular, it does not account for influence of patients' subjective experiences of OPC. Finally in Chapters 6 & 7, based on the experience of this study and on a review of the literature, a conceptual model is proposed in order to assist with an understanding of how OPC might work. This model focuses on the nature of the impact of OPC on treatment adherence, through its effect on the patient and on the system within which the patient is being treated. It suggests that a balance needs to be struck between the persuasiveness versus the coerciveness of the Outpatient Commitment procedure. An ineffectual mechanism may discredit the procedure as a persuasive aid to treatment adherence. Conversely, an overly coercive mechanism may actually deter patients from accepting any form of assistance for their illness. This model forms the basis of recommendations for future research to test the effectiveness of OPC and to compare or contrast different forms of OPC with each other and with other less formal mechanisms of coerced community psychiatric treatment. Australia, given its relatively uniform structure and administration of mental health services, is in a good position to compare the benefits or otherwise of the rather disparate forms of OPC being introduced into each of its various states and territories. With a multi-centre randomised controlled trial of OPC in this setting, it may then be possible to make recommendations about which form of OPC most effectively and collaboratively assists in the improvement of poor treatment compliance, and which group of patients with serious mental illness are likely to benefit most from its application. It may also assist with determining OPC's relative clinical merit when compared with other less formal coercive/persuasive clinical interventions for treatment non-compliance. Without attempts to study and confirm the empirical evidence for the 'clinical efficacy' of OPC, this increasingly internationally accepted model of OPC oriented community psychiatric care runs the risk of being prematurely challenged in some future wave of mental health reform. As in the example of de-institutionalisation, the ultimate future of OPC may, however, rest not with the law but with the advent of better and more effective treatments for psychotic disorders.
Personal attributes in inter-personal contexts: statistical models for individual characteristics and social relationships
The thesis develops models for social phenomena based on two primitive concepts: individual and relation. The models - based on the p* class of models for social networks - are designed to examine the inter-dependence of individual characteristics together with the social relations that exist among those individuals. The goal of constructing such models is to extend the capacity to develop rich descriptions of social processes. Relations among individuals are represented by a network or networks of interpersonal ties. The first part of the thesis describes models solely for such sets of relational ties. Techniques to represent data dependencies, approaches to model interpretation, and methods for valued attribute and relational data, are developed. (For complete abstract open document)
The relationship between anxiety vulnerability and stress in the cognitive processing of threat-related information
In order to clarify the relationship between anxiety vulnerability and clinical anxiety, information-processing models have been employed to examine the cognitive biases of anxious individuals for threat-related information. At the core of these models are research findings indicating that anxiety-linked attentional biases render high trait anxious individuals disproportionately vulnerable to the effects of stress. The current research, following the model of Williams, Watts, MacLeod, and Matthews (1988), tested the hypothesis that attention to threat-related information is due to the interaction of trait anxiety and state anxiety. Five comparable studies employed emotional Stroop and probe-detection paradigms to assess the attentional biases of high and low trait anxious individuals to threat-related words in response to elevations of stress. Four of the studies assessed the preconscious and conscious attentional biases of adults and one study investigated the attentional biases of children. This focus allowed developmental comparisons that had not been undertaken previously. The studies were comparable to each other and to previous research. The studies sought to clarify the effects of different forms of stress on the anxiety-linked attentional biases and to assess the effects of these stressors on domain-specific stimuli. The hypotheses were that, in response to elevations in state anxiety, high trait anxious individuals show increased attention to threat and low trait anxious individuals show avoidance of threat. It was expected that these threat-related attentional biases are identified at both preconscious and conscious levels of processing, and more when the stimuli are related to the individuals’ domain of concern. Contrary to expectations, only one study found the predicted pattern and this result occurred at a conscious level of processing. In addition to the lack of support for the hypotheses, a counter-intuitive alternative pattern that was the converse of predictions was identified in four of the five studies. In this pattern, in response to elevated stress, there was a trend for high trait anxious individuals to show decreased attention to threat and low trait anxious individuals to show increased attention to threat. The pattern was identified, in various studies, at conscious and preconscious levels of processing, and more in response to domain-specific stimuli. Adults and children showed similar levels and types of attentional biases. The results of the current studies show some convergence with previous research. The findings are discussed in the context of a proposed model that incorporated aspects of Williams et al’s theories (1988; Williams, Watts, MacLeod, & Mathews, 1977) and Mogg and Bradley’s (1988) theory. This model suggests that high and low trait anxious individuals’ patterns of threat-related attentional biases vary according to their different levels of reactivity to stress, which affects their threat threshold. Due to differences in this threat threshold, high and low trait anxious individuals show divergent attentional responses under the same level of external stress. The model incorporates the avoidance effects identified in previous research and theory. This model may explain both the current counter-intuitive findings and past inconsistencies in the literature. It may also clarify how individuals with different levels of anxiety vulnerability show divergent attentional responses to stress elevations. It is suggested that inclusion of the notion of subjective stimulus threat value into the cognitive processing paradigm may clarify some of the unresolved issues raised in this research.
