Characteristics of the postcounseling reproductive decision-making process: an explorative study.

An in-depth, recorded interview of 30 couples 2-3 years after genetic counseling explored the characteristics of the postcounseling decision-making process, including the role of guilt feelings towards the proband. The study concerned couples with an affected child, sib, or spouse. Results were evaluated by 2 to 4 judges. In contrast to other studies, a generally unstructured decision-making process was found whereby guilt feelings played a significant role in more than half the couples. Guilt feelings were more predominant in couples with an affected sib than in those with an affected spouse. Lack of structure did not seem to complicate the decision-making process. Therefore, authors do not advocate promotion of structuring the decision-making process. Genetic counselors might focus on understanding counselees' feelings concerning the reproductive decision. Acceptance of apparently irrational considerations is particularly important, because these feelings indicate the influence of unconscious motives. Another important aspect of supporting counselees is to understand the role played by guilt feelings toward parents or an affected sib.

Model identifying the reproductive decision after genetic counseling.

To assess the identifiability of reproductive planning after genetic counseling, a model was designed to study 8 relevant factors influencing reproductive decisions after genetic counseling. Altogether, 164 couples were interviewed at home 2 to 3 years after genetic counseling. The factors were arranged in a flow chart distinguishing 3 groups: reproductive outcome prior to genetic counseling, desire to have children, and interpretation of information gained from genetic counseling. The model based upon these retrospective data showed that reproductive decisions were identified correctly in 91% of the cases. The model consisted of 8 factors and documented the urgency of the desire to have children and the interpretation of the genetic risk. In addition, linear discriminant analysis of the 8 relevant factors enabled identification of the reproductive decision in 96% of the cases. This model may prove helpful to counselors and counselees by showing what other couples have decided in comparable circumstances and for which reasons.

Factors influencing the reproductive decision after genetic counseling.

Here we report a follow-up study involving interviews with 164 couples 2-3 years after genetic counseling to assess the influence of various factors on their reproductive planning. The results show that the desire to have children and the absence of personal experience with the disorder (no close relative being affected) are important single factors for the decision to opt for having children after genetic counseling. The magnitude of the genetic risk is of relative importance in reproductive planning. Seventy percent of the couples with a high genetic risk (greater than 15%) opted for having children. When the disorder was perceived as severe and the risk was interpreted as high, 72% opted for having children. The availability of prenatal diagnosis became important only in combination with a high genetic risk (greater than 15%). Forty-seven percent of the couples with a high genetic risk refrained from having children when prenatal diagnosis was not available. In the absence of prenatal diagnosis, couples who had an affected child were more cautious about trying again than those who did not--50% versus 14% decided to abstain. This study has provided some insight into the complexity of reproductive decision-making after genetic counseling. The findings may help genetic counselors and clinical geneticists understand and support counselees in their decision-making process, which is "multi-factorial."

Presymptomatic DNA testing for Huntington disease: identifying the need for psychological intervention.

UNLABELLED: In the Dutch presymptomatic DNA-testing program for Huntington disease (HD), 29 individuals with increased risk and 44 with decreased risk were followed-up 6 months after test results. A prognostic model was built aimed at identifying individuals at risk for psychological maladjustment, as measured by the Impact of Event Scale, the Beck Hopelessness Scale, the General Health Questionnaire, and the Social Support Questionnaire. RESULTS: 1) The more that applicants suffered from intrusive feelings about HD and tried to avoid HD-related situations, prior to the test, the greater the chance that they will experience this 6 months after the test if they proved to be at increased risk; 2) the more that both individuals with increased risk and those with decreased risk who suffered from the threat of having HD tried to avoid HD-related situations prior to the test and the less satisfied they were with available support, the greater the probability that they will show avoidance behavior after the test; 3) the more pessimistic that individuals with increased risk as well as those with decreased risk were about their future prior to the test, the more they avoided HD-related situations and the more dissatisfied they were about their available support (pretest), the greater the probability that they will become depressive and suicidal. Psychological adjustment was also studied as a function of a) intrusion/denial-avoidance pattern over time and b) healthy mental functioning/future expectancies. Most individuals with increased risk (86%) seem to cope well thus far, although this was based largely on strong psychological defenses and dependent on satisfactory relationships.(ABSTRACT TRUNCATED AT 250 WORDS)

On attitudes and appreciation 6 months after predictive DNA testing for Huntington disease in the Dutch program.

