Can parents adjust to the idea that their child is at risk for a sudden death?: Psychological impact of risk for long QT syndrome.

Can a parent adjust to the idea that its child is at risk for a sudden death? This question is raised by a diagnostic procedure in which children were tested for an inherited Long QT Syndrome (LQTS). This potentially life-threatening but treatable cardiac arrhythmia syndrome may cause sudden death, especially in children and young adults. The long-term psychological effects are described for parents whose children were tested for inherited LQTS. The adverse short-term impact of such testing has been described previously. The goal of this investigation is to determine whether this distress endures. Thirty-six parents completed measures of psychological distress. With the twenty-four parents of carrier children, a semi-structured interview was held 18 months after DNA disclosure. Parents of carrier children reported more distress than parents of non-carrier children. Parents of carrier children remained vulnerable to high levels of distress; up to one-third of these parents showed clinically relevant high levels of distress. High levels of distress were reported by parents of carrier children who (1) were highly distressed at previous assessments, (2) were familiar with the disease for a longer time, (3) had experienced a sudden death in the family, (4) were lesser educated, and who (5) were unsatisfied with the given information. Parents were particularly concerned about possible hazardous behavior during puberty. We conclude that the continuous threat of developing LQTS symptoms despite prophylactic treatment affected the psychological well-being of the parents for a long time. In light of the tempetuous developments in the areas of cardiac genetics, periodical information on new insight and developments may act as a buffer for the parents' (growing) concerns about their child's inherited disorder.

High distress in parents whose children undergo predictive testing for long QT syndrome.

OBJECTIVES: To assess the psychological effect of predictive testing in parents of children at risk for long QT syndrome (LQTS) in a prospective study. METHODS: After their child was clinically screened by electrocardiography and blood was taken for DNA analysis, and shortly after delivery of the DNA test result, 36 parents completed measures of psychological distress. RESULTS: 24 parents were informed that at least one of their children is a mutation carrier. Up to 50% of the parents of carrier children showed clinically relevant high levels of distress. Parents who were familiar with the disease for a longer time, who had more experiences with the disease in their family and who received positive test results for all their children were most distressed. CONCLUSIONS: Predictive ECG testing together with DNA testing has a profound impact on parents whose minors undergo predictive testing for LQTS.

An extended family suddenly confronted with a life-threatening hereditary arrhythmia.

OBJECTIVE: This exploratory study serves to illustrate the psychological impact on an extended family in the process of genetic counselling and testing for a potentially life-threatening arrhythmia, the long-QT syndrome (LQTS). METHOD: All members of the third generation and their partners (n=11) were interviewed, the mutation carriers with partners twice. In addition they completed measures for anxiety and depression three times in 18 months. RESULTS: During the interviews these family members emphasised the damaged solidarity when the family is divided into carriers and noncarriers of a mutation in a LQTS predisposing gene. This demonstrates one way in which a family can react to the reality of being at risk of a potentially severe disease. Rewriting family history and mourning early death seem other ways to deal with this. The distress scores, especially of the women, were moderate to clinically high, not because of their own chance of having an arrhythmia but more due to their children's risk. CONCLUSION: Mothers need educational even more than emotional support, because the lifestyle of their carrier children is in need of radical change. The setting of a combined outpatient cardiogenetic clinic with a medical and psychosocial staff meets such needs efficiently.

Parents' responses to disclosure of genetic test results of their children.

The psychological reactions of 22 parental couples and 3 single parents were investigated after disclosure of genetic test results of their children. The children were tested for the early-onset, monogenetic cancer disorder multiple endocrine neoplasia type 2. Participants came from 13 different families and were aged between 28 and 47 years. Parents who were informed that their child was a gene carrier reacted with resignation, showed moderate to high levels of test-related and general anxiety, but few psychological complaints. Daily activities were disturbed in 43% of the parents with carrier-children. There was little disruption of the parents' future perspective, apart from some socioeconomic disadvantages and increased parental concern for the carrier-children. Most parents with carrier-children showed restraint with respect to short-term prophylactic treatment. Parents with favorable test results showed significantly less anxiety and no disturbance in their daily activities. They did not, however, seem to be reassured by the DNA test result. These parents questioned the reliability of the DNA test, wanted confirmation of the test results, and were eager to continue screening of their noncarrier children. Parents, especially those with a lower level of education and/or a pessimistic view of the future, were distressed by unfavorable test results. Additional counseling is advised to prevent parents of carrier-children worrying unnecessarily, or parents with children in whom the disease gene was not found being not reassured. Am. J. Med. Genet. 94:316-323, 2000.

