Whole document restricted, see Access Instructions file below for details of how to access the print copy. / Zinc is an important trace metal in human biology. It plays an active role in enzymic reactions, or simply serves in a structural capacity on a number of cytoplasmic and nuclear proteins. Zinc modulates receptor responses to various excitatory and inhibitory neurotransmitters. It has biphasic effects on several enzymes critical for cell survival and the induction of apoptotic cell death. At a particular concentration threshold, it is cytotoxic both in vitro and in vivo. Recent studies have indicated that zinc may be involved in several neuropathological conditions such as Alzheimer's disease, epilepsy, traumatic head injury and cerebral stroke. This investigation focused on the role of zinc in the context of an Alzheimer's disease paradigm. Rat primary cortical neurons were exposed to freshly-prepared (non-aged) or aggregated (aged) Aβ1-42 protein (20 µM; a highly toxic Aβ species), in the presence or absence of equimolar concentrations of zinc chloride (ZnCl2), or copper chloride (CuCl2).Zinc significantly attenuated, while copper potentiated the neurotoxic effects of non-aged Aβ1-42 after 48 h chronic exposure. Similarly, zinc, but not copper, reduced neuronal death 48 h following exposure to the aged peptide. A metal chelator, DTPA, also showed a protective, but limited effect (only observable at 24 h post-treatment) against the neurotoxicity of aged peptide. At the concentration tested, zinc alone had no effect on neuronal survival, although copper was found to be slightly neurotoxic after 48 h incubation. As hydrogen peroxide (H2O2) production by Aβ has been reported to mediate its cytotoxicity, an in vitro test system was used to identify if zinc affected this process. It was found that co-incubation of zinc (10 µM) with Aβ1-42 peptide alone (10 µM) or with Aβ1-42 and copper (1 µM) showed a significant decrease of Aβ-mediated H2O2 formation using TCEP assay in vitro. This finding suggested that the neuroprotective effect of zinc may not only be due to its capacity to hinder Aβ's redox activity, but also zinc's ability to preclude Aβ-mediated H2O2 generation. A mechanism for these effects of zinc is yet to be determined. As oxidative/nitrosative stress has been widely reported to occur in AD brain, and since zinc metabolism is believed to be dysfunctional in AD brain, the current study also set out to elucidate if cerebral zinc metabolism may be affected by nitrosating agents in vivo. Three unrelated nitric oxide-generating compounds were administered into rat hippocampus. Using Timm's and TSQ stain, a histochemical and a fluorescent staining for zinc, respectively, it was observed that sodium nitroprusside (≥2 nmol) and spermine-nitric oxide complex (≤200 nmol), but not the peroxynitrite-producing agent 3-morpholinosydnonimine (≤200 nmol), caused perikaryal zinc accumulation among certain neurons in the hippocampus. Both membrane impermeable and permeable metal chelators, EDTA and TPEN, respectively, blocked perikaryal zinc staining of hippocampal neurons. Data obtained from EDTA treatment suggested that the source of perikaryal zinc staining was mostly extracellular. Previous reports have shown that metal chelating agents have the capacity to protect neurons and minimize damage from brain insults. The preceding studies showed that chelators minimized perikaryal zinc acccumulation, precluded Aβ's redox activity, and partly reduced Aβ neurotoxicity. Thus, to further assess the possible beneficial effect of these compounds, DTPA, BP, or BC (25 µM) was incubated with a mixture of Aβ1-42 (2 µM) and Aβ1-40 (20 µM). DTPA abolished, while BP delayed the Aβ1-42-mediated Aβ1-40 "seeding" process. This result suggested that contaminating trace metals have an obligatory role in the nucleation-dependent Aβ fibrillogenesis, which is believed to be linked to Aβ neurotoxicity, and AD neuropathology. These results imply that zinc has a biphasic role in AD etiology and disease progression, and that the use of metal chelators to buffer pathologically excessive zinc and other metals, particularly the redox active copper and iron, may have a potential therapeutic value against AD symptomatology.