We have studied the 6-month follow-up attitudes of 63 individuals, after predictive testing for Huntington disease (HD). Reducing uncertainty (81%) and family planning (60%) were the major reasons for taking the test. Twenty-four individuals were diagnosed as having an increased risk (+/- 98%), and 39 a decreased risk (+/- 2%). Among those with an increased risk, denial or minimization of the ultimate impact of the increased risk result was observed. Most of them (84%) rated their current life situation, at the very least, as being good. Twenty-one percent of individuals with an increased risk who originally planned to have a family, decided to refrain from having children. Sixty percent of those with increased risk who still wished to have children, would choose to have prenatal testing. In most individuals with increased risk, the test result did not increase the previously expected control over their own future. Half of the partners of persons with increased risk acknowledged the burden of the future disease. Half had no one in whom they could confide. They showed loyalty to the denial and avoidance reactions of their spouses. Half of the individuals with decreased risk denied the impact of the result, as reflected by absence of relief, and emotional numbness. A third of persons with decreased risk experienced involvement with problems of affected relatives. We found that 20% of all participants were discontented with the support given by their general practitioner, who is normally regarded as being the most significant professional for aftercare. Our findings suggest that the perpetuation

Presymptomatic DNA-testing for Huntington disease: pretest attitudes and expectations of applicants and their partners in the Dutch program.

We studied the baseline attitudes, prior to testing, of 70 applicants at risk for Huntington disease (HD) and their partners in the Dutch presymptomatic DNA-testing program. Two thirds of the applicants were female; 36% already had children. The main reason (60%) for undertaking the test was for family planning. Other reasons were either to reduce uncertainty (43%) or to obtain certainty (38%). Partners of applicants stated that planning for the future was for them the most important reason (76%). Significantly more at-risk females (42%) than males (16%) anticipated an unfavorable test outcome. Quite remarkably, most applicants and partners denied that a positive result might have adverse effects on either personal mood, quality of life, or marriage. Only a few did not expect that a favorable result would induce relief. The eventual outcome of the test was expected to enable applicants to gain control over their future, whatever the results. Hence, we propose that the applicants form a self-selected group, based on their expectation that they will not be emotionally affected by either result.

Migraine and defense mechanisms: psychophysiological relationships in young females.

Two psychological defense mechanisms, repression and self aggression, were studied in 23 young female migraine patients who had not been receiving treatment for their complaints and in 23 relatively headache free matched controls. All subjects were psychology students. Each subject was classified as high or low on repression and self aggression using the defense mechanism inventory. During three separate sessions: adaptation, intelligence test and real-life stress (an examination which was part of the psychology curriculum) pulse amplitudes of the temporal and digital arteries, frontal, temporal and corrugator EMGs, forehead temperature, skin conductance, and heart and respiration rate were measured. The migraine patients showed a trend towards more repression of their emotions and significantly more self aggression than the controls. Self aggression appeared to be positively associated with the headache frequency in the migraine group. With regard to the physiological measurements, in both groups repressors showed a modest tendency to enhanced sympathetic activity. Self aggression was not found to be related to any physiological measure of sympathetic activity, but, instead, related to less temporal blood flow. In general, associations were found between psychological defense mechanisms and physiological activity, which is suggestive of the existence of physiological pathways along which emotional inhibition might contribute to an attack of migraine after a stressful situation.

