Biomarkers of the Innate and Adaptive Immune System Responsible for the Pathogenesis of Multiple Sclerosis - A Narrative Review - Juniper Publishers

Neurology & Neurosurgery - Juniper Publishers  

Abstract

Introduction: Multiple Sclerosis (MS) is a complex neurodegenerative disease whose pathophysiology involves demyelinating changes, axon injury, oligodendrocytic death, neuron apoptosis, and inflammation and demyelination of both white and gray brain matter.

Discussion: The role of T cells/B cells has been fairly well documented in MS patients. Analysis of inflammatory infiltrates reveals that CD8+ T cells are found in active lesions while B cells are mainly concentrated in the meninges. Secretory B cell products play an important role in the apoptosis of neurons and the death of oligodendrocytes in MS patients. However, MS cannot be characterized by immune responses; there are genomic components as shown by gene knockout studies. Although there is no cure for MS, it has recently been discovered that increased doses of melatonin may have therapeutic effects.

Conclusion: While the research of MS is ongoing, it is clear that the role of innate and adaptive immunity should not only be the central factor in further understanding the progression of the disease but also the focus of future therapeutic targets. In this review, we focus primarily on immune responses characterized by lesion analysis and inflammatory response in MS patients.

Keywords: Multiple sclerosis; Innate immunity; Adaptive immunity; Biomarker; T cell; B cell; Interleukin

Abbrevations: MS: Multiple Sclerosis; CNS: Central Nervous System; GWAS: Genome-Wide Association Studies

Introduction

Multiple Sclerosis (MS) involves an immune-mediated process in which an abnormal response of the immune system is directed against the body’s Central Nervous System (CNS). Demyelination and inflammation are the primary factors of MS, affecting the formation of plaque in the CNS. This results in MS’s clinical manifestations, which are vision impairment, fatigue, weakness, depression, numbness, bowel changes, loss of muscle coordination and bladder dysfunction. Depending on the affected areas of the CNS, most MS patients will experience phases of deteriorations, flare-ups or exacerbations before the emergence of a new symptom [1,2]. The cause or etiology of MS is not fully understood. However, there is a likely correlation between various factors, influenced by genetic and environmental dynamics. Despite this, research confirms that MS is an autoimmune disease. These studies are corroborated by Genome-Wide Association Studies (GWAS), which identify over 100 MS risk loci, numerous of which intersect in many gene activations of other autoimmune diseases [3,4]. Diseases that cause dysregulation in the immune system are at the highest risk of causing contraction of MS. The progression of MS is found to be correlated with various biomarkers including immune cells and members of the IL1 cytokine family [5]. In this review we attempt to identify the role of innate and adaptive immunity and provide a comprehensive role of biomarkers in the pathogenesis of MS. In addition, we hope to highlight possible strategies/therapeutic targets in order to slow the progression of the disease and improve the quality of life of MS patients.

Discussion

The role of innate immunity in multiple sclerosis

Multiple sclerosis is generally accepted as an autoimmune disease that causes neurodegeneration in the brain; however, some recent studies have suggested that neurodegeneration in progressive MS may be independent of inflammation. In a study exploring the validity of these claims, researchers investigated the correlation between neurodegeneration, inflammation, and disease development in MS stages. They studied 67 MS autopsies from various phases of the disease, comparing it to 28 controls free of neurological disease and brain lesions. Analysis of inflammatory infiltrates in relation to lesion activity revealed that T cells are actually the source of the most prominent inflammation in the active lesions. Moreover, T-cell infiltration in the meninges was highly noticeable in comparison to the cortical parenchyma, which had little to no T cell infiltrates. It is also interesting to note that CD8 and CD4 positive T cell infiltration supported previous studies, which found that CD8 positive T cells infiltrate the most in MS lesions. Similarly, B-cells and HLA-Dpositive microglia cells and macrophages revealed a comparable pattern of inflammation; B-cells were mainly seen in meninges, with only a few isolated in the parenchyma in concentrations ten times lower than T cells. The most intense inflammation was found in patients with relapsing/acute disease, followed by patients in which the disease was progressing. T- and B-cell occurrence was similar in those patients, but plasma cell ratio was different-they were seen more prominently in patients suffering from a progressive form of the disease [6].