The nexus or linkages between loneliness, stigma, health complaints, and primary medical care in older New Zealanders was explored from a social constructionist perspective. The intent of the studies was the support and explanation of the underlying arguments of the thesis. For this age group loneliness is a clinical condition which merits greater recognition, diagnosis, and treatment from general practitioners than it presently receives. As a society we silence and stigmatise loneliness in our senior citizens making it likely that they will present indirectly to their doctors when experiencing severe effects of the condition. This behaviour will increase their risk of inappropriate medical intervention at possible cost to themselves and to society. A cross sectional, randomly selected survey of 300 New Zealanders over 60 years old, aimed to establish the patterns of loneliness in the sample using quantitative analysis. The second qualitative study used the methodology of discourse analysis to identify the themes concerning loneliness and medical care in the accounts of older adults, and how these were used. Fourteen people, deemed by their doctors to be lonely and to need frequent medical care, were interviewed in order to further knowledge of the dynamics of loneliness and the medical encounter. Fifteen percent of the sample of 300 had moderate to severe loneliness scores. The sociodemographic indicators of loneliness were extremely easy for a practitioner to recognize. Less than 2% of the total of self reported doctor visits were explicitly for loneliness. According to Barsky's (1981) model, the most likely pathways to the doctor were through symptom amplification and lowered self ratings of health, with a less likely pathway through focusing on and worrying about symptoms, leading to perceived need for medical care. The predictive variances in regressions of loneliness on all health outcomes, except for self reported visiting of more than one doctor for symptoms, were lower for chronic than for situational loneliness. The most important conclusions from the second study were the identification of three rhetorical strategies or "etcetera clauses" which provided a social prescription for the indirect presentation of loneliness by older people. Loneliness may be discussed with the doctor; if it affects your physical health; if you are consulting for another reason; and if the doctor picks it up. Also, the individual doctor defines loneliness as a worthy, or non-worthy, condition for consultation.

Hypnosis has been used as a treatment modality to change physiological functioning almost since it was discovered. Particularly, it has been used in the treatment of psychosomatic illnesses. A series of studies was planned to explore the use of hypnosis within the context of recent advances in the field of psychoneuroimmunology. Type I hypersensitivity reactions were chosen as indicators of immunological functioning in allergy. Study One: This study using modern methodology and statistical analyses set out to test the hypothesis that it was possible to decrease reactions to histamine by hypnotic suggestion. Five subjects, all asthmatic and untrained in hypnosis, were given three hypnotic sessions where they were asked to control their reactions to histamine. These sessions were to be compared to three baseline sessions. A decrease in reactions was noted on the second administration of histamine calling into question studies that relied on a two session comparison. On subsequent sessions much unexplained variance was encountered, with the day upon which the sessions took place contributing significant amounts of the variance, giving rise to questions about what could cause these day to day changes. Study Two: Given the results of Study One, a method was subsequently devised in which serial, five-fold dilutions of allergen or histamine were administered to the subject's forearm with a standard Osterballe-type prick lancetter and reactions were recorded photographically on slide film. Areas were determined by computer-assisted image analysis. Seven healthy volunteers were tested for 8 sessions (testing included Profile of Moods Scale and Brief Mood Rating questionnaires, blood pressure, pulse and skin temperature). Mean wheal size and titration gradient data from allergen reactions correlated strongly with the psychological factor of liveliness but not irritability, although no manipulation of mood was involved. A stepwise regression analysis accounted for 61% of the variance of the allergen data, and 31% was from the liveliness factor alone. Thus, the more lively the subject felt, the smaller was the allergic response. The third study looked at a sample of 117 adult New Zealand subjects who volunteered to be tested with the Harvard Group Scale of Hypnotic Susceptibility (Form A). 38 of these people also were tested on a second test used to assess hypnotisability, the Creative Imagination Scale. Results indicated that the CIS can be administered with a minimum of preamble negating the value of special "think-with" instructions. It appears from the evidence in this study that both the CIS and the HGSHS:A measure characteristics that are stable over the years since the tests were first published. Reassuringly, they both can be used throughout the adult age group, with neither age nor sex testing differentially. The means and standard deviations were found to be similar to those of university aged students from various countries and cultures around the world over the years. The two hypnotisability tests were found to be correlated with each other but on a factor analysis each loaded separately giving evidence that the two tests are assessing different but related abilities. Study Four was an intervention study using 38 subjects who participated in a control session and cognitive-hypnotic intervention session that used the skin test methodology developed in Study Two. When the results of the two sessions were compared, significant decreases were found in the size of the wheals after skin testing with allergen or histamine. The hypnotic method employed in this study used three specific procedures that appear to have contributed to the high success rate: challenge to the assumption that the subject has 'no imagination', self-generated scenes and the entire process had the seriousness removed so there was little or no fear of failure. Again, the significance of mood variables was considerable in ameliorating the skin test responses, and hypnotisability was a significant factor in predicting success at being able to use the intervention. Overall, these four studies have revealed that hypnosis can be used to change at least one aspect of physiological functioning, reactivity to skin tests. Mood variables have emerged as important mediators, with implications that mood should be assessed whenever physiological variables are being measured.