[Long QT-interval syndrome and investigation of heritability: psychological reactions in three generations in one family]. / Het lang-QT-intervalsyndroom en erfelijkheidsonderzoek: psychische reacties in drie generaties van een familie.

DNA diagnostics were carried out in a family after the long QT interval syndrome had been diagnosed in one of its members. The psychic reactions to this testing were different from those seen in other hereditary diseases such as Huntington's disease. This was probably due to the sudden and unexpected occurrence of the arrhythmia. The family members in whom clinical and DNA diagnostics gave purely negative findings were not relieved, owing to solidarity with the affected relatives. Their partners did not understand this response. The anxiety and concern of the gene carriers had nothing to do with their own health status but with that of their carrier children. These parents were in need of educational counselling and advice. The results of clinical and DNA diagnostics affected the family relationships: in carriers the feeling of closeness grew, while the non-carriers were afraid of loss of family closeness.

Distress in MEN 2 family members and partners prior to DNA test disclosure. Multiple endocrine neoplasia type 2.

Multiple endocrine neoplasia type 2 (MEN 2) is an autosomal dominant early-onset cancer disorder. In the Netherlands presymptomatic genetic testing for MEN 2 is offered to testees from the age of five years. We report on adults requesting testing for themselves (n=90) and on parents who want an at-risk child to be tested (n=26). Sociodemographic, personality, and attitude characteristics, and levels of psychological distress, were determined for applicants and their partners in the predisclosure phase of testing. These participants showed only mildly increased levels of psychological distress, defined as heightened scores on measures of general and test-related anxiety, and of psychological complaints. Compared with a normal population, high levels of anxiety and health complaints were found in applicants who were younger than 25 years and single, and in persons who generally tended to react to distressful situations with anxiety or depression. These characteristics were particularly evident in young applicants (<25 years). Our study shows that people who feel ambivalent towards DNA testing and who are more vulnerable to psychological distress are more likely to agree to participate in the test as part of a collective application by members of a hereditary cancer family.

Who Is at Risk for Psychological Distress in Genetic Testing Programs for Hereditary Cancer Disorders?

Presymptomatic identification of disease gene carriers is becoming an increasingly common part of the clinical management of hereditary cancer disorders. With an expected increase in the number of requests for DNA testing and the limited resources for counseling, the amount of time genetic counselors are able to spend with test candidates will decrease. It is therefore important for counselors to identify persons at risk for psychological distress. Based on a review of experiences with Huntington disease and cancer patients, we describe factors likely to evoke distress in genetic cancer candidates. We also discuss the sometimes widely different ways that test candidates and their partners respond to genetic testing. By exploring risk factors for distress in relevant domains of the research, we can offer counselors guidelines for determining who may need extra counseling.

Active listening to cancer patients' stories.

Approximately two thirds of all Dutch cancer patients have severe emotional problems; shortly after their change from the treatment regime into the regime of medical controls. Half of them even need professional support. It is, therefore, important that a professional listens with empathy to the patient's version of the illness story. Story telling helps to overcome the existential crisis of being a cancer patient; it is an essential step in the revalidation process. Themes and open questions which structure the communication are suggested in this article.

Psychological aspects of genetic counselling: a review of the experience with Huntington's disease.