Link between the adaptive and innate immunity

Factors that trigger inflammation are crucial for the pathogenesis of MS. Given this, single nucleotide polymorphisms play an important role as they can amplify the expression of inflammatory cytokines and mediators. Multiple studies have indicated that MS patients have high pro-inflammatory and inflammatory cytokine serum levels. One of the most potent and crucial components of innate immunity is the IL-1 family [7]. Vigne and colleagues found that IL-36α, IL-36β, and IL-36γ, members of the IL-1 family are crucial in the production of proinflammatory cytokines as most CD4 T lymphocytes and murine bone marrow-derived dendritic cells constantly expressed IL- 36R. This was substantiated by high levels of IL-6, IL-12, IL-1β, IL-23 and TNF-α seen in bone marrow-derived dendritic cells. These pro-inflammatory cytokines were affected by IL-36 more than any other IL-1 cytokine. IL-36 was also found to stimulate the production of IFN-γ, IL-17 and IL-4 by CD4 T cells. This clearly demonstrates the key role that IL-36R ligands play, not only in the relationship between innate and adaptive immunity, but also in the stimulation of T-helper responses [8].

Importance of serum level of interleukin 36 in relapsing-remitting MS

In a study recruiting 49 relapsing remitting MS patients and 41 healthy individuals, researchers evaluated the implications of Interleukin (IL)-36 in the pathogenesis of MS. The results of their study indicated that there is a significantly higher concentration of IL-36 serum levels in patients with MS [9]. In a separate study examining the expression of IL-36 colonic epithelial cells in patients suffering from inflammatory bowel syndrome, it was revealed that ulcerative colitis patients had higher expression of IL-36α and IL-36γ in comparison with IL-36β. Monocytes plasma cells and T cells were the main sources of this increased expression of IL-36α and IL-36γ. IL- 36α is found to be largely responsible for the formation of acute phase proteins and expression of CXC chemokine, along with the stimulation of MyD88 adaptor proteins TRAK1, IRAK1 and TRAF6 [in conjunction with IL-36γ. This stimulation of adaptor proteins triggers activation of AP-1, NF-κB and phosphorylation of MAPKs. Furthermore, it was found that siRNAs and MAPK inhibitors for c-Jun, AP-1 and NF-κB considerably downregulated IL-36-induced expression of the XCX chemokine [10].

Melatonin effects in peripheral t-helper lymphocytes in RR-MS

Melatonin is known to be a modifier of T helper (Th) 1, Th17 and Treg, the presence of which, along with increased Th22 cells in peripheral blood, are associated with MS progression. In fact, the gene encoding the Th22 receptor il22ra2 actually makes patients more susceptible to MS disease [11]. In a 2017 study, researchers investigated the effects of in vitro administration of melatonin on T-helper (Th) 1, Th9, Th17, T22, and Treg responses. Results of the study showed that melatonin effectively decreased: CNS infiltration of T cells expression of adhesion molecules and the following chemokines: IL2, IL12, IFN-gamma, and TNF. In-vitro melatonin in phytohemagglutinin-stimulated peripheral blood mononuclear cells showed a reduced Th1 response. In addition to Th1, Th9 and Th22 responses were also found to be reduced by melatonin treatment [12]. The study further suggested that blocking IL9, IFN gamma, TNF, and IL17A could be potential forms of treatment since all these cytokines increase T-cell infiltration of the CNS, causing oligodendrocytic and neuronal death [12]. Thus, melatonin may be able to improve the quality of life of MS patients through regulation of Th cells and chemokines.

Naïve, memory, and effector T cells in progressive MS

In order to better understand T-cell activation, researchers studied CD26-dipeptidyl peptidase IV and CD49d. CD26 is associated with T helper (Th) 17 cells and the activation of T cells while CD49d is seen when T cells enter the central nervous system. In one study to help determine the role of CD49 in the progression of MS, researchers used Natalizumab, a monoclonal antibody that attaches to the CD49d receptor. At the end of the 15-month treatment period with natalizumab, there was a statistically significant reduction of inflammatory mediators along with less damage to tissues CD28+ and CD4+ terminally differentiated effector memory T cells were increased in primary progressive MS patients [13].

Researchers analyzed the difference in percentages and absolute numbers of T cells before and after natalizumab treatment, along with their expression of CD26 and CD49d. They found that the absolute number of circulating CD4+ and CD8+ CD28+ EM and TEMRA T cells increased post-treatment, which is consistent with the idea that natalizumab prevents these T cell subsets from entering the CNS. Additionally, treatment of natalizumab decreased the percentage of cells expressing CD26 in all cell subsets of CD4+ and CD8+ T cells besides CD26+ CD28- TEMRA T cells, which already show the lowest expression of CD26 in untreated patients and controls. Lastly, they found a decrease in the frequency of T cells expressing CD49d in all cell subsets of CD4+ and CD8+ [13]. These findings encourage future studies to look into additional benefits that natalizumab may provide MS patients.

