Disease variables and depression affecting the process of coping in families with a somatically ill parent.

AIM AND METHODS: Based on the investigation of 134 families with a seriously ill parent and 214 offspring, we compared--by means of semistructured psychiatric interviews--the capacity of the ill and the healthy parent and their children to cope with various diseases. We evaluated how disease characteristics such as duration and severity of the disease (assessed by the Karnofsky Index) and associated depression [measured by the Beck Depression Inventory for parents and the Depression Inventory for Children and Adolescents (Depressions-Inventar für Kinder und Jugendliche) for children] influence the coping capacity of all family members. RESULTS: The coping capacity of patients with organic disease (cancer, multiple sclerosis, other somatic diseases) is significantly higher than that of patients with somatization disorder, whereas the depression score of patients with organic disease is significantly lower than that of patients with somatization disorders. The depression of the patient negatively influences his/her coping capacity. Children's coping capacity does not differ with respect to the parental illness and is not influenced by their own depression. There are significant correlations between the coping capacity of children and their healthy and ill parents affected by organic disease (multiple sclerosis, other somatic diseases, cancer), but not between children and healthy and ill parents with somatization disorders. Multivariate regression analysis shows the mutual influence of coping capacities between the parental couple as well as between the parents and their children. The better the patient (partner) is able to cope with a severe disease, the higher are the values of the coping capacity of the partner (patient). Children older than 6 years with a severely ill, nondepressed and well-coping parent cope well. These results do not apply to parents with somatization disorders. CONCLUSIONS: Patients with organic disease cope better and are less depressed, whereas patients with somatization disorders have a lower coping capacity and a higher depression score. Children older than six years cope better. Comprehensive care of a patient with a severe illness has to include his/her family in order to evaluate coping capacities of all family members, particularly of small children, and to assess and treat associated parental depression.

[Supporting severely ill and dying children. Suggestions for practical interventions]. / Begleitung schwer kranker und sterbender Kinder. Empfehlungen für die Praxis.

In our culture, the death of a child is a rare, but shocking experience. Supporting severely ill or dying children requires knowledge of developmental psychology and consideration of their social environment. This article summarizes aspects of children's concepts of death and outlines the psychological reactions of seriously ill children and adolescents. Finally, the authors provide practical suggestions for meaningful interventions.

Pretreatment social functioning predicts 1-year outcome in early onset psychosis.

OBJECTIVE: The aim was to investigate the association of pretreatment social functioning (12 months before initial presentation) with symptom dimensions and social functioning at 1-year follow-up. METHOD: Fifty-six adolescents, age 14-18, first admitted for early onset psychosis, were evaluated at baseline and 1-year follow-up assessing psychopathology (PANSS), social functioning (Strauss and Carpenter Prognostic Scale), and duration of untreated psychosis (DUP). RESULTS: Adolescents with low pretreatment social functioning were at risk of more severe negative symptoms and lower social functioning at follow-up. Negative symptoms at baseline were less predictive and DUP was not predictive in this sample. CONCLUSION: Results of this study suggest a strong longitudinal inter-relatedness between social functioning and negative symptoms in this age group. An integrative treatment approach including family interventions, social skills training, long-term specialized work/school rehabilitation, and adequate antipsychotic treatment is warranted to improve both, social functioning and negative symptoms.

Memory of childbirth in the second year: the long-term effect of a negative birth experience and its modulation by the perceived intranatal relationship with caregivers.

