The adult attachment interview: rating and classification problems posed by non-normative samples

Non-normative samples can pose major procedural and coding challenges to interviewers and raters of the Adult Attachment Interview (AAI). With reference to interview transcripts drawn from a population of personality disordered offenders detained in a high-security hospital, specific difficulties are identified and discussed. These difficulties have their roots in three separate but overlapping areas: extreme attachment-related experience; interviewees' psychological or psychiatric state; and factors relating to the context in which the interview is conducted. They raise questions about whether and when the use of the interview should be restricted, the rating rules elaborated and/or the rating system expanded. Suggestions are made as to how some of the difficulties might be addressed.

Disorganised attachment behaviour among infants born subsequent to stillbirth

There is limited evidence that siblings of stillborn infants are more vulnerable to psychological problems. This case-controlled study examines the relationship between previous stillbirth and the next child's pattern of attachment and explores factors in the mother which may be associated with and which may explain the pattern of infant attachment. We examined 53 infants next-born after a stillbirth, and 53 control infants of primigravid mothers. Maternal demographic, psychiatric, and attachment data were collected in pregnancy, and self-report measures of depression collected in the first year. Infant attachment patterns to the mothers were assessed when the infants were 12 months old using the Ainsworth Strange Situation Procedure. Infants next-born after stillbirth showed significant increase in disorganisation of attachment to the mother compared with control infants (p < .04). The difference was not accounted for by differences in psychiatric symptoms or demography. It was strongly predicted by maternal unresolved status with respect to loss as measured in the Adult Attachment Interview, and less strongly by maternal experience of elective termination of pregnancy and by the mother having seen her stillborn infant. The study adds weight to previously reported clinical observations, that infants born after stillbirth may be at risk of an increase in psychological and behavioural problems in later childhood. The strong association between disorganisation of infant attachment and maternal state of mind with respect to loss suggests that the mother's state of mind may be causal, and raises interesting questions about the mechanism of intergenerational transmission. Given the existing evidence of later developmental problems, longer-term follow-up of these children would be valuable.

The use of a hydrofibre dressing in fulminating necrotizing fasciitis

This article describes a case of necrotizing fasciitis in a 52-year-old man with previously undiagnosed diabetes. Treatment involved massive debridement and subsequent dressing of the open surgical wound. A modern hydrofibre dressing (Aquacel) was inserted intraoperatively and subsequently continued postoperatively. Wound healing occurred over 3 months and the patient was discharged with no disability. The dressing managed the exudate level and kept the wound moist. It also was well tolerated by the patient, was comfortable and easy for the nurses to remove and apply.

Incidence, correlates and predictors of post-traumatic stress disorder in the pregnancy after stillbirth

BACKGROUND

Many women may suffer psychological symptoms after stillbirth and in the subsequent pregnancy. Stillbirth has not been demonstrated previously to be a stressor for post-traumatic stress disorder (PTSD).

AIMS

To assess incidence, correlates and predictors of PTSD during and after the pregnancy following stillbirth.

METHOD

A cohort study of pregnant women whose previous pregnancy ended in stillbirth.

RESULTS

PTSD symptoms were prevalent in the pregnancy following stillbirth. Case-level PTSD was associated with depression, state-anxiety and conception occurring closer to loss. Symptoms generally resolved naturally by 1 year post-partum (birth of healthy baby).

CONCLUSIONS

Women are vulnerable to PTSD in the pregnancy subsequent to stillbirth, particularly when conception occurs soon after the loss.

