Manuela Fleming

Bullying, burnout, and mental health amongst Portuguese nurses.

Bullying is a concept commonly used to describe situations in which an individual is persistently treated in an abusive manner over a period of time, with a feeling of not being able to counterattack or defend him-or herself against the abuse. In this study we investigated both the prevalence of bullying in Portuguese nurses and the relationship between the symptoms of burnout and mental health in nurses who report being bullied. Participants were 107 nurses of the Portuguese Public Health System. We concluded that one out of six (13%) nurses had experienced bullying in the past six months. The three most common types of bullying behaviour experienced by the nurses were doing tasks below their level of competence, having areas of responsibility removed or replaced with more trivial or unpleasant tasks, and being exposed to unmanageable levels of workload. Bullied nurses had significantly higher levels of emotional exhaustion and lowered levels of mental health compared with non-bullied colleagues.

Psychological aspects of pre‐symptomatic testing for Machado–Joseph disease and familial amyloid polyneuropathy type I

Machado–Joseph disease [MJD, also spinocerebellar ataxia type 3 (SCA3)] and familial amyloid polyneuropathy type I (FAP‐I or ATTR V30M) are neurodegenerative disorders, inherited in an autosomal dominant fashion, which have a high prevalence in Portugal, probably due to a founder effect. MJD and FAP‐I are late‐onset diseases, with symptoms emerging usually during adulthood. CGPP, which is the national reference centre for these disorders, has a genetic lab that offers diagnostic, pre‐symptomatic and prenatal testing and an outpatient clinic to counsel and follow relatives at risk for hereditary ataxias, FAP‐I and Huntington disease (HD). The present work is a review of our 10‐year experience with psychological counselling of individuals at risk for MJD and FAP‐I. Persons at risk for FAP‐I may show a better response to pre‐symptomatic testing than those who are at risk for MJD and HD because of the availability of liver transplantation, which may improve their health and life expectancy. Psychological well‐being and specific distress of MJD and FAP‐I test applicants, before undergoing genetic testing (baseline level) and 3 to 6 months after disclosure of test results, have shown a low level of change, both in identified carriers and non‐carriers. A major goal of psychological characterization of at‐risk individuals for MJD and FAP‐I is to determine the factors that influence the uptake of genetic testing.

Prenatal diagnosis of Machado-Joseph disease by direct mutation analysis

MJD is the most frequent dominant ataxia and an incapacitating disorder. Onset is most frequently during the reproductive years, and genetic counselling is its only means of prevention. The causative mutation—an expansion of a (CAG)n on chromosome 14q32.1—can now be directly detected. We now report the first two cases of prenatal diagnosis (PND).

Psychological Follow-up of Presymptomatic Genetic Testing for Spinocerebellar Ataxia Type 2 (SCA2) in Cuba

Presymptomatic testing for spinocerebellar ataxia type 2 (SCA2) in Cuba started five years ago. We have now investigated the psychological impact of test results on 150 individuals at 50% risk for SCA2. In a prospective study, psychological instruments were used to evaluate depression, anxiety and family functioning (1) before testing and (2) one year after disclosure of the test result. One year after, anxiety and depression levels decreased both in carriers and non-carriers, but anxiety decreased significantly more in carriers. Pathological levels of anxiety were seen mostly in members of dysfunctional families, but decreased more in them than in other consultands. Presymptomatic testing thus seems to have been especially beneficial for these testees, possibly due to a greater gain from the psychosocial support received. It would be pertinent to evaluate now the impact of other psychosocial variables and perform longer-term longitudinal studies.

Cocaine Addiction and Family Dysfunction: A Case-Control Study in Southern Brazil

Family-related factors play a crucial role in the onset, development, and maintenance of drug misuse and addiction. To investigate the hypothesis that families with a cocaine addicted son display more dysfunction than control families, we applied the Personal Authority in the Family System and the Self-Report Measure of Family Functioning to 67 case triads (child–father–mother) in which the son was an inpatient with a primary diagnosis of cocaine abuse or dependence and to 67 matched control triads from the community (Pelotas, Brazil) in 2000. Case children, mothers, and fathers were significantly more likely to present nuclear family triangulation than their matched control subjects. In addition, case triads had a significantly greater chance of perceiving family functioning as enmeshment. These results suggest both structural and functional differences in these families. We argue for the need of interventions in the family as a whole and for further research in this area.

Cocaine addicts and their families. An empirical study of the processes of identification.

The processes of identification between adolescent cocaine addicts and their parents were studied in 402 subjects, in total 134 familial triads (father“mother”son), subdivided into two groups of 67 triads, one of these groups having as the child an adolescent of masculine sex dependent on cocaine and the other, equal in number, being a control group, duly matched for age and socio‐economic status. The instrument employed was the Rorschach test (1922), limited to the application of the Lerner Defense Scale (LDS; Lerner & Lerner, 1980). The findings in the affected triads showed up as consistent statistically for the presence of intense processes of pathological identification, especially between father and son, a sign of the importance of the presence of disturbances of paternal function in the development of this addiction. The utilisation of very regressive defence mechanisms, above all of projective identification, was the predominant mode of procedure in triads with a dependent child. In comparisons between the fathers the odds ratio (OR) for projective identification was 8.66 to 1, which points to the association between cocaine addiction and the primitive mental functioning of the fathers. With empirical methodology these findings serve to corroborate the psychoanalytical conclusions based on studies of single case studies, testifying that the dysfunctions of identificatory phenomena in familial functioning are predominant in the mental organisation of cocaine addicts.