OBJECTIVE: To assess the memory of various subdimensions of the birth experience in the second year postpartum, and to identify women in the first weeks postpartum at risk of developing a long-term negative memory. DESIGN, METHOD, OUTCOME MEASURES: New mothers' birth experience (BE) was assessed 48-96 hours postpartum (T1) by means of the SIL-Ger and the BBCI (perception of intranatal relationships); early postnatal adjustment (week 3 pp: T1(bis)) was also assessed. Then, four subgroups of women were defined by means of a cluster-analysis, integrating the T1/T1(bis) variables. To evaluate the memory of the BE, the SIL-Ger was again applied in the second year after childbirth (T2). First, the ratings of the SIL-Ger dimensions of T1 were compared to those at T2 in the whole sample. Then, the four subgroups were compared with respect to their ratings of the birth experience at T2 (correlations, ANOVAs and t-tests). RESULTS: In general, fulfillment, emotional adaptation, physical discomfort, and anxiety improve spontaneously over the first year postpartum, whereas in negative emotional experience, control, and time-going-slowly no shift over time is observed. However, women with a negative overall birth experience and a low level of perceived intranatal relationship at T1 run a high risk of retaining a negative memory in all of the seven subdimensions of the birth experience. CONCLUSIONS: Women at risk of developing a negative long-term memory of the BE can be identified at the time of early postpartum, when the overall birth experience and the perceived intranatal relationship are taken into account.

Indication for psychotherapy in offspring of a parent affected by a chronic somatic disease (e.g. multiple sclerosis).

Based on the transcripts of video-recorded, semi-structured interviews with 41 offspring (aged 6-18 years) of parents with multiple sclerosis, we evaluated the indication for psychotherapy. These results were then compared with the previously determined coping ability of each child/adolescent. Psychotherapy was indicated for 22 out of the 41 children/adolescents. There was a significant relation between the indication for psychotherapy and the children's inability to cope with the parental disease. The present findings confirm the risk of mental health problems in children of somatically ill parents. In our sample, half of the children and adolescents were estimated to benefit from individual psychotherapy, which might enhance their ability to cope with the parental illness.

CYP1A2 is not required for 2,3,7,8-tetrachlorodibenzo-p-dioxin-induced immunosuppression.

One of the most sensitive and reproducible immunotoxic endpoints of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) exposure is suppression of the antibody response to sheep red blood cells (SRBCs) in mice. Immunosuppression occurs in concert with hepatomegaly and associated induction of several hepatic cytochrome P450 enzymes, including CYP1A2 which is responsible for the hepatic sequestration of TCDD. In this study, TCDD-induced immunosuppression was evaluated in C57BL/6N CYP1A2 (+/+) wild-type and compared with that of age-matched CYP1A2 (-/-) knockout and CYP1A2 (+/-) heterozygous female mice. Groups of mice were given a single gavage dose of 0, 0.03, 0.1, 0.3, 1.0, 3.0 or 10.0microg TCDD/kg, followed 7 days later by immunization with SRBCs. Serum was obtained 5 days after immunization and body, spleen, thymus and liver weights were measured. sheep red blood cell (SRBC) antibody titers were determined by an enzyme-linked immunosorbent assay (ELISA). Anti-SRBC titers were suppressed at 1.0, 1.0 and 0.3microg TCDD/kg for CYP1A2 (+/+), CYP1A2 (+/-), and CYP1A2 (-/-) mice, respectively, which indicated a three-fold increase in TCDD-induced immunosuppression for the CYP1A2 (-/-) mice. This increase in TCDD-induced immunosuppression may be due to the inability of CYP1A2 (-/-) mice to sequester TCDD in the liver leading to a higher dose to the immune system. In CYP1A2 (+/+) mice, a dose of 3.0microg TCDD/kg was sufficient to increase the liver weight, while in CYP1A2 (-/-) mice no increase in liver weight was observed. Application of analysis of variance and dose-response modeling approaches indicate that there is little evidence that the immunosuppression dose-response curves, for the three strains, differ in the lower part of the dose-response range. Thus, CYP1A2 is not required for TCDD-induced immunosuppression in the mouse.

Differential effects of two lots of aroclor 1254: congener-specific analysis and neurochemical end points.