Meeting the needs of people with cancer for support and self-management

Health professionals tend to consider that they are in the best position to decide treatment options for cancer patients despite research evidence that a feeling of powerlessness can affect health outcomes and the inclusion of patient empowerment within government policy. This article describes a focus group study, carried out in collaboration with the University of Warwick, aiming to elicit the needs of people with cancer and their carers/supporters, the reactions to these needs and the strategies adopted to obtain support and self-management skills. The methodology was II two-stage focus groups carried out in four English cities in 1998, involving 54 people with cancer and 14 supporters. The main study findings identified a parallel 'journey' to the previously described emotional and medical cancer journey in the form of an epistemological journey of 'identity shifts' as people progressed through their disease. People required additional emotional and psychological support when these shifts were taking place and used a variety of strategies to obtain this, including the use of complementary therapies and other strategies designed to increase their sense of control. The article concludes by describing a 'holistic' approach to cancer care which supports patient empowerment and recommendations for implementing the research findings into practice.

Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care

OBJECTIVE

To ascertain any differences between care from nurse practitioners and that from general practitioners for patients seeking "same day" consultations in primary care.

DESIGN

Randomised controlled trial with patients allocated by one of two randomisation schemes (by day or within day).

SETTING

10 general practices in south Wales and south west England.

SUBJECTS

1368 patients requesting same day consultations.

MAIN OUTCOME MEASURES

Patient satisfaction, resolution of symptoms and concerns, care provided (prescriptions, investigations, referrals, recall, and length of consultation), information provided to patients, and patients' intentions for seeking care in the future.

RESULTS

Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices. For children, the mean difference between general and nurse practitioner in percentage satisfaction score was -4.8 (95% confidence interval -6.8 to -2.8), and for adults the differences ranged from -8.8 (-13.6 to -3.9) to 3.8 (-3.3 to 10.8) across the practices. Resolution of symptoms and concerns did not differ between the two groups (odds ratio 1.2 (95% confidence interval 0.8 to 1.8) for symptoms and 1.03 (0.8 to 1.4) for concerns). The number of prescriptions issued, investigations ordered, referrals to secondary care, and reattendances were similar between the two groups. However, patients managed by nurse practitioners reported receiving significantly more information about their illnesses and, in all but one practice, their consultations were significantly longer.

CONCLUSION

This study supports the wider acceptance of the role of nurse practitioners in providing care to patients requesting same day consultations.

Incidence and demographic correlates of eating disorder symptoms in a pregnant population

OBJECTIVE

To obtain a picture of eating disorder symptoms in a population of pregnant women.

METHOD

Five hundred thirty women attending antenatal follow-up clinics at a large London district general hospital during a 4-week period were surveyed. The Eating Attitudes Test (EAT), the Edinburgh Postnatal Depression Scale (EPDS), and a demographic questionnaire were administered. Unadjusted relative risks and their 95% confidence intervals were calculated for a series of prognostic factors.

RESULTS

4.9% of women scored above the recommended threshold on the EAT in pregnancy. Eating disorder symptomatology was found to be associated with younger age, previous symptomatology, lower educational attainment, poorer housing, employment status, and previous miscarriage.

DISCUSSION

The meaning and potential implications of high levels of eating disorder symptomatology in a pregnant population are discussed in the light of the physiological and psychological effects of eating disorders on both pregnancy outcome and infant development.

Comparison of stage-matched and unmatched interventions to promote exercise behaviour in the primary care setting

This study examined the effectiveness of stages of change-based counselling for exercise delivered by nurses in four primary care centres. Two-hundred and ninety-four subjects enrolled, recruited from patients attending 30-min health checks. The average age of participants was 42.4 years (SD = 15.1) and 77% were female. Participants completed a questionnaire assessing stage of exercise adoption, self-efficacy and exercise levels. Each centre was assigned to either one of three experimental conditions or to a control condition. Participants were counselled accordingly, receiving either stage-oriented exercise materials with counselling (stage plus counselling), stage-oriented materials without counselling (stage no counselling), non-staged materials with counselling (counselling only) or the current level of advice (control). Sixty-one percent (n = 180) returned follow-up questionnaires. When baseline differences in self-efficacy, age and gender were controlled for, there was no significant group or interaction effect for stage. There was a significant time effect (F = 3.55, P = 0.031). Post hoc analyses showed that significant differences were between baseline and 2 (t = -3.02, P = 0.003) and 6 months (t = -2.67, P = 0.009). No changes in self-efficacy and exercise levels were observed. Stage-based interventions were not superior to the other interventions. All single-contact interventions, while having no impact on exercise behaviour and self-efficacy, did enhance motivation to change.