Previous stress and acute psychological defence as predictors of perinatal grief--an exploratory study.

We evaluated whether the emotional reactions of women at 2-6 weeks after the prenatal diagnosis of a lethal anomaly and at 3 months after perinatal loss might be predicted by previous stress and acute psychological defence reactions to the diagnosis. Previous stress was defined objectively as a history of major life event(s) and having received professional mental health treatment in the past, and subjectively as the disposition for feelings of inadequacy and anxiety. Forty-one women were interviewed and completed measures on their history of major life events, whether they had received professional mental health treatment in the past, inadequacy, acute psychological defence reactions and perinatal grief. Regression analyses showed that inadequacy was the most strongly positive predictor of perinatal grief shortly after receiving the unfavourable diagnosis and three months after perinatal loss. In addition to inadequacy, having received professional mental health treatment in the past led to significantly more intense grief, but only shortly after receiving the unfavourable diagnosis. Previous life events intensified grief three months after perinatal death. The grieving process was significantly moderated by the defence of 'principalization' while it was significantly intensified by 'turning aggression against oneself', but only shortly after receiving the unfavourable diagnosis. These effects were not contaminated by relationships with pregnancy-related variables. Our findings imply that psychological support for women with perinatal loss should particularly be offered to those who have been identified as generally anxious, who have reported previous major life events and have received professional mental health treatment in the past.

Quality of Life in patients with resected oesophageal cancer.

Quality of Life (QL) is hard to assess and seldom measured in patients having carcinomas with an unfavourable prognosis. Oesophageal cancer is one of the malignancies with a low 5-year survival rate. Dysphagia (problems in swallowing food) is considered to be the most important indicator of QL in patients with oesophageal carcinoma. Moreover, the psycho-social aspects and subjective QL in cancer have recently gained importance. The present study investigated QL in a 132 patients with oesophageal cancer. Eighty-three of them had a surgical operation (removal of part of the oesophagus and part of the stomach, followed by a reconstruction of the digestive tract). Sixty-seven patients filled in questionnaires before and after the operation. Complete sets of data were obtained from 62 patients. Time interval between operation and postoperative assessment varied from 3 to 7 months. Indicators of QL were: Psychological Distress, Physical Symptoms, Global Evaluations, Activity Level, Swallowing Problems and Food Intake. Swallowing Problems showed moderate correlations with the other QL indicators. Physical Symptoms increased, whereas the Activity Level, Psychological Distress, and Swallowing Problems decreased; Global Evaluations remained unaltered.

Psychological variables as predictors of the length of post-operative hospitalization.

The extent to which measures of anxiety and personality characteristics, which had been assessed preoperatively, could predict the length of hospital stay following surgery, above and beyond what could be predicted on the basis of biographical, medical-status and post-operative anxiety variables, was examined in 58 patients with gall-bladder disease. Hierarchical multiple regression analysis revealed that gender, previous operations, complications and State Anxiety (A-State) measured on the third day post-operatively, jointly explained a significant proportion of the variance in the length of hospitalization. Neither preoperative anxiety measures nor personality characteristics had any significant incremental value in the prediction.

Psychic effects of physical training and relaxation therapy after myocardial infarction.

The psychological impact of exercise training and relaxation therapy was investigated in 156 myocardial infarction patients. They were randomly assigned to either exercise plus relaxation and breathing therapy (Treatment A: n = 76) or exercise training only (Treatment B: n = 80). Patients in Treatment A improved on three out of eight psychological measurements (anxiety, well-being, feelings of invalidity). No change was demonstrable in Treatment B. The difference between the treatments was significant for wellbeing (p less than 0.005). Physical outcome, measured by exercise testing was positive in about half of the patients (Treatment A: 55%, Treatment B: 46%). A negative outcome occurred less in Treatment A (p less than 0.05). Training success was not associated with psychic benefit. The association differed for the two treatments. It was concluded that exercise training was effective for some but not for all cardiac patients, and that a psychic effect of exercise could not be demonstrated. Relaxation therapy enhanced physical and psychic outcome of rehabilitation.