The implementation and evaluation of telecounselling as a treatment modality for problem gambling
There is an extensive range of problems and maladaptive behaviours for which people may seek counselling. One of these is problem gambling. The extent of gambling in the community and the incidence of gambling problems have become issues of great concern to many in the Australian community. Counselling in the face-to-face setting may not be available or appropriate for some individuals with gambling difficulties. Potential barriers to the provision of counselling services for problem gamblers means that innovative techniques for counselling service delivery must be developed and evaluated. Provision of counselling services using modern telecommunications technology is one such innovative strategy. (For complete abstract open document)
Evaluation of the Bilingual Case Management Program in community mental health services in Melbourne
This thesis describes the evaluation of a program to employ bilingual staff in case management positions in community mental health services in Melbourne, Australia. A literature review showed that no previous research in Australia had investigated the impact of bilingual staff on clients of mental health services. While research conducted in the USA shows that ethnic matching (matching clients and clinicians on the basis of language or ethnic background) increases service use, its impact on outcome domains such as social functioning remains uncertain. (For complete abstract open document)
Chinese-Australian families' help-seeking behaviours for mental illness
This thesis includes two studies: a survey of Melbourne's Chinese community and a family interview study. The survey was based on 418 respondents while twenty-eight caregivers participated in the family interview study. The survey explores how depression and schizophrenia are understood and are dealt with in a migrant Chinese community. The purpose of the family interview study was to examine the pathways to care for mental disorders, the social representation of illness and families' experiences of illness. Social knowledge about mental illness, physical illness and the concepts of normal human experiences of distress influenced the labelling of experienced conditions. Disorders were labelled as ‘a mental illness’, ‘a physical illness’, ‘a normal problem’ or ‘an abnormal problem’. Results indicated that schizophrenia was likely to be labelled as a mental illness and psychiatrists were seen as the main form of help. On the other hand, depressive disorder, anxiety disorder and post traumatic stress disorder were likely to be labelled as a ‘normal problem’, an ‘abnormal problem’ or a ‘physical illness’ and were likely to be treated by family members, friends, a traditional Chinese medicine physician or a Western physician. Labels given determined initial responses to the problem but the work also indicates a dynamic relabelling process developed by exposure to the social and professional systems. Pathways to care are intimately related to illness understandings which in themselves are in some respects relatively dynamic. The present study suggests that health professionals and the health institutions need to take into account patients' and family members’ explanations of illness in order to improve access to their services and in order to improve the quality of the services they deliver to the community.
The experience of depression: women's perspectives
Reports from epidemiological survey data identify that twice as many women than men suffer with depression over the life cycle. From reviewing the broad research literature, it appears that many studies focus on only one aspect of a bio-psychosocial model and, do not consider how these aspects interact. (For complete abstract open document)
A Comparison of an internet-based and face-to-face group intervention to modify body dissatisfaction and disturbed eating in young women
Objective: This study compared the effectiveness of a new manual-based group intervention program, The Body Image and Eating Behaviour Program, for women with sub-clinical body dissatisfaction and disturbed eating behaviours, using two delivery modes: a traditional Face-to-Face group intervention and an Internet-based intervention with interactive on-line group sessions in synchronous time. The program was conducted weekly over an 8-session period. Predictors of a good treatment outcome for the intervention program were examined with both delivery modes combined. Methods: Participants (18-30 year old women) were recruited by advertisements on Melbourne university campuses and at community health agencies. They were randomly assigned to group (Face-to-Face group n=19, Internet-based group n=21). Body dissatisfaction, disturbed eating behaviours, psychological status, and stage of change were assessed using standardized instruments prior to and immediately after the intervention, and at two months follow. Results: A 2 (group) X 3 (testing occasions) within subjects repeated measures analysis of variance was used to examine time and between group differences. Significant improvements on all clinical outcome variables were observed at post-test and maintained at follow-up in both groups. However, there were no significant between group differences. Hierarchical multiple regression analyses were used to examine predictors of treatment outcome at follow-up. Milder depression scores predicted greater improvement in binge eating frequency while a greater improvement in bulimic pathology and self-esteem at follow-up was predicted by more severe body dissatisfaction scores. Stage of change before treatment was not a predictor of outcome. Qualitative research demonstrated that the Internet-based delivery mode was a less confronting way of seeking help and a convenient and supportive medium to disclose personal information. However, participants had more difficulty exploring deeper psychological issues in the Internet-based group and forming close bonds with each other due to the speed and flow of the discussion. Discussion: The treatment program was valuable in both delivery modes and was found to be very acceptable by participants. The Internet, with the potential to over-come obstacles of distance and provide a discrete mode of treatment delivery, showed promising results at improving body satisfaction and disturbed eating behaviours in young women. Findings demonstrated inconclusive evidence for predictors of a good treatment outcome.