Aroclor 1254 is a widely studied commercial polychlorinated biphenyl (PCB) mixture which, by definition, contains 54% chlorine by weight. Recent reports indicate substantial differences in the congener composition among Aroclor lots and hence their biologic effects. We designed the current study to compare the effects of two lots of Aroclor 1254 (lots 6024 and 124-191). We analyzed these two lots for PCB congeners, polychlorinated dibenzofurans (PCDFs), polychlorinated naphthalenes (PCNs), and polychlorinated dibenzodioxins (PCDDs). We used previously established techniques for analyzing intracellular Ca(2+) buffering and protein kinase C (PKC) translocation to test their biologic activity in neuronal preparations. PCB congener-specific analysis indicated that ortho and non-ortho congeners in these two lots varied in their percent contribution. Among all congeners, the percentages of non-ortho congeners (PCBs 77, 81, 126, and 169) were higher in lot 6024 (2.9% of total) than in lot 124-191 (0.02% of total). We detected no dioxins in these two lots (< 2 ppb). Although there are some differences in the congener composition, total PCNs were similar in both lots: 171 ppm in lot 6024 and 155 ppm in lot 124-191. However, total PCDFs were higher in lot 6024 (38.7 ppm) than in lot 124-191 (11.3 ppm). When we tested these two Aroclors on Ca(2+) buffering and PKC translocation in brain preparations, the effects were significantly different. Although lot 124-191 was more potent on PKC translocation than lot 6024, lot 6024 was slightly more active on Ca(2+) buffering than lot 124-191. These effects could not be attributed to the differences in the percentage of non-ortho congeners or PCDFs because they were inactive on these two parameters. The effects could not be attributed to PCNs because the levels were almost similar. The effects seen with two lots of Aroclor 1254 in neuronal cells were also not predicted based on the TCDD toxic equivalents (TEQs), although TEQs predicted the effects on ethoxyresorufin-O-deethylase (EROD) or methoxyresorufin-O-deethylase (MROD) activities. It is possible that the differential effects seen in neuronal cells could be caused by differences in the composition of ortho-congeners in these two mixtures, because PCBs with ortho-lateral substitutions can exhibit different activities on the selected neurochemical end points. Because of these differential effects with different lot numbers, the composition of Aroclor mixtures used in investigations should be disclosed.

Differential effects of two lots of aroclor 1254 on enzyme induction, thyroid hormones, and oxidative stress.

Aroclor 1254 is a commercial mixture of polychlorinated biphenyls (PCBs), which is defined as being 54% chlorine by weight. However, the congener composition varies from lot to lot. Two lots which have been used in toxicity studies, 124-191 and 6024 (AccuStandard), were analyzed for their congener composition. Lot 6024 has approximately 10 times the dioxin toxic equivalents (TEQ) of lot 124-191. The purpose of this study was to determine if the difference in the TEQ of the two lots explains the different in vivo responses seen on a weight basis. Male Long-Evans rats (70 days old) were treated orally with a single dose of 0-1,000 mg/kg of each lot. Hepatic ethoxy-, methoxy-, and pentoxyresorufin O-deethylase (EROD, MROD, and PROD, respectively) activities as well as serum thyroxine (T(4)) concentrations and measures of oxidative stress were determined 4 days after treatment. Results, on a weight basis, indicate that lot 6024 led to a greater induction of EROD, MROD, and PROD but not total T(4) reduction. The differences in TEQ between the lots explained the differential induction of EROD and MROD but did not account for the induction of PROD nor decreases in T(4). PROD induction is not due to dioxin-like congeners, whereas the decrease in serum T(4) levels may involve multiple mechanisms. Effects on the antioxidants ascorbic acid and uric acid were seen only at the highest mass dose for both lots and were not explained by the difference in TEQ. These results illustrate that the differences in the TEQ explain the differences in the strict dioxin-like effects (EROD, MROD induction), but the non-dioxin-like congeners cause other effects that are not associated with the aryl hydrocarbon receptor (e.g., PROD). In addition, supra-additive effects also occur in the mixture (T(4), oxidative stress). Thus, current results demonstrate that overall toxicity cannot be predicted on the basis of the TEQ values. It is also critical that the lot number is reported in studies conducted with Aroclor 1254 because the congener composition and therefore the effects observed can be very different.