Home measures of anxiety, avoidant coping and defence as predictors of anxiety, heart rate and skin conductance level just before invasive cardiovascular procedures.

The question was whether anxiety, heart rate and skin conductance level just before invasive cardiac procedures could be predicted by anxiety related measures obtained at patients homes approximately 3 weeks before treatment. Trait measures of avoidant coping and defence were provided by sixty-three male and thirty-three female patients who were scheduled for a diagnostic or interventional heart catheterization. In hospital physiological measures were registered continuously during a 20 min interview and subsequently patients reported their anxiety. Results with hierarchical regression analysis showed that sex, age, medical variables and state anxiety at home explained 62% of state anxiety in hospital. Female sex predicted high anxiety in hospital while advanced age predicted low anxiety. Medical variables and measures of coping and defence did not add a significant contribution to this prediction of anxiety. Skin conductance and heart rate measures could not be predicted by the psychological measures collected at home.

Characteristics and motives of women choosing elective induction of labour.

Personal characteristics of healthy term pregnant women who chose elective induction or spontaneous onset of labour and the motives for their choice were assessed. Almost 50% of 237 women with uncomplicated pregnancies opted for elective induction when offered the opportunity. These women appeared to have had more complaints during their pregnancy and menstrual periods, more complications in their obstetrical history and to be more anxious about their labour than women who chose a spontaneous onset of labour. Predominant motives were a feeling of safety and the desire to shorten the duration of pregnancy. These characteristics and motives seem to reflect a lack of trust in physical reproductive functions. It is concluded that in evaluating effects of elective induction of labour, pre-existing differences between women who choose elective induction and women who opt for a spontaneous onset must be taken into account.

Personality traits of patients suffering extreme dental anxiety.

In order to investigate the relationship between dental anxiety and some personality traits, a group of 103 patients suffering extreme dental anxiety and therefore enrolled in a special treatment program were compared with controls sampled at random. The mean scores of the controls on dental anxiety measurements and on questionnaires dealing with personality traits were transformed into 50 with standard deviation equal to 10 to make them mutually comparable, and these subsequently were used as reference points, from which the likewise transformed mean scores of the anxiety group have to differ substantially if both groups stem from different populations. The mean scores were tested for difference with ANOVA. It appears that the anxious patients are more neurotic, i.e. more unstable, than the controls. Moreover, the patients feel themselves more uncertain with regard to having control, are less decisive, have a lower self-esteem, are less inclined to act and are, in general, anxious persons. These findings may have implications for selecting the most appropriate approach for amelioration of their anxiety or support of their coping capacity.

Effect of a special dental program upon extreme dental anxiety.

Dental anxiety of 60 extremely anxious dental patients enrolled in a special program, was measured multioperationally before and immediately after treatment, and 6 months later. The mean anxiety level was substantially lowered during the course of treatment, indicating a favourable effect of the program. After 6 months dental anxiety was still at the lower level.

Differentiating regular from irregular dental attenders of either sex by linear discriminant analysis.

The present article describes an attempt to improve the prediction of dental attendance, results by using an additional number of variables and performing discriminant analyses, done separately for men and women. It appears that regular and irregular dental attenders might be discriminated on the basis of mathematically combined variables and interactions. The (number of) variables selected by the analysis to differentiate regular from irregular male attenders differ(s) from those selected for female attenders. About 80% of all respondents can be classified correctly, but this is largely due to the assignment of actual regulars to classified regulars. The use of differing sets of prior probabilities affects the classification results, namely, either the classification of the regulars or that of the irregulars improves. In the discussion attention is given to the seemingly contradictory results of the Mann-Whitney tests per variable on the one hand and the discriminant analyses on the other. In this connection, the finding that 'education' plays a different role for men than for women is discussed. The validity of the variable 'last visit' is dubious. It is concluded that when differentiating regulars from irregulars, a division of the respondents according to sex makes sense because of the (number of) variables associated with their regular dental attendance. Furthermore, it seems warranted to say that the classification of the irregulars fails because the reversed scores on the variables with which the regulars are classified don't contain all information needed for the prediction of irregular dental attendance. Lastly, notwithstanding the use of more variables in the present study, the results are not better than those in the previous one, in which just three factors were used.

