Relation between anxiety, depression and locus of control of patients with multiple sclerosis.

This study was concerned with examining relation between anxiety, depression and locus of control (LC) in Croatian multiple sclerosis (MS) patients in order to determine an indication for psychotherapeutic intervention. The participants were 457 MS patients attending central state medical rehabilitation program at VaraZdinske Toplice, asked to fill in the locus of control inventory and Crown-Crisp Experiential Index (CCEI) questioner of personality in the clinical setting. In order to determine whether locus of control changes along natural course of MS, patients were grouped according to the duration of the disease: less than five years, five to 10 years and more than 10 years. The results demonstrated that 405 (88.6%) MS patients exhibited external locus of control while 52 (11.4%) had internal locus of control. Moreover, as the disease progressed, locus of control shifted more to externality. Analysis of gathered data confirms connectivity of external locus of control with anxiety and depression. Results of anxiety and depression level on CCEI questionnaire show continuously increased values regardless on duration of illness. Croatian MS patients like other chronically ill externally oriented patients' show more maladaptive behaviour, which has been strongly linked to anxiety and depression and this, is indication for psychotherapeutic support.

Increase of frequency of post-traumatic stress disorder in disabled war veterans during prolonged stay in a rehabilitation hospital.

AIM: To explore possible causative factors in the development of post-traumatic stress disorder (PTSD) in disabled Croatian war veterans. METHOD: The sample comprised 42 disabled Croatian war veterans, aged 19 to 44 years, accommodated in the VaraZdinske Toplice Rehabilitation Hospital for the purpose of long-term physical rehabilitation. Manifestation of PTSD symptoms (Mississippi Scale for Combat-Related Post-Traumatic Stress Disorder) and anxiety levels (Spilberger's State Trait Anxiety Inventory) were tested in 1994 and 1999. RESULTS: Patients with PTSD symptoms had significantly higher anxiety levels then patients without PTSD symptoms. The percentage of patients manifesting PTSD increased from 19% in 1994 to 41% in 1999. Over the same period, the anxiety levels decreased in the patients with PTSD. CONCLUSION: Anxiety and PTSD seem to share common etiologic grounds. Nevertheless, staying in the same homogenous group for a substantial period of time, in combination with inadequate social support and deficient psychological care, may contribute to the development of the PTSD symptomatology.

Countertransference problems in the treatment of a mixed group of war veterans and female partners of war veterans.

AIM: Analysis of countertransference problems in the treatment of a heterogeneous group of war veterans. METHOD: The method used in this work was psychodynamic clinical observation and analysis of countertransference phenomena in group therapy. RESULTS: In the beginning of our work, we faced with a regressive group, which was behaving as it was re-born. The leading subject in the group was aggression and the need for hospitalization to protect them and their environment from their violence. With the development of group processes, a feeling of helplessness and lack of perspective appeared, together with suicidal ideas, which, because of the development of group cohesion and trust, could be openly discussed. With time, the group became a transitional object for its members, an object that gave them a feeling of safety but also a feeling of dependence. CONCLUSION: The role of the therapist is to support group members in becoming independent. The therapist's function is in controlling, containing, and analyzing of the destructive, regressive part and in encouraging the healthy parts of the patient. With the integration of good therapeutic process, the healthy parts of the patient gain control over his or her regressive parts.

Trauma and reconstruction in a large group of refugees.

The study is a continuation of a research which the expert team started in refugee and displaced persons' settlements in Croatia. By studying a group of refugees in its entirety we could not avoid noticing its extremely regressive position. Faced with the refugees' numerous existential problems we took the role of good, caring and tender mother (a good object) who will protect her children, give them security, meet their essential needs. Looking at the group dynamics, in the light of Melanie Klein's theory, we noticed the existence of schizo-paranoid and depressive position in the group, manifesting itself through the gap occuring as defense from its self-destructiveness, i.e. as the protection of introjected object which has be saved from destruction because the true "good object" was destroyed. Through the analysis of schizo-paranoid and depressive position of large group of refugees the aim of our work was to enable the group to gradually overcome the schizo-paranoid position and transfer into a more mature phase of development, thus creating a favorable atmosphere for maturation and self-protection.