Gender-specific differences in the process of coping in families with a parent affected by a chronic somatic disease (e.g. multiple sclerosis).

Based on the investigation of 52 families and their 87 offspring by means of semistructured interviews, we evaluated the coping abilities of the parent affected by multiple sclerosis (MS), the healthy parent and their children. The results show that the gender of the child significantly influences his or her coping behaviour. Daughters cope better than sons, independently of the gender of the MS-affected parent. Only the daughter's coping is positively affected by age and disease variables. The correlation between the coping behaviour of parents and children is significant between children and their healthy parents and even stronger between children and healthy parents of the same gender. Healthy mothers and daughters cope better with the increasing disability of the father. This is not the case for healthy fathers and sons. Gender seems to be an important moderating factor in chronic parental disease and it has complex effects on the coping capacity of children.

Birth as a multidimensional experience: comparison of the English- and German-language versions of Salmon's Item List.

Results concerning satisfaction with the birth experience in different trials are difficult to compare, owing to a lack of internationally used research scales. Salmon's Item List (SIL) is easy-to-handle and would therefore be very helpful for research as well as for obstetric clinic quality control. Two hundred and fifty-one patients were investigated using a German-language version of SIL (SIL-ger); the statistical evaluation was carried out by means of a principal components analysis. Principal components analysis revealed two major findings: (1) as stated by other authors the birth experience is multidimensional, each aspect influencing the others in a non-linear way; (2) in addition to Salmon's dimensions (i.e. postnatal 'fulfillment', intranatal 'physical discomfort' and intranatal 'emotional distress') another postnatal dimension labeled 'negative emotional experience' was detected. Not only are intranatal experiences multidimensional, but so too are evaluative feelings afterwards. In addition to fulfillment, as developed by Salmon, a dimension of negative emotional experience needs to be taken into account. This dimension does not correlate in a linear way with fulfillment. It is appropriate to use SIL in research. Before using it for purposes of clinical quality control, however, larger samples need to be evaluated in order to prove the stability of the factor structure.

[Psychoanalytic diagnosis and routine pedagogic management]. / Psychoanalytische Diagnostik und pädagogischer Alltag.

The results of the psychoanalytic evaluation of a patient gathered during the diagnostic process can only be applied in appropriate educational procedures if an undisturbed dialogue exists within the multidisciplinary treatment team of a ward. Pedagogic activities based on such assessments bring about a continuous verification or falsification of the primary diagnostic evaluation. They not only reflect it's quality but also furnish new information. In loop-like movements the position of the evaluation at the beginning of the in-patient treatment is supplemented or revised. Every traumatic experience, be it dissociated or otherwise isolated from consciousness, because of the continuous vulnerability of the traumatised subject can be triggered and reactivated under special conditions. The practical interlock of the results of the psychoanalytic assessment at the beginning and the educational activities of everyday-life during hospitalisation are exemplified by the case history of a multiple traumatised adolescent.

[Quality of pedagogy in inpatient child and adolescent psychiatry]. / Qualität der Pädagogik in der stationären Kinder- und Jugendpsychiatrie.

In the discussion about the interdisciplinary in-patient treatment in child and adolescent psychiatry up structural questions have been more important than questions concerning qualitative aspects of the team process up to now. While the problems to solve became more complex (for example in the treatment of severely traumatised children), teams in charge of the care are challenged to define their position on a qualitative level of the treatment. A consensus between psychiatric and educational points of view is of particular importance. In order to contribute to an interdisciplinary discussion, 14 propositions from the point of view of child and adolescent psychiatry about the quality of pedagogy are put forward.

[Brief report of the working group OPD-CA (children and adolescents) Axis II: interpersonal relations]. / Werkstattbericht der Arbeitsgruppe Achse II: Beziehungsverhalten.