This thesis sets out to explore some psychosomatic dimensions of chronic musculoskeletal pain. Pain is a phenomenon which is universally recognised and experienced but nevertheless presents a very real epistemological problem. For convenience, the philosophical approach chosen here is that of linguistic parallelism which views pain as a range of abstract concepts defined in a variety of ‘languages’ or disciplines in a complementary and interactive way. Psychiatric formulations of pain include the concepts of conversion, object relations and the associations of pain with a developmental history of suffering and defeat and a diagnosis of depression. These ideas have been to some extent confirmed by nomothetic studies of pain patients. Chronic, as opposed to acute, pain is associated with a broad range of physical, emotional and social changes and is a problem of such clinical magnitude that special multidisciplinary clinics have now become a feature of clinical services in most large centres. My own experience as a psychiatrist working in the Auckland Pain Clinic is described in this thesis. Over a four year period, 172 patients were assessed, comprising 15-20% of the total referrals to the clinic. The modal age was 45-54 years, with a male/female ratio of 7:10. The duration of pain was 5-10 years, the back being the most common site and musculoskeletal pain was by far the most frequent presentation. Most of the patients presented with psychiatric disorders in the neurotic-personality disorder spectrum; depression, anxiety and hysteria being frequent diagnoses. These findings are similar to other studies reviewed. Treatment was instituted in half of the patients seen and half of the treated patients improved or recovered. One third of the original sample returned a completed follow-up questionnaire 18 months to 5 years after presentation. Just under a half remained improved or recovered, the treated patients faring no better or wrose than those who refused or were not offered treatment, or who were referred elsewhere. There was a high rate of further consultation amongst all groups, but especially so for those who declined treatment. The treated patients and those referred elsewhere were significantly more likely to have found the psychiatric consultation helpful. EMG feedback, drug withdrawal and psychotherapy were more frequently associated with improvement than pharmacotherapy on short-term evaluation. On follow-up only EMG feedback maintained an advantage, Issues which emerged were the relationships between chronic pain, depression and antidepressant medication response; the role of anxiety and tension in chronic pain and the strong tendency towards continued help seeking amongst the majority of patients. Muscle tension has been invoked in the aetiology and maintenance of a variety of pain syndromes. The most intensively researched areas have been tension headache and temporomandibular joint pain where EMG feedback has become an established treatment technique, although there is still some controversy as to whether EMG feedback has any advantage over relaxation training as such. The use of EMG feedback training in other musculoskeletal conditions has been less well researched and doubt remains as to the role of generalised muscle tension in the causation of these conditions. An EMG feedback study was undertaken at the Auckland Pain Clinic using a within-subjects control- design. Eighteen subjects (12 females and 6 males) with neck and back pain were studied in terms of subjective reports of pain and EMG activity measurements under standardised conditions. Three conditions were compared, viz EMG feedback training, a control condition and a waiting list condition. The sequences of presentation of these conditions was counterbalanced in a design using two sets of latin squares to pick up any order effects. EMG feedback was the only treatment which significantly reduced EMG activity across sessions. An order effect was evident in that biofeedback was most effective when presented first but less so when presented after the control condition. Although estimates of present pain correlated with EMG activity, there was no statistical difference between pain score reductions when EMG feedback and control conditions were compared. Pain scores tended to decline during both conditions but the scores for “worst pain over one week” tended to rise. During the waiting list condition, present pain tended to increase while “worst pain over one week” tended to decline. Eleven subjects experienced an overall decrease in pain scores at the end of the study, while seven had increased pain. Declines in pain scores tended to be associated with a biofeedback training effect but this