This thesis maps out the role of and the presentation of mechanisms occurring in an interaction, in this instance in a therapy relationship. The concept of psychoanalytic defences and other related mechanisms served as the bases for identifying these in the therapy process. In other words, defences are studied as an event in a relationship. This means that the mechanisms are identified by looking at both the therapists' contributions and the patients' responses in this context. The study is based on audio taped psychotherapy sessions. Seven patients were used as subjects. All seven were undergoing brief psychotherapy. Three subjects were undergoing cognitive analytic therapy (CAT) and four subjects were undergoing brief psychoanalytic therapy. All available sessions were transcribed. The transcripts of selected sessions have been used for an in- depth analysis. The methodology for the in-depth analysis was adapted from methodology developed for decision-making analysis. The defensive mechanisms and manoeuvres used by the patients have been identified by the analysis, as well as the therapist's various inputs have been described as they occur in the process. The nature of the identified mechanisms are described as they take place. The effects of the defensive mechanisms have been discussed in terms of the patients' difficulties and in terms of the impact these mechanisms are having on the ongoing therapy relationship. Finally the findings are discussed in the light of their correspondence to the existing psychoanalytic literature.

No description available.

The serotonin (5-HT) system has been implicated in both depression and reward and punishment processing. This thesis presents data from four studies designed to better understand the role of serotonin in decision-making and mood. Following the general introduction and description of the main experimental methods, the first experimental chapter presents a study that examined the relationship between naturally-varying 5-HT1A receptor availability, measured using positron emission tomography, and decision-making in healthy volunteers. This study identified correlations between 5-HT1A receptor availability in the hippocampal complex and both impulsivity and sensitivity to the probability of an outcome during decision-making. The second experimental chapter examined decision-making in healthy volunteers 3 days following MDMA (3,4-methylenedioxymethamphetamine) administration, when serotonin transmission is thought to be reduced. A specific type of decision-making process, “pruning” (the reflexive avoidance of aversive outcomes when searching through a tree of potential decisions), was significantly attenuated 3 days following MDMA administration. However, the expected positive relationship between the attenuation in this decision-making process and low mood was not observed. The third experimental chapter attempted to extend this finding using the acute tryptophan depletion method, which removes tryptophan (the precursor to serotonin) from the diet and is thought to reduce serotonin synthesis. Performance on three decision making tasks (pruning, gambling and impulsivity) was examined in healthy volunteers following tryptophan depletion. Results revealed that treatment decreased participants’ choosing of high probability gambles. The final chapter examined pruning in unmedicated depressed patients, and found that they behaved very similarly to healthy volunteers when evaluating aversive outcomes in the context of a tree of potential decisions, despite the hypothesised disruption to the serotonin system in this disorder. These experiments provide a more complete understanding of the relationship between serotonin, decision-making and mood, and are discussed in relation to theories of depression that pose a central role for disrupted decision-making.

The aim of the study, to investigate prospectively the outcome of an admission cohort of psychiatric patients at successive intervals with special reference to the attainment of long-stay statue, was prompted by the lack of such prospective studies in the psychiatric literature. A review of the existing literature revealed that previous studies in the U.K. were largely descriptive accounts of the-long-stay patients containing no reference to the factors which determined the continued retention of these patients. On the other hand, because studies on prediction of outcome in terms of length of hospitalization were found to have been carried out largely in the United States and on male patients, the relevance of their findings to the study of the predominantly female British psychiatric hospital population could only be regarded as marginal. However, from the findings of the studies in both countries three hypotheses, relating prolonged psychiatric hospitalization to social disadvantage, severity of illnesss and early selection, were derived. To test these hypotheses a prospective follow-up study of a total one-year cohort of admissions to the Royal Edinburgh Hospital was designed. For the purpose of the study long-stay was defined as a continuous stay of 12 months in hospital. A limited amount of data was available on the whole cohort at admission. This was supplemented by data obtained by interviewing 162 patients who remained in hospital for six months. These patients were again interviewed 12 months after admission whether they were still in or out of hospital. Thus a large body of information was available on patients retained for six months. This included sociodemographic data, details of previous psychiatric history, clinical and behavioural ratings, diagnosis and data on the patients' functioning and prospects as rated by their doctors. These data were used to study the characteristics of patients retained for six months. Successive comparisons of the characteristics of patients who were discharged with those who were retained were carried out to identify the factors associated, firstly, with retention for six months and, secondly, with further retention for 12 months. Patients retained for six months were found to be largely female, elderly, single or widowed and out of work. They received a good deal of support from their relatives. Clinically, they were characterised by the absence of florid symptomatology and the presence of a marked degree of motor retardation and social withdrawal. The factors which determined retention for six months included, for the under 65 age group, being single, living with a first degree relative, being unemployed or retired, having had a long recent admission and being admitted on a compulsory order; and, for the over 65 age group, being over 75 years, having had no previous psychiatric admission and being admitted to a psychogeriatric or rehabilitation ward. A diagnosis of senile or presenile dementia determined continued retention for both age groups. Retention for 12 months, on the other hand, was determined largely by a diagnosis of dementia. For the remaining patients, being elderly, retired or unemployed, not obtaining weekend passes, having no contact with the social worker, being rated as unemployable, difficult to accommodate in the community and requiring permanent institutional care were among the six months' factors determining further retention. Consultants correctly predicted the outcome of the large majority of their patients. The social disadvantage hypothesis received qualified support; of the four parameters, only disadvantage in terms of age and employment was found to be directly related to retention in hospital; the relationship of marital status and living group to outcome proved to be a complex one. The severity of illness hypothesis was supported when diagnosis was used as an index of severity, but not, when symptom severity was used as an indicator. The early selection hypothesis was supported in the sense that the majority of the six months patients proceeded to become long-stay. However, stating a definite wish to remain in hospital did not determine the attainment of long-stay status. The significance of the findings and their implications for the management of those patients and for further research are discussed.