Operationalization of relations is tried out following an interpersonal circular model (SASB) using observation and description of behavior in dyadic and triadic relationship configurations. On a vertical and on a horizontal axis the amount of loving kindness versus hostile aggressivity and of independence versus control is determined. Different dyadic and triadic relationship configurations (e.g. child to mother or researcher to child) and also the emotional resonance of the investigating person will be rated according to anamnestic data, observed and videotaped sequences of interaction, play episodes or symbolic relationships in projective tests. Such ratings can be performed in a module like form and will be used not only in clinical practice but also in settings of scientific research. The minimal standard for a clinical examination consists of the evaluation of the child with his parents.

Effects of CYP1A2 on disposition of 2,3,7, 8-tetrachlorodibenzo-p-dioxin, 2,3,4,7,8-pentachlorodibenzofuran, and 2,2',4,4',5,5'-hexachlorobiphenyl in CYP1A2 knockout and parental (C57BL/6N and 129/Sv) strains of mice.

TCDD is the prototype and most potent member of the highly lipophilic polyhalogenated aromatic hydrocarbons (PHAHs), which are persistent and ubiquitous environmental contaminants. In both acute and subchronic animal studies, there is a specific accumulation of TCDD in liver greater than in adipose tissue. The inducible hepatic binding protein responsible for this hepatic sequestration of TCDD and its congeners has been shown by our laboratory to be CYP1A2 (J. J. Diliberto, D. Burgin, and L. S. Birnbaum, 1997, Biochem. Biophys. Res. Commun. 236, 431-433). The present study was conducted using knockout (KO) mice lacking expression of CYP1A2 (CYP1A2-/-) in order to investigate the role of CYP1A2 gene on the disposition of TCDD, 4-PeCDF (a dioxin-like PHAH), and PCB 153 (a nondioxin-like PCB) in KO (CYP1A2-/-) mice and age-matched parental mice strains (C57BL/6N: CYP1A2+/+, Ah(b/b) and 129/Sv: CYP1A2+/+, Ah(d/d)). Mice were dosed (25 microgram [(3)H]TCDD/kg, 300 microgram [(14)C]4-PeCDF/kg, or 35.8 mg [(14)C]PCB 153/kg bw in a corn oil vehicle) orally and terminated after 4 days. Residues of administered compounds in collected tissues and daily excreta were quantitated using (3)H or (14)C activity. Results demonstrated differential effects in disposition for the various treatments within the three genetically different groups of mice. In KO mice, TCDD, 4-PeCDF, and PCB 153 had very little hepatic localization of chemical, and the major depot was adipose tissue. In contrast, parental strains demonstrated hepatic sequestration of TCDD and 4-PeCDF, whereas disposition of PCB 153 in parental strains was similar to that in KO mice. Another difference between KO mice and parental strains was the enhanced urinary excretion of 4-PeCDF. This study demonstrates the importance of CYP1A2 in pharmacokinetic behavior and mechanistic issues for TCDD and related compounds.

Child development and early triadic relationships.

A study of early development beginning in pregnancy and extending to the end of the child's first year of life is presented. The aim is to understand the relational processes of early childhood by using the concepts of triadification and triangulation. A prospective longitudinal study was conducted with forty-one parents and their first-born infants. The parents subjective views about their parenthood and the unborn child were systematically analysed during pregnancy, targeting their representations of their own childhood experiences their partnership, and their relationship with their fantasised child. These dimensions were compared with the quality of dyadic and triadic parent-child interactions observed after the child was born. The pre-natally assessed level of triangulation in the parental fantasies correlated strongly with the quality of triadic interactions with the 4-month-old infant in a play situation and with the quality of dyadic interactions with the one-year-old infant in a stressful situation. The authors conclude that the child's relational development can be understood in triadic terms from the beginning, but that there is a regressive pull towards two-plus-one relationships under conditions of emotional dysregulation. Consequences for a psychoanalytic theory of early development are discussed.

