A vicious circle: transgenerational attachment representations in a case of factitious illness by proxy.

Attachment theory offers a robust way to investigate transgenerational child maltreatment; first because there is a coherent theoretical hypothesis of how this might be mediated by the development of insecure working models of relationships, and second, because there is existing evidence from prospective studies that transgenerational attachment patterns can be predicted. Specifically, attachment theory may be particularly useful in cases of Fictitious Illness by Proxy (FIP), where the maltreating behavior is characterized bv disordered illness behavior and care-eliciting. We present a case history, using the Adult Attachment Interview (AAI), which examines attachment and child maltreatment in three generations. A single case history allows for hypothesis generation about the genesis of FIP behavior.

Maternal behaviors associated with smothering: a preliminary descriptive study.

OBJECTIVES: To describe maternal behavior in 15 women identified as having smothered their children. DESIGN: A descriptive study of maternal behavior and interaction with her child, using videotapes of mother and child together. These were obtained by covert video surveillance in a hospital setting. Maternal behavior was rated using an assessment schedule designed to be used with video. RESULTS: The mothers showed a range of behaviors. Three groups emerged; one whose interaction with the child resembled normal maternal behavior, a second who interacted in a hostile way, and a third who showed a paucity of interaction. CONCLUSION: These preliminary data suggest that smothering may reflect more than one type of abnormal maternal relationship or attitude towards children. This may have implications for treatment and prognosis.

Psychological therapies for post-traumatic stress disorder.

BACKGROUND: After exposure to traumatic stressors, a subgroup of survivors (20-30%) will develop post-traumatic stress disorder (PTSD). AIMS: Since the incidence and prevalence rates for PTSD in the community are significant, it is important that general practitioners and psychiatrists be familiar with possible therapeutic options. In this review we shall look at the published evidence about the effectiveness of psychological treatments for PTSD. METHOD: The psychopathological mechanisms involved in PTSD are discussed. Studies of the effectiveness of different psychological therapies are reviewed. RESULTS: The review suggests that persistent fear or shame reactions are key aspects of PTSD. Evidence from systematic reviews suggests that psychotherapeutic treatments are effective in the therapy of reactions based on fear, and may increase the effectiveness of pharmacological therapy. There is less systematic evidence for the efficacy of interventions for symptoms based on shame. CONCLUSIONS: Although a proportion of patients with complex or chronic PTSD may require specialist interventions, most patients can be treated effectively by a general psychiatric service which can offer both pharmacological and psychological interventions.

Ethics of community psychiatry.

Psychiatric care in the community gives rise to ethical dilemmas which resemble those associated with predominantly institutional care. However, there are also dilemmas specifically associated with community care, many of which are conceptual as well as practical. Papers addressing both conceptual and practical ethical dilemmas are reviewed including some papers which deal with the ethical issues associated with violence in the community by the mentally ill.

Psychiatric staff as attachment figures. Understanding management problems in psychiatric services in the light of attachment theory.

BACKGROUND: Attachment theory argues that psychological development and functioning are affected by our earliest attachments to care-givers. Failed or pathological attachment in childhood may give rise to repetition of maladaptive attachment patterns in adulthood. METHOD: Analysis of therapeutic relationships in the light of attachment theory. RESULTS: Relationships between patients and both psychiatric care-givers and institutions may resemble attachment relationship. CONCLUSION: An attachment perspective may be useful for understanding common behavioural disturbances in general psychiatric settings, and support the use of clinical strategies which focus on containment of arousal and the management of anxiety states.

Brain blood flow in anxiety disorders. OCD, panic disorder with agoraphobia, and post-traumatic stress disorder on 99mTcHMPAO single photon emission tomography (SPET).

BACKGROUND: We compared regional cerebral blood flow (rCBF) in three groups of patients with DSM-III-R anxiety disorders. METHOD: Fifteen patients with obsessive -compulsive disorder (OCD), 15 with panic disorder with agoraphobia (PA), and 16 with post-traumatic stress disorder (PTSD) and a similar group of healthy controls were assessed on brain-dedicated high-resolution SPET. RESULTS: MANOVA revealed significant rCBF differences between diagnostic groups (F = 4.4; d.f. = 3, 57; P = 0.007) and between cerebral regions (F = 6.4; d.f. = 1, 57; P = 0.01) in OCD and PTSD compared with PA and healthy controls, limited to bilateral superior frontal cortices and right caudate nuclei. Whole brain blood flow correlated positively with anxiety (r = 0.24, n = 46, P = 0.05). Beck depression scores correlated significantly negatively with left caudate rCBF (r = -0.24, n = 46, P = 0.05) and right caudate rCBF (r = -0.31, n = 46, P = 0.02). PTSD syndrome severity correlated significantly negatively with the left caudate (r = -0.49, n = 16, P = 0.03) and with right caudate rCBF (r = -0.7, n = 16, P = 0.001). CONCLUSIONS: Functional rCBF differences in anxiety disorders could relate to repetitive, intrusive, distressing mental activity, prominent in both OCD and PTSD.

Informed consent and psychiatric research.

The general problem with research is that its purpose does not necessarily benefit an individual patient now. In psychiatry the specific problem is that psychiatric patients may have a reduced mental competence, because of their illness. Thus the specific clinical problems of the research subjects may impede the ethical requirements of the research. To try to solve this conundrum, we may need to move away from a vision of psychiatric ethics which is rights and individual based, and find another, which understand that ethical decision are made in the context of relationship: psychiatrist-patient, patient-society, analyst-patient, psychiatrist-society.

Psychological trauma and its influence on genuine and false complaints of sexual assault.

Events that cause fear leave effects, both physical and psychological. In the last 20 years, it has been recognized that criminal assaults are also fearful events which, like war atrocities and civilian disasters, can have profound effects upon the psychological health of victims. In this paper, some of the research describing the psychological effects of crime will be reviewed, with particular emphasis on allegations of sexual assault. The impact of trauma on crime victims in relation to the prosecution process will be discussed, including the relevance of trauma to the issue of false allegations of sexual assault. The paper will conclude with some recommendations for research.

Should doctors be more proactive as advocates for victims of violence?

Currently the management of adult victims of violence by general practitioners and accident and emergency departments is reactive, concerned almost exclusively with the management of physical injuries. Professor Jonathan Shepherd outlines some ideas for a more proactive approach on the part of doctors to improve the protection and support of vulnerable people; to deal with psychological sequelae; to take the responsibility of making an official complaint to the police away from seriously injured people, who are unable to give or withhold consent to disclosure; and to prevent assailants inflicting further injuries. We asked a sociologist, a psychiatrist, a moral philosopher, and a police surgeon for their comments.

Paradoxical intention and anti-exposure in a non-compliant, obsessive-compulsive ritualiser.

A woman with persistent obsessive-compulsive rituals showed limited improvement with exposure therapy, because of her refusal to comply fully with treatment and a lack of homework practice. She was negativistic towards therapists. Following a relapse, she was asked to try anti-exposure and to increase rituals. Paradoxically, this led to marked self exposure to the feared situation, and self-imposed response prevention, with resultant improvement, whereas anti-exposure instructions are generally anti-therapeutic in obsessive-compulsive disorder.