Stillbirth as risk factor for depression and anxiety in the subsequent pregnancy: cohort study

OBJECTIVE

To assess women's symptoms of depression and anxiety during pregnancy and the postpartum year in the pregnancy after stillbirth; to assess relevance of time since loss.

DESIGN

Cohort study with four assessments: in third trimester and 6 weeks, 6 months, and 12 months after birth.

SETTING

Outpatient departments of three district general hospitals; subjects' homes.

SUBJECTS

60 women whose previous pregnancy ended in stillbirth after 18 weeks' gestation; 60 matched controls.

MAIN OUTCOME MEASURES

Depression and anxiety measured by Edinburgh postnatal depression scale, Beck depression inventory, and Spielberger state-trait anxiety scale.

RESULTS

In the third trimester women whose previous pregnancy had ended in stillbirth were significantly more depressed than control women (10.8 v 8.2; P=0.004) and had greater state anxiety (39.8 v 32. 8, P=0.003) The difference was accounted for by those women who conceived less than 12 months after the stillbirth, who were also more depressed at 1 year. Results in those who conceived 12 months or more after stillbirth were similar to those in their controls at all points and showed lower trait anxiety 1 year post partum. One year after the birth 8% of control women and 19% of subjects scored high for depression (P=0.39), with most of the depression among the more recently bereaved (28% v 11%; P=0.18). In the women who had experienced stillbirth, depression in the third trimester was highly predictive of depression 1 year after subsequent birth (P</=0.0005).

CONCLUSION

Vulnerability to depression and anxiety in the next pregnancy and puerperium is related to time since stillbirth, with more recently bereaved women at significantly greater risk than controls. As there are problems for mother and infant associated with high anxiety and depression during and after pregnancy, there may be advantage in waiting 12 months before the next conception.

Incidence and demographic correlates of depressive symptoms during pregnancy in an inner London population

This paper reviews the literature on antenatal depression and reports on a recent survey of depressive symptoms among 407 women attending an inner London antenatal clinic. The high level of depressive symptoms in this survey was in line with that recently reported from a deprived inner-city population in the United States. Depressive symptoms were associated with having no educational qualifications, being unmarried, the woman being unemployed, having poor support from a partner if present, and being in second or subsequent pregnancy. Doctors should be aware that women are not especially protected from symptoms of depression during pregnancy. The association with socioeconomic problems suggests that this is one aspect of morbidity among disadvantaged people. There is a need for more research on the causes of depression during pregnancy and on evaluation of medical treatment and social intervention.

Public health. The missing link

The government's strategy for public health may fail because of a lack of co-operation between organisations. Primary care, as presently constituted, has little energy to take on public health. The strategy places too much stress on the role of health authorities and too little on primary care and local communities. The predominance of the medical model in public health needs to be addressed.

Giardia carriage in aboriginal and non-aboriginal children attending urban day-care centres in South Australia

A survey of Giardia lamblia prevalence was carried out in Adelaide, South Australia, among Aboriginal and non-Aboriginal children attending day-care centres. A single-stool examination in 178 children aged 6 years and under revealed an overall prevalence rate of 10.7% with all carriers being 1-4 years of age. Within this age group, Giardia prevalence among Aboriginal children (11/32) was significantly higher than that among non-Aboriginal children (eight of 99) (Chi-square analysis, P less than 0.001). Furthermore, among Aboriginal children, a significant association (P less than 0.05) was found between giardia carriage and the family's contact with rural Aboriginal settlements or people from these areas. Aboriginal children with no rural contact had a giardia prevalence similar to non-Aboriginal children.