Building esprit de corps: learning to better navigate between "my" patient and "our" patient

Excellence in the care of hospital patients, particularly those in an intensive care unit, reflects esprit de corps among the care team. Esprit de corps depends on a delicate balance; each clinician must preserve a sense of personal responsibility for "my" patient and yet participate in the collaborative work essential to the care of "our" patient. A harmful imbalance occurs when a physician demands total control of the decision-making process, especially concerning end-of-life treatment options. Although emotional factors may push a physician to claim decision-making exclusivity, compounded by a legal framework that overemphasizes individual responsibility, esprit de corps can be preserved through timely communication among clinicians and a recognition that optimal care for "my" patient requires effective team practice.     

The diagnosis and assessment of individuals prodromal for schizophrenic psychosis

Accurate identification of individuals in the earliest symptomatic stages of psychosis offers new hope for developing more effective treatment strategies. Recently, research clinics have been set up to identify and possibly treat individuals who are seen as being at ultra-high risk of developing a psychotic disorder. This article reviews and describes measures that are currently being used and further developed in order to determine both the diagnostic criteria for the prodromal state and the severity of these putatively prodromal symptoms.     

The singles scene: safe sex practices and attitudes among at-risk heterosexual adults

Heterosexual transmission of HIV accounts for 80% of AIDS cases worldwide and is the main mode of transmission in sub-Saharan Africa and some Asian countries. The extent of heterosexual HIV transmission will likely increase in Western countries. The safe sex practices and attitudes of 58 male and 54 female heterosexuals in Melbourne, Australia, aged 20-40 years, of mean age 27.4 years, were assessed through interview and questionnaire. Study participants were recruited at discotheques and bars catering to single adults. Respondents' attitudes toward safe sex were generally positive, although those attitudes were not always reflected in actual sexual practice. High levels of sexual activity were reported, including high risk behaviors such as unprotected anal sex with casual and regular partners by both men and women. Situational and partner characteristics frustrated the practice of safe sex despite intentions to use condoms. Few men and half of the women explicitly discussed condom use with their sex partners. These findings are similar to those which one would expect from a sample of adolescents.     

Onset of obsessive-compulsive disorder: premorbid conditions and prodromal phase

This article focuses on the clinical onset of obsessive-compulsive disorder (OCD), specifically addressing the age of onset, gradual and acute onset, and whether there are some types of premorbid conditions or a prodromal phase that predispose individuals to the onset of OCD. Clinical and epidemiological studies have come to different conclusions regarding age at onset as well as regarding differences between the sexes. Data gleaned from research to date have demonstrated a relationship between OCD and obsessive-compulsive personality disorder (OCPD), although OCPD does not appear to be the more prevalent personality disorder among patients with OCD. Preliminary research has suggested that Axis I disorders may predispose individuals to OCD onset; however, the significance of this relationship remains to be clarified. Evidence of the association between OCD and subthreshold obsessive-compulsive syndrome suggests that these disorders lie on a continuum of severity, with some cases developing OCD while others do not.     

The singles scene: Safe sex practices and attitudes among at-risk heterosexual adults

Patient uncertainty is associated with conditions with no known cause or cure, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), and despite its potential role in chronic illness management, it is still a poorly understood concept. This study constitutes an in-depth investigation of patient uncertainty in SLE and RA. We conducted (i) structured interviews with a sample of rheumatology health care professionals (HCPs) (n?=?8) and (ii) in-depth, semi-structured interviews with a sample of SLE (n?=?17) and RA (n?=?15) patients. Interviews were audio-taped, transcribed verbatim and analysed thematically using detailed line-by-line coding. Patient uncertainty was conceptualised in a framework of five domains: symptoms and prognosis, medical management, self-management, impact and social functioning. Even though these five domains were present in both the SLE and RA data, there were some differences at the sub-domain level. Several sources of uncertainty were put forward by the HCPs and subsequently confirmed in the patient interviews including the illness trajectory, age, gender and timing. Patients reported uncertainty relative to various aspects of their illness, its management and impact. Finally, HCPs discussed the behavioural and psychosocial impact of uncertainty, which further suggests its important role in patient management.     

The effects of a mentoring program on at-risk youth

This study examined an intensive mentoring program that focuses on youth deemed at-risk for juvenile delinquency or mental illness. Mothers and teachers completed the Child Behavior Checklist, and youth completed the Hopelessness Scale for Children, the Piers-Harris Self-Concept Scale, and the Self-Report Delinquency Scale. The youth (ages 10 to 17) either participated in the mentoring program (intervention, n = 34) or remained on the waiting list (nonintervention, n = 34) for 6 months. Repeated-measures ANOVAs assessed changes from preintervention to postintervention and indicated significant improvement in problematic behaviors for the intervention group. Mentoring appeared to affect African American youth differently than Caucasian and Latino youth. There were no significant interactions involving gender. The findings of this study supported the positive influence of mentoring on at-risk youth.     

The predictive validity of teacher nominations: A five-year followup of at-risk youth

The purpose of this study was to examine the predictive validity of a teacher nomination procedure for identifying at- risk children. Two hundred and twenty-five children were nominated by their teachers as well- adjusted (n= 75), socially withdrawn (n=76), or socially aggressive (n=74) during the fourth grade. Five years later, 198 of these children (88%) were located and their adjustment evaluated. Significant differences among the nominated children were found on a variety of measures, including academic grades, sociometric status, and social behavior. In addition, differences in school dropout and delinquent offenses were noted. Results are discussed in terms of the validity of teacher nomination procedures and their utility in identifying at- risk youth.     