Changes in pulse rate among the civilian population during air-raid alerts in the city of Zagreb.

This investigation was performed in Zagreb and its surroundings in 1991 and 1992 during the war against Croatia. The study included 50 civilians who, at the moment of the sounding of the air-raid siren, had a continuous electrocardiogram recorded as part of the routine cardiologic examination. The frequency of the pulse was read out from the electrocardiogram at four different times: before the sounding of the siren, the moment of the sounding of the siren, the moment of cessation of the alert, and 1 hour afterward. The mean values of the pulse were calculated for each time point. The subjects were divided into four groups according to the length of exposure to the air-raid alerts (September 15, 1991 to January 3, 1992). The results show a significant increase in pulse frequency at the moment of the sounding of the air-raid siren compared with before the air-raid siren (p < 0.001). However, no significant difference was found between the beginning and the end of air-raid alert campaign (p > 0.05). We conclude that within the civilian population of the city of Zagreb there was no adaptation to traumatic war situations as indicated by a lack of pulse reaction after a period of time under air-raid alerts. In other words, civilians always reacted with increased pulse frequency at the moment of the sounding of the air-raid siren.

[Group psychotherapy in the treatment of post-traumatic stress disorder]. / Grupna psihoterapija u lijecenju posttraumatskoga stresnog poremecaja.

Working with psychotraumatized war veterans we perceived their extremely regressive position, which is accompanied by several destructive and autodestructive compulsions. Facing the multiple traumatic experiences which they lived through, a certain degree of regression has been appearing, since even a satisfying "nourishing-indulgence of their needs" cannot completely make up for their pre-war position. In this way occurred the splitting between ideal (introjected) object and real object, in which were projected all bad experiences, and which is still persecuting and wants to destroy. Through interactions between all group members of traumatized patients we analyzed the phenomena and the specificities of these groups-particularly their regressive position. The aim of the group psychotherapy was to enable progressive overcoming of regressive position and transition into a more mature stage of development, thus creating a favorable climate for growing up and independence.

Anxiety in a large group.

Anxiety in a large group is a phenomenon much written about, but always as a subjective experience of the therapist and patients. Large group with its regressive situation stimulates the occurrence of archaic defense mechanisms, which gives the leader a special role as one who can influence, with his interventions, the intensity of anxiety. In order to prove the hypothesis of higher anxiety in a large group than in median and small groups, the authors measured the level of anxiety at the beginning and at the end of each of ten consecutive large group sessions.

Anxiety as a possible predictor of acute GVHD.

In order to determine the influence of anxiety on the development of BMT complications and survival, we analysed data on 35 consecutive patients undergoing BMT in our Centre between June 1992 and December 1994. All patients received bone marrow from HLA-identical MLC non-responsive siblings. For GVHD prophylaxis, all patients received cyclosporin (CsA) and short methotrexate (MTX). The diagnosis and severity of acute GVHD were defined according to the Seattle Transplant Team criteria. The patients were tested with the Spielberger STAI test as a measure of anxiety as a state (STAI-S) and as a trait (STAI-T). The STAI-S/1 and STAI-T/1 were performed during the first week of isolation (day -5 to day -3 prior BMT) and STAI-S/2 and STAI-T/2 at the end of the discharge from laminar air flow units (day +35 to day +40 post-transplant). During isolation all patients had daily psychiatric support. Out of 35 patients, 31 (89%) fulfilled the STAI-S and STAI-T during the first week and at discharge from laminar air flow isolation. The level of anxiety at the beginning of isolation as measured by STAI-S/1 and STAI-T/1 tests had been significantly higher in patients who subsequently developed acute grade II-IV GVHD as compared to patients with GVHD grade 0-I (P < 0.001), irrespective of age, sex or stage of the disease prior to BMT. In those patients who died, the STAI-S/1, STAI-T/1 and STAI-T/2 tests had been almost identical to those of surviving patients, while STAI-S/2 had been significantly higher (P = 0.034). These data clearly indicate an association between the level of anxiety and the risk for BMT complications, but this should be confirmed in further controlled clinical trials.