Presymptomatic DNA-testing for adult-onset diseases has serious psychological consequences. Here the psychological consequences of presymptomatic DNA-testing for Huntington's disease are reviewed. Both carriers and non-carriers experience emotional reactions after disclosure of their test result. However, up to today no long-term adverse emotional consequences have been revealed. Future research on other adult-onset genetic diseases should provide information about the reactions of children. In genetic counselling, attention should be paid to the reactions of people with a decreased risk. Genetic counselling must focus on the whole family and not on the individual applicant.

Psychological risks of genetically testing children for a hereditary cancer syndrome.

Parents in families with a hereditary cancer syndrome are often familiar with periodical clinical testing of both themselves and their children. Genetic testing is an additional early diagnostic option that is becoming available for an increasing number of hereditary cancer syndromes. Participants in genetic counseling programs for cancer syndromes are often parents who apply for their children. If a child is identified as a carrier of a specific disease-causing gene mutation, sometimes its parents must decide on when it will be treated can treatment be postponed until expression of the disease or should the child receive presymptomatic surgery? We discuss some of the possible risks of genetically testing children: distress as a result of ambivalent feelings towards testing, preoccupation with disease-related signs, changes in family interactions, the burdening prospect of a future disease and medicalization of the carrier-child.

Efficacy of rhenium-186-etidronate in prostate cancer patients with metastatic bone pain.

UNLABELLED: Rhenium-186-etidronate has been developed for pain relief of bone metastases and has previously been studied with regard to toxicity, pharmacokinetics and dosimetry. Its palliating effect on bone pain has not been studied extensively. To justify further efficacy investigations, patients participating in two toxicity studies were studied using a strict pain assessment methodology. METHODS: Forty-three patients entered the study, 37 of whom were evaluable for pain assessment. Administered dosages ranged from 1295 MBq (35 mCi) to 3515 MBq (95 mCi) 186Re-etidronate. Pain relief was assessed using a handwritten diary containing questions reflecting the multidimensional character of chronic pain. The diary was marked twice daily for a maximum of 10 wk (2 wk prior to and 6/8 wk after the injection). A response was determined using a specific decision rule, in which pain intensity, medication index and daily activities were core determinants. RESULTS: A response was reached in 54% (20 of 37) of the patients and varied from 33% (n = 6) in the "35-mCi" group to 78% (n = 7) in the "50/65-mCi" group to 70% (n = 7) in the "80/95-mCi" group. CONCLUSION: Pain assessment using the multidimensional pain model showed that 186Re-etidronate is an effective agent in the treatment of metastatic bone pain in prostate cancer and warrants further placebo-controlled studies.

Psychosocial consequences of DNA analysis for MEN type 2.

Multiple endocrine neoplasia type 2 (MEN-2) is characterized by medullary thyroid carcinoma in combination with pheochromocytomas and, sometimes, parathyroid adenomas. Since 1993, the psychosocial implications of DNA analysis for MEN-2 have been studied in the Netherlands. This article summarizes the first results of that study. Individuals who applied for DNA analysis cited the need to reduce uncertainty as the major reason for wanting the test. An unfavorable test outcome resulted in anxiety and depression but also relief. Immediate preventive treatment was preferred to continued periodic screening. Carriers were preoccupied with disease-related complaints, and identified with other carriers and MEN-2 patients. A favorable test led, in most applicants and partners, to both relief and worry. Some noncarriers felt guilty and isolated from their families. One year after counseling, participants reported fewer psychosomatic complaints.

Three conflicts as a result of causal attributions.

There is a difference between the causal attributions of cancer (Ca)-patients and those of myocardial infarction (MI)-patients. MI-patients go through and check their autobiographies looking for the possible causes suggested by the medical world. Ca-patients on the contrary search for possible explanations. This is probably due to the lack of medical knowledge on the cause and course of their disease. They search through their autobiographies and the result is idiosyncratic, very personal attributions with which they create an explanation which is often not in accordance with the physicians' view. These attributions of Ca-patients are a source of conflicts, both within themselves (doubt), with their physicians and with their partners or other close relatives. Nevertheless they stick to their own explanations, although often secretly and with ambivalence, and despite the conflicts which they produce.