B lymphocytes role in MS

Lisak et al. [14] investigated the role of secretary B cells on the apoptosis of neurons and oligodendrocytes. Secretory products of B cells were taken from both patients with RRMS and control patients and then were treated onto oligodendrocytes. Investigators found that in the secretory product secreted from 13 MS patients, 58% oligodendrocytes died from exposure compared to only 4% in oligodendrocytes treated with secretary product in control patients. Human neurons, when treated with secretory products from RRMS patients, showed a similar trend with over half experiencing neuronal death compared to only ten percent of neurons when treated with control samples. As a result, it is evident that although the mechanism of B cell interaction is not fully understood, it plays a major role in cell death especially in RRMS patients and needs to be further investigated [14].

Hydroxylase effects on immunity

25-hydroxycholesterol (25-OHC) not only initiates a signaling cascade that suppresses the production of IgA but also has antiviral properties. While 25 OHC needs to be further investigated, 24S-Hydroxycholesterol 24S-OH-chol has been fairly well documented. Leoni and colleagues had shown that 24S-OH-chol is synthesized in the brain and its distribution through plasma may serve as a biomarker for the progression of MS. In a study conducted on 118 patients who suffered from MS it was demonstrated that older patients, presumably those who had suffered from MS for a longer duration, had reduced 24S-OH-chol plasma levels compared to age matched controls. As a result, the progression of MS may be correlated with a loss of neuronal cells that synthesize oxysterols [15].

The role of oxysterols

Chalmin and colleagues investigated both how oxysterols modulate/contribute to T lymphocyte morphology and play a role in MS autoimmunity through the use of MS Ch25h -/- mice models. Ch25h is a gene that is highly involved in both cholesterol and lipid metabolism. They reported that 16 days post immunization, only 15 % of Ch25h-/- mice developed MS and 43 % had remained symptom free. The Ch25h knockout had no influence on immune system activation in the periphery as CD 4+ T cells and wild type T cells with immunization of myelin oligodendrocyte glycoproteins revealed the same number of leukocytes, IFN-g, IL-17A and IgG proliferation. Moreover, the study demonstrated that Ch25h may actually intensify inflammatory signals and impair trafficking of CD 44+ and CD4 + T cells [16]. While here we have highlighted the importance of the CH25H gene, there are over 100 genetic markers that may increase the likelihood of MS in a given population.

Conclusion

investigating the role of T cells/B cells and cytokines. These essentially have served as biomarkers for the progression of MS and much of the clinical focus has been on finding ways to regulate them. Currently two of the most effective treatments available to clinicians are increased use of melatonin and administration of the monoclonal antibody Natalizumab, both of which work to regulate inflammation and cytokine activity. Current clinical trials have also noted the importance of immune system regulation in slowing down the progress of MS and as a result the majority of phase 3 clinical trials running today have a focus on immune regulation. While over 100 genetic markers have been discovered for MS, gene therapy has yet to become a viable form of treatment, but perhaps may be an alternative in the future. 

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Are we Aware of Preoperative Anxiety? - Juniper Publishers

Anesthesia & Intensive Care Medicine - Juniper Publishers

Introduction

The preoperative anxiety is a temporary emotional state caused by anxiety, nervousness, fear and high autonomic nerve system activation arising from these feelings that the patients have prior to the operation [1]. It is known that endocrine systems also play a role in preoperative anxiety symptoms [2]. Preoperative anxiety, a common phenomenon in preoperative patient evaluation, is a process that starts from the date of planning a given operation and progressively intensifies up to the moment of the operation itself. The incidence of preoperative anxiety has been reported to range from 11% to 80% among adult patients [3]. In children, preoperative anxiety has been shown to be a risk factor for postoperative state-anxiety [4].

Preoperative Anxiety Overview

There are many risk factors for preoperative anxiety in patients undergoing elective surgery. History of cancer, psychiatric disorders, future self-perception, depressive symptoms, traitanxiety, pain level, history of smoking, extent of surgery to be performed, female gender, years of formal education and physical status constituted independent risk factors for high preoperative state anxiety [5]. Every patient is known different levels of anxiety due to various aspects such as the previous experiences, personality characteristics, anesthetics and surgery types to be applied and the pain expectation after the surgery [6]. In addition to the negative effects of preoperative anxiety on vital findings, it was also reported that it extends the recovery period and the staying time in hospital and that it has negative effects on postoperative pain and on nausea and vomiting [5,7].

Anxiety can produce aggressive reactions that result in an increase in the distress experienced by the patient, and make the management and control of postoperative pain more difficult [8,9]. In addition, anxiety may determine more frequent demands for analgesics in patient-controlled analgesia [10], as well as increased intraoperative anesthetic requirements [3]. It may also produce a lower level of satisfaction with the treatment. Therefore, individuals in charge of preoperative management would probably be more effective in handling a patient’s preoperative anxiety if they had more knowledge about potential predictors of preoperative anxiety. Anxiety may interfere substantially with a patient’s comfort, quality of