[Physical manifestations of anxiety during group psychotherapy]. / Tjelesne manifestacije tjeskobe tijekom grupne psihoterapije.

Anxiety is always accompanied by certain somatic sensations related to certain organs. The author, using the results obtained in the course of the median group sessions, exceptionally anxiogenic in their very nature, measures the intensity of somatizations of anxiety by means of v. Zerssen questionnaire at the beginning and at the end of the sessions. He also observes the distribution of somatizations, according to organic systems (cardiovascular, respiratory, urogenital, gastrointestinal, locomotor and sensorium). What is interesting is the distribution of significantly pronounced somatizations, which indicates that the most frequently pronounced discomforts are related to sensorium. This was to be expected in view of the fact that the population of neurotic patients was being observed while other systems are approximately equally represented. The results shown indicate that the median group situation leads to an increase of anxiety, resulting in subsequent homeostasis disruptions, and to somatizations of anxiety. In such circumstances, it is locomotion that is most inhibited by group situation itself.

[Changes in relevant attitudes of nurses after one year of working with Balint groups]. / Promjene u relevantnim stavovima medicinskih sestara nakon godinu dana rada u Balintovim grupama.

The present study was carried out in the Popovaca Psychiatric Hospital and the examinees were nurses (N = 44) allocated to educative work in Balint groups. Authors discuss if any change may occur in the attitude towards some relevant notions during the one-year educative work in Balint groups. A graphic form of semantic differential was used as the measuring instrument. The findings of this study suggest that during the educational process the attitude towards notions "education", "doctor" and "myself" becomes more negative. The attitude towards the notion "patient" remains unchanged.

[Transference and countertransference problems in patients treated with bone marrow transplantation]. / Transferni i kontratransferni problemi u radu s bolesnicima lijecenim transplantacijom kostane srzi.

Psychological problems that restrain the patient before, during and after the bone marrow transplantation (BMT) are multiple and are very complex and often have significant effect on the transplantation procedure itself. What patient is going through followed with his expectations and dependence on the transplantation team, together with development of an archaic transference develops a number of counter-transference reactions within the team members. If we assume that during the time spent in a sterile unit and isolation, because of the regressive position, patients use early defending mechanisms, which again, reflect in the reactions of the team members. The aim of this project is to analyse transference and counter-transference problems of the patients and the team members during the BMT. The method used was psychodynamic clinical observance and analysis of transference and counter-transference problems of patients and the team members during the process of transplantation. Thirty-five patients with acute myeloblastic and acute lymphoblastic leukemia, treated with allogenic BMT, were observed during their stay in a sterile unit over the 5-year period. Transplantation procedure, based on observation of psychological dwelling and transference reactions of the patients, is divided into five phases while, from the perspective of the team members, the counter-transference problems are revealed especially during the moments of helplessness. The most important mechanism that the team members are using to protect themselves from this feeling is "selective avoidance of psychological", in other words, avoidance of empathy.

Psychosomatic subdecompensation.

The ego of a psychosomatic patient enters the relations with the external world in a very archaic way. In new traumatic situations such a personality structure possesses a very poor repertoire of adaptation mechanisms. Owing to the lack of intrapsychic elaboration of the trauma, the conflict is solved in an "interpersonal" way. The authors emphasize the importance of interpersonal conflict as an actual necessity of maintaining the connection with reality. Such a response in the development corresponds to the fixation or regression to the conflict with the object from the subphase of practising. Unpleasure, because of the early forbidding of pleasurable activities by the object, is experienced as actual, thus the object becomes a hindrance in itself. The increased hostility is being discharged through the interpersonal conflict with the object. The quality of the actual object (the therapist) affects the development of the conflict, i.e. it either allows a more successful reparation of the patient's personality structure or brings about a deeper regression.