was not statistically significant. Improvement in pain was associated with high Present pain/EMG correlations when a rank order correlation was computed. This study provides some support for the use of relaxation methods in the management of musculoskeletal pain. It suggests that muscle tension may well play a role in the production and/or maintenance of musculoskeletal pain, although it does not account for all of the variance. The more interpersonal factor of illness behavior may well explain some aspects of pain not accounted for by pathophysiological factors such as muscle tension. Parson’s notions of the sick role and Mechanic’s concept of illness behavior have stimulated the by Pilowsky and Spence. We have made use of this questionnaire development of an “illness behavior questionnaire”/in a study involving 200 pain patients. A cluster analysis of these results produced profiles very similar to those found in Adelaide and adds validity to the groupings described by pilowsky and spence. Characteristically, patients with chronic pain tend to view their problems in somatic terms and to deny other problems in their lives, or if problems are admitted, to ascribe these problems to their pain. Illness behaviour profiles were found to cut across diagnostic categories when results from patients overlapping between the clinical diagnostic study and the illness behavior study were analysed. These illness attitudes therefore seemed to provide an alternative level of description to diagnostic systems. An analysis of therapeutic outcome in patients undergoing the biofeedback trial did not support the use of illness behaviour profiles as a prediction patients discussed here. Third is the Freudian mechanism of “conversion” which may account for pain syndromes where pathophysiological changes are not necessarily evident. These three concepts provide interlinking mechanism between adverse life experiences(with unpleasant affect) and musculoskeletal pain. These are part of an intrapersonal system which is potently influenced by the interpersonal and physical environment of the individual. Illness behaviour is at the social interface between intrapersonal and interpersonal systems. Research directions are suggested which may further elucidate the workings of this proposed psychosomatic formulation of chronic musculoskeletal pain

The use of mental health legislation to determine involuntary treatment for people suffering from mental illness (civil commitment) is a controversial issue, centred on the ability of civil commitment to be coercive by limiting patients’ choice, autonomy and self-determination The intent of the New Zealand Mental Health (Compulsory Assessment and Treatment) Act 1992 was to limit coercion by emphasising informed consent (even if treatment can be administered without it); recognising the civil rights of patients subject to civil commitment; and encouraging involuntary treatment in the least restrictive environment (the community). However, there is no evaluative research that considers the extent to which patients subjected to the legislation perceive coercion. The aim of this thesis was to consider the extent to which mental health legal status equates with coercion, the factors that impact on patients’ perceptions of coercion and the factors that have the potential to ameliorate such perceptions. Empirical cross-sectional comparison studies, measuring perceived coercion using a validated psychometric measure, were undertaken at three points during the implementation of civil commitment. These involved a comparison between involuntary and voluntary patients admitted to acute inpatient psychiatric services, a comparison between involuntary patients admitted to acute psychiatric inpatient services and involuntary patients admitted to forensic psychiatric services, and a comparison between involuntary and voluntary outpatients. The studies found that legal status is only a broad index of the amount of coercion perceived by patients. Some voluntary patients feel coerced and some involuntary patients found the process non-coercive. Perceptions of coercion cannot be fully explained by socio-demographic and clinical characteristics, or by coercive incidents that occur throughout the process of civil commitment. Rather, the perceptions relate to the total experience of civil commitment, including the interactive processes with clinicians. In this regard, involving patients in proceedings that are experienced as fair and just (procedural justice) has a marked impact on reducing patients’ perceptions of coercion. In conclusion, the findings are underscored by legal requirements and ethics in order to provide clinical guidelines for implementing civil commitment.