[Operationalized psychodynamic diagnosis in childhood and adolescence--a contribution to quality assurance]. / Operationalisierte psychodynamische Diagnostik im Kindes- und Jugendalter--Ein Beitrag zur Qualitätssicherung.

Adopting a therapeutic view on diagnosis in child and adolescent psychiatry a psychodynamic diagnostic manual seems to be necessary, that may provide reliability in the assessment of intrapsychic processes. Multiaxial diagnosis of children's and adolescent's psychiatric disturbances may thus be completed with additional psychodynamic assessment procedures. In adults an operationalized procedure of psychodynamic assessment (OPD) already exists. In child and adolescent psychiatry a working group for psychodynamic diagnostic (OPD-KJ) has been founded. In 4 areas (subjective experiences of disturbances, relationships, intrapsychic conflicts and psychic structure) diagnostic manuals are being worked out. Fundamental questions of developmental psychopathology and diagnostic procedures have to be addressed. The basic proposition takes into account that children should not be psychodynamically compared with adults, but normally have a basic capacity to adapt to environment on a high level of psychic organisation in all developmental stages. Reports of the ongoing work are being given.

[The adolescent psychiatry department: organization and initial experiences]. / Jugendpsychiatrische Abteilung: Aufbau und erste Erfahrungen.

As in most parts of Switzerland, there was a lack of possibility to hospitalise adolescents in specialised psychiatric wards. In 1993, after a long preparatory period, it became possible to admit the first patient to the newly established adolescent psychiatric department at Basel, a subunit of the university hospital. The department is conceived as an open ward, where patients are being cared for by an interdisciplinary team of psychiatric nurses and paedagogics, besides many other professionals. Milieutherapeutic techniques, psychotherapy and pharmacotherapy are practised side by side. The conceptional ideas, gradual building of the ward and the experience of the first three years clinical experiences are summarised in this article.

[Therefore force, when obsession is present?]. / Drum zwinge, wem ein Zwang gegeben?

To force somebody means inflict pressure on him. Obsessive-compulsive behaviour (OCB) is a feature of relationships. In early infancy, repetitive biological functions rapidly become automatic psychic functions. Small children often try to relate to their surrounding in a constrained manner in order to re-establish their omnipotence. Play and transitional space are opposites of OCB. Anxiety and constraints show an inverse relation to each other. In many cases, OCB in infants and small children has no clinical relevance. OCB is characterised by a high intrapsychic persistence during the whole period of psychophysic development. Obsessive-compulsive diseases (OCD) may serve as defence against oedipal strivings or against psychotic functioning. It is addressed against the self, an inner object or a relevant person of the surrounding. OCD correspond to a relational illness. In this situation an involved person becomes rapidly involved in the constraint problem. To maintain an adequate form of relationship within such transferential movements, a continuous "unchaining" is necessary. During transference, regressive anxieties and rages are expressed in a personalised form. Verbalised by the therapist, they become ready for transformation. The relationship may now open up to allow the inclusion of a third person.

Role of CYP1A2 in hepatic sequestration of dioxin: studies using CYP1A2 knock-out mice.

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD, dioxin), most potent of the polyhalogenated aromatic hydrocarbons, has been studied in a variety of genetically normal species. Transgenic mice lacking a cytochrome P450 1A2 gene were used to study the influence of the CYP1A2 gene on the hepatic sequestration and distribution of TCDD, 4-PeCDF (2,3,4,7,8-pentachlorodibenzofuran; dioxin-like compound), and PCB 153 (2,2',4,4',5,5'-hexachlorobiphenyl; non-dioxin-like PCB (polychlorinated biphenyl)). The knock-out mice were compared to their age-matched lineage strains of C57BL/6N (1A2+/+; Ah(b)) and 129/Sv (1A2+/+; Ah(d)) for each compound. As demonstrated by the liver-to-adipose tissue (L/F) concentration ratios, there was no hepatic sequestering of TCDD and 4-PeCDF in the transgenic knock-out mice.