No description available.

No description available.

This thesis describes the methodology and findings of an investigation of the role of araitriptyline ("Elavil" "Tryptiaol* "Tryptanol") in the treatment of female patients hospitalised with depressive states. At the conclusion of the investigation the rate of response that had been obtained was so high that a general review of the treatment of depressive states was undertaken for purposes of comparison. This review forms an introduction to the study.

Alcoholism is a major social and medical problem in Scotland and convictions for drunkenness offences increase each year; there is evidence that most drunken offenders are alcoholics. A minority of vagrant alcoholics are known to medical sources and penal management of drunken offenders has resulted in the offender repeatedly passing through courts and prison, receiving little if no help with his alcoholism. Legislation in England and Wales has been enacted, but not implemented, to remove the penalty of imprisonment for drunk and disorderly behaviour, and a Home Office Working Party has recommended the establishment of detoxification centres to deal with public drunkenness. The aims of the project on which this thesis is based were to assess the feasibility and effect of adding a detoxification service to a Regional Poisoning Treatment Centre and to a psychiatric hospital, and to evaluate the effectiveness of this detoxification, assessment and referral service for socially deteriorated alcoholics. The cohort consisted of 100 Edinburgh males who were alcoholics, were receiving no current treatment for alcoholism and who had a history of convictions for drunkenness offences. The cohort were randomly allocated to proband and control groups, the latter receiving no treatment. The probands were able to use the detoxification facility when intoxicated or having alcohol withdrawal symptoms, and police agreed to waive their right to prosecute a proband if found drunk and incapable, instead to take him to the detoxification centre. This experimental period lasted one year. The characteristics of the subjects are described and compared with the findings in other studies, the individuals being found to have a high degree of medical, psychological and social pathology. The detoxification programme is described - the management of withdrawal symptoms, medical investigations and methods of assessment and referral. Difficulties were encountered when the project was located in the Regional Poisoning Treatment Centre and these are described and discussed together with a review of the literature on attitudes of doctors and nurses towards alcoholics. Relatively few problems were encountered after transfer to the psychiatric hospital. Data is presented on admissions for detoxification, and medical morbidity over and above detoxification and withdrawal was recorded in about 50% of the admissions. Eleven of the cohort died in a 2-year period, twice the rate for the general population. Evaluation of the results showed that during the experimental year the change from the penal to the medical system was effective with a greatly diminished penal record among the proband group, while the controls continued to be prosecuted and imprisoned at the same rate as in the pre-experimental year. The assessment and referral service was likewise effective, the number of admissions to, and time spent by, the proband group in psychiatric hospitals and rehabilitative hostels being greatly increased with respect to both their own pre-experimental year and when compared with the controls. Eighty-five per cent of the cohort were followed up one year after enrolment and a questionnaire assessment showed the probands to have improved with respect to health, accommodation, drinking habits and their subjective impression of the quality of their lives. An additional survey of random drunken offenders showed that two-thirds had had three or more previous convictions for drunkenness, half had been in prison on that account and probably two-thirds were alcoholics. Three-quarters would have preferred a detoxification centre to a police cell when arrested for drunkenness. It is concluded that it is feasible to manage drunken offenders in a medical and rehabilitative system rather than by the penal system. The effects of adding a detoxification service to a Regional Poisoning Treatment Centre and to a psychiatric hospital led to the conclusion that the former, in our experience, is not a suitable location, and that staff trained in psychiatric methods are necessary. It is recommended that detoxification centres should be based in hospitals, with a close social work liaison. It is further concluded that the detoxification and assessment facility was effective for the individuals, though long-term benefit can only be assessed when better rehabilitative facilities are available than was the case in this project. Some implications for the management of future detoxification centres are discussed. A superficial costing exercise indicated that a change from penal to medical management of drunkenness need not be more expensive, and can probably be carried out in Scotland under existing legislation.

No description available.

No description available.