Chronic Fatigue Syndrome (CFS) is an illness characterized by persistent debilitating fatigue of uncertain origin. Precipitating and perpetuating factors of this illness are thought to be distinct and the aim of this thesis was to gain greater insight into the role of cognitive factors which may maintain the condition. This work was guided by two central frameworks, the self-regulatory model of illness representations and the cognitive taxonomy of psychopathology. These were used to define the different cognitive constructs and to investigate the way they function as a system to maintain pathological schema and disability in CFS. Three studies using different methodologies were conducted to test the hypotheses. The first employed a descriptive comparative design to ascertain whether CFS patients have unique cognitions which contribute to their disability over time. The sample was comprised of CFS patients without depression (n=39), CFS patients with a concurrent diagnosis of depression (n=14), patients with a primary diagnosis of depression (n=20); and healthy controls (n=38). The groups were matched in aggregate for age, gender, race, and education. Subjects completed the Cognitive Errors Questionnaire-Revised, which measures cognitive distortions relevant to both general and somatic events, and the Illness Perception Questionnaire, which measures the five dimensions of the illness representation in conjunction with other standard measures. Between-group analyses confirmed that the depressed group was distinguished by a low self-esteem, feelings of guilt and self-recriminations, the propensity to make cognitive distortions across all situations, and to attribute their illness to internal, stable and global factors. In contrast, the CFS patients were characterized by low ratings of their current health status, a strong illness identity, external attributions for their illness, and distortion in thinking that were specific to somatic experiences. CFS depressed patients had lower self-esteem than non-depressed patients and had the most pessimistic illness beliefs. A six month follow-up showed that CFS patients' cognitive structures and level of disability remained remarkably stable. Illness identity, serious consequences, somatic errors, and limiting coping accounted for a substantial proportion of the variance in CFS patients’ disability scores over time. These results are discussed in terms of their support for both of the cognitive models. CFS patients appeared to have distinct cognitions which were associated with ongoing disability. The subsequent two quasi-experimental studies were conducted in a single laboratory session. The first of these used standardized neuropsychological tests to determine whether psychological variables, particularly somatic focus, interfere with CFS patients’ performance on high load attention tasks. The discrepancy between CFS patients’ subjective reports of concentration and memory difficulties and objective evidence of these deficits was also investigated. The subjects included 25 CFS patients matched for age, gender, and intelligence with two groups of healthy controls. One of these groups underwent a somatic induction procedure as part of the investigation of the effects of somatic preoccupation on attention tasks. The tests included the verbal memory subscales from the Wechsler Memory Scale-Revised and the Paced Auditory Serial Addition Task (PASAT), a measure of divided attention and speed of information processing. The analyses of the induction data failed to support the validity of this procedure resulting in the somatic control group being dropped from the analysis. Consistent with previous studies the principal deficit in the CFS group appeared to be on the PASAT. The CFS group appeared to be less accurate than healthy controls in their appraisal of their performance, which were related to negative mood rather than objective performance. Depression was also related to high performance expectations in the CFS group, but not the controls. The results did not support the original assumption that somatic preoccupation contributes to neuropsychological difficulties in CFS. However, mood factors were clearly shown to impact on both the objective and subjective experience of symptoms. The aim of the final study was to investigate the concordance between the self-report data collected in study one and information processing biases in CFS. Comparisons of the CFS patients and healthy controls on a modified Stroop attention task and a self-schema memory task, found no evidence of an illness-related bias in CFS patients’ processing of information. Rather, they demonstrated a significant tendency to be distracted by and remember depressed-relevant stimuli. The exception was their propensity to make somatic interpretations. These results are discussed in terms of the defensiveness hypothesis, which proposes that CFS patients’ negative, external illness perceptions and somatic distortions may act as a defence against underlying feelings of low self-esteem. The complex nature of CFS patients’ cognitive structures was revealed and the need to use measures which do not rely on self-reports was clearly demonstrated. These studies provided further support for the central role of cognitive factors and mood in perpetuating CFS.