Three factors predicting irregular versus regular dental attendance: a model fitting to empirical data.

A tentative theory, based upon the results of a survey that was performed in an urbanized village in the Netherlands, and proposing that the (ir)regularity of dental attendance is predicted by 1) dental anxiety, 2) the family dental health pattern and 3) the preference for preservation of the teeth, has been explored with loglinear models (logit approach). It has been shown that dental anxiety in combination with preference for preservation of the teeth is significantly associated with the (ir)regularity, but the family dental health pattern has a modifying effect. The probabilities of being an irregular dental attender were estimated for the levels discernible in the two predictor variables and with the odds of irregular dental attendance corresponding 95% confidence intervals were approximated. The results were discussed and it seems warranted to conclude that (ir)regular dental attendance dependent on the levels of the variables, mentioned above, is predicted more or less accurately. A further exploration of the theory and the variables involved seems worthwhile.

Regularity of dental attendance in the Netherlands related to preference for preservation of teeth.

In order to study the relationship between regularity of dental attendance and the value attached to the retaining of the teeth, a survey has been carried out among 25-yr-olds in Amsterdam. The value attached to retention was operationalized threefold and was analyzed with, among others, principal component analysis for discrete variables (HOMALS). It has been found that regular dental attenders, compared to irregulars, give a higher priority to retention of the teeth than to other items, are willing to spend a larger amount of money to prevent loss of the teeth, and have a greater aversion to full dentures at both the present age and when 50 yr old. These findings are discussed. Based upon measures of association between the three operationalizations of the value attached to retention of the teeth, it is suggested that these operationalizations deal with different aspects of the attitude towards full dentures.

Value of the teeth.

A random sample of 542 respondents answered questions concerning the value assigned to the teeth, dental attendance pattern, oral health status, and dental anxiety. Non-linear multivariate analysis showed the data regarding value attached to the teeth to contain two dimensions, of which the second one was deleted due to extreme answer patterns (skewed distributions) on the pertinent variables. Repetition of the analysis, including a plot of the respondents, made it possible to discern four subsamples, characterized by specific answer patterns. In the discussion attention was given firstly to the separate variables estimating the value attached to the teeth, and next to the four subsamples, taking into consideration the dental attendance pattern, oral health status, and dental anxiety. It was concluded that the multivariate approach reveals that the respondents are of a rather high heterogeneity.

Dental anxiety, the parental family and regularity of dental attendance.

A survey was carried out among 25-yr-old inhabitants of Amsterdam in order to study the relationship between regularity of dental attendance on the one hand and dental anxiety, dental upbringing of the respondents, dental behavior of the parents, education, sex, and the interactions between these independents, on the other. The data were analyzed hierarchically with regression analysis, the logistic approach. Dental anxiety, sex, dental upbringing and the interaction between education and anxiety, in that order, were found to be of importance for the prediction of regularity of dental attendance. Two other terms, though lacking substantial standardized regression coefficients, namely education and the interaction between education and dental upbringing, are also present in the model found. The prediction of one being a regular attender is satisfactory, but the classification of the irregular attenders is disappointing. The effect is discussed of the rather large non-response and attention is given to the effect of dental upbringing in regard to coping resources in the dental situation. It has to be concluded that other factors must be included to achieve an improvement of the classification of the irregular attenders. Dental anxiety, although of importance, cannot account for an adequate differentiation between regular and irregular attenders.