The mental pain of the psychoanalyst: A personal view

Abstract Mental pain is a common concern of psychoanalysts in their professional life. Combining her clinical experience with previous contributions by others, the author presents a personal overview of the patient-triggered mental pain of the analyst. Countertransference is considered to be the major source of the analysts work-derived mental pain. This type of mental pain is not to be avoided or discarded by the analyst. Rather, the analyst will benefit from tolerating and even welcoming professional mental pain: in most cases, mental pain will bring with it rich clinical material that, upon interpretation, will help him or her to offer previously intolerable contents back to the patient in a transformed version that now becomes acceptable. The analysts mental pain may emerge in his dreams; clinical examples of this phenomenon are presented. It is suggested that there is an increased chance of the analyst undergoing mental pain when treating patients suffering from severe psychopathology, and a clinical case is reported to illustrate this assertion. The author proposes that a lifelong effort is to be expected from analysts in terms of enhancing their threshold of tolerance to professional mental pain. In situations of mental pain, analysts must be particularly aware of the need to modulate their interpretations before transmitting them to the patient. The capacity of analysts to transform their mental pain (Ta, according to Bion) will depend on the plasticity of their container functions, the quality of their transformation abilities and, in particular, their threshold of tolerance to mental pain.

Assessing medically unexplained symptoms: evaluation of a shortened version of the SOMS for use in primary care

BackgroundTo investigate the validity and stability of a Portuguese version for the Screening for Somatoform Symptoms-2 (SOMS-2) in primary care (PC) settings.MethodsAn adapted version of the SOMS-2 was filled in by persons attending a PC unit. All medically unexplained symptoms were further ascertained in a clinical interview and by contacting the patients physicians and examining medical records, attaining a final clinical symptom evaluation (FCSE). An interview yielded the diagnosis of Clinical Somatization (CS) and the diagnosis of current depressive and anxiety disorders.ResultsFrom the eligible subjects, 167 agreed to participate and 34.1% of them were diagnosed with somatization. The correlation between the number of self-reported and FCSE symptoms was 0.63. After excluding symptoms with low frequency, low discriminative power and not correlated with the overall scale, 29 were retained in the final version. A cut-off of 4 symptoms gave a sensitivity of 86.0% and a specificity of 95.5% on the FCSE and 56.1% and 93.6% at self-report. Stability in the number of symptoms after 6 months was good (k = 0.57).ConclusionsThe 29 symptoms version of the SOMS-2 with a cut-off of 4 showed a high specificity and sensitivity, being reliable as a referral tool for further specialized diagnosis.

The Perceived Advantages and Disadvantages of Presymptomatic Testing for Machado-Joseph Disease: Development of a New Self-Response Inventory

This study describes the construction of a self-response inventory to evaluate the perception of advantages and disadvantages of the Machado-Joseph disease presymptomatic testing, in 44 individuals at-risk for this disease. The results showed that the reliability of this inventory was satisfactory. Factor analysis revealed a bidimensional structure: perceived advantages (pros) and perceived disadvantages (cons) of presymptomatic testing. Social desirability was found unrelated to the total scores of our inventory. Additional correlation studies, with other scales, confirmed the convergent validity of the instrument. These results suggest adequate construct validity. This inventory thus seems to be a proper instrument to assess expectations involved in the decision-making process of Machado-Joseph disease presymptomatic testing.

Distinction between mental pain and psychic suffering as separate entities in the patient's experience

Abstract Mental pain and psychic suffering are herein defined as two separate concepts in psychoanalysis. The concept of mental pain lies at the core of psychoanalysis; it was introduced by Freud and was further elaborated by a number of investigators, mostly by Bion. Mental pain refers to a pain that the patient reports as being impossible to describe in words, and lacking any associations, whereas psychic suffering can be both named and described by the patient. Mental pain is derived from non-tolerance on the part of the psychic apparatus when it is harmed by very painful emotions. In contrast to psychic suffering, mental pain resists elaboration and transformation by dream-work. How to address and transform the patients mental pain is a major challenge facing the analyst in his clinical work because mental pain may halt or slow the progression of the analytical process. To overcome this hindrance, the work of the analyst is focused on helping patients to modify their mental pain into psychic suffering, that is, to reactivate in the patient the chain of transformations that generates thought. The analyst is also challanged with the mental pain of the patients because he has himself to tolerate the mental patient induced by counter transference. Suggestions for the analyst on how to deal with the mental pain of the patient during psychoanalytic therapy are proposed.