This thesis uses the concepts and methods of community psychology, and. applies them to what is called here a “comprehensive community project”. This is a project that undertakes to meet the needs of a community by fostering and strengthening the community’s own resources. The objectives of the research were : (1) to establish a comprehensive community project in the Auckland. suburbs of Birkdale and Beachhaven, and (2) to propose and. test a model for project organization and evaluation. The model was derived. from the systems approach to programme evaluation which provides a reasoned and. logical approach to all aspects of programme management. The model proposed involved systematic steps from initial programme planning to outcome measurement. The steps are, specifying the "system” or particular project, forming the values from which interventions would be derived, assessing needs and. resources, setting annual goals for activities from the foregoing steps, allocating available resources to activities, implementing and. reviewing activities, measuring outcome after one year, and feedback of this information for project improvement. Application of the model to the “Birkdale Project” showed that the model was relevant to management needs, and. Information yielded by application of the model was used. in day-to-day decision making. Thus the model was instrumental in establishing the Birkdale Project, and. in producing the vigorous project that resulted. in the first year a wide range of activities involving a significant portion of the population were provided. to meet community needs, and almost all the Project’s annual goals were attained. Although the project was established largely by paid professionally trained people, at the end. of the research period. the project was managed and run by non-professional residents. It was concluded. that the systems approach is highly appropriate to the development of comprehensive community projects, and has general advantages to the wider field of community psychology as a method for practice and research.

This thesis is based on two theoretical models of chronic illness: Large, Butler, James, and Peters (1990) introduced a systems model of musculo-skeletal pain which incorporated many of the variables believed to be important in the development and maintenance of pain. Feldman’s model (1974) addressed the difficulties of adapting to chronic illness. Five studies evaluated specific aspects of these models. The epidemiology of pain in New Zealand (NZ) was derived from a psychiatric epidemiology project. Approximately 80% of NZ adults had experienced a life disrupting episode of pain which had required medical consultation. Subjects who reported episodes of pain were more likely to have psychiatric diagnoses of anxiety, depression, and phobia. They were more likely to describe their health as poor and were currently consulting their doctor more than people who did not report an experience of pain. The estimated average cost of health consulting by people attending Auckland Hospital Pain Clinic (AHPC) for the previous year was $1333(NZ). Most people had some subsidy of costs. The health consulting of the AHPC group was higher than that reported in the NZ health literature. Self image and the experience of pain were assessed in two studies. The first asked subjects at AHPC to describe the typical thoughts, feelings, and behaviours, of someone with chronic pain. Subjects described loss of self esteem, alienation from family and friends, fear of the future, frustration and anger. The descriptions focused on psychological aspects of the experience of pain. The second study of self image used repertory grid technique. Two standardised Illness Self Construct Repertory Grids (ISCRG) were evaluated. Issues in the use of standardised grids are discussed and some aspects of ISCRG application are explored. The two ISCRG indicated subjects often identified themselves as a physically ill person and felt isolated from others. People with pain and their "closest other” (CO) completed the ISCRG(A) and questionnaires on the quality of their relationship. Closest others overestimated the role of the physical illness in their partners’ life and believed that they understood them better than the individual with pain thought they did. The personality dimensions of alexithymia and hypnotisability have been hypothesised as pathways for the development of psychosomatic illness. Individuals with chronic pain were tested to establish whether they weremore alexithymic and more hypnotisable than subjects in a general population control group. This was not verified. The constructs of alexithymia and hypnotisability require critical examination. The experience of pain is common and is associated with psychological distress and high health service use. Self construct appears to be a major factor determining response to pain and to treatment programmes. Chronic pain appears to be a particular challenge for individuals who must accept alteration in their lifestyle with perhaps little understanding of what the future may hold. / Whole document restricted, but available by request, use the feedback form to request access.

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