The dreams of a cancer patient: a "royal road" to understanding the somatic illness

In this paper we have presented the principal dreams of a 39-year-old female patient in order to demonstrate how closely the dreams were linked with the understanding of her cancerous condition. The analysis, lasting over a period of eight years, ended with the remission of the patient's cancerous condition to the point where she was without pain and symptom-free. The findings suggested that her dreams played a special role in her analysis by providing important landmarks regarding her treatment's progress and state of her cancerous condition. In a general sense, it was concluded that the patient's dreams did provide a "royal road" to understanding her somatic illness. Specifically, it was concluded that, first, the patient's dreams were able to represent quite reliably, in symbolic form, the state of her cancerous condition; second, that the cancer condition and transference-countertransference reactions were closely entwined; and third, that each of the patient's dreams seemed to be introduced by a crisis situation connected with a traumatic early memory.     

The psychosocial characteristics of at-risk high school students.

This study examined differences between high school students who were at risk for school failure and a control group of peers. Statistically significant differences were found with respect to locus of control, self-concept, and personal styles of learning. Implications focused upon approaches and suggestions regarding the use of such knowledge in facilitating improved adjustment and achievement in at-risk students.     

Behaviorally at-risk African American students:The importance of student-teacher relationships for student outcomes

The purpose of this exploratory study was to examine the associations between the student-teacher relationship and outcomes for African American students who were behaviorally at-risk for referral to special education. Students were identified by their teachers as having behavior problems. Participants were 44 students and 25 teachers from two suburban and three urban elementary schools in a mid-western state. A multi-rater, multi-method approach was used. As teacher-reports of student-teacher relationship quality increased, there were also increases in positive social, behavioral, and engagement outcomes for students. Similarly, as student-reports of student-teacher relationship quality increased, there were increases in positive behavioral, engagement, and academic outcomes. Additional analyses of dyadic relationship patterns showed that as the relationship pattern improved (moving from negative concordance to discordance to positive concordance), there were increases in positive social, behavioral, and engagement outcomes for students. Implications for school practice are discussed.     

Biological markers of cognition in prodromal Huntington's disease: a review

Huntington’s disease (HD), an autosomal-dominant genetic disorder, has historically been viewed as a degenerative movement disorder but it also includes psychiatric symptoms and progressive cognitive decline. There has been a lack of consensus in the literature about whether or not cognitive signs can be detected in carriers before clinical (motor) onset of the disease, i.e., prodromal HD. However, recently validated mathematical formulas to estimate age of clinical onset, refined over the past 5–7 years, have allowed researchers to overcome the methodological limitation of treating all prodromal carriers as a homogenous high-risk group (i.e., whether they may be 2 or 15 years from diagnosis). Here we review 23 articles on the HD prodrome, all of which related cognition to a biological marker of disease burden (i.e., genetic load, neuroimaging). All studies found at least one cognitive domain was associated with disease burden in prodromal HD participants. There was greater variability in both the detection and cognitive domain affected in those farther from onset (or those with less pathology) while most studies reliably found declines in visuomotor performance and working memory in those closer to onset. These findings indicate that cognitive signs can be reliably detected in the HD prodrome when comparing cognition to additional disease markers, however, there continues to be significant variability on cognitive findings among large and methodologically rigorous studies. This may reflect true heterogeneity in the prodromal HD phenotype which must be further explored by analyzing intra-individual variance, determining demographic risk factors associated with decline/protection, and examining if particular HD families exhibit distinct cognitive profiles. These and additional future directions are discussed.     

Family functioning and eating attitudes and behaviors in at-risk early adolescent girls: The mediating role of intra-personal competencies

The relation between perceived family functioning, intra-personal competence, and eating attitudes and behaviors was examined in a sample of at-risk, ethnically diverse, early adolescents. Both family functioning and intra-personal competencies were related to eating attitudes and behavior. However, adolescent intra-personal competence, defined as self-control, negative, and positive coping, mediated the relationship between family functioning and eating attitudes and behaviors. Results suggest that by early adolescence, important aspects of family environment have consolidated into individual differences in competence and/or personality. Results are discussed within a developmental framework emphasizing the influence of the family on adolescent psychosocial development. The implications of these data for prevention and intervention with at-risk adolescent girls are also discussed. This work was supported by the National Institute of Drug Abuse, NIH, under Grant DA 07031, to Thomas J. Dishion. Appreciation is expressed to the parents and adolescents who participated in this study, as well as the staff at the Project Alliance office in Portland.     

Family functioning and eating attitudes and behaviors in at-risk early adolescent girls: The mediating role of intra-personal competencies

The relation between perceived family functioning, intra-personal competence, and eating attitudes and behaviors was examined in a sample of at-risk, ethnically diverse, early adolescents. Both family functioning and intra-personal competencies were related to eating attitudes and behavior. However, adolescent intra-personal competence, defined as self-control, negative, and positive coping, mediated the relationship between family functioning and eating attitudes and behaviors. Results suggest that by early adolescence, important aspects of family environment have consolidated into individual differences in competence and/or personality. Results are discussed within a developmental framework emphasizing the influence of the family on adolescent psychosocial development. The implications of these data for prevention and intervention with at-risk adolescent girls are also discussed. This work was supported by the National Institute of Drug Abuse, NIH, under Grant DA 07031, to Thomas J. Dishion. Appreciation is expressed to the parents and adolescents who participated in this study, as well as the staff at the Project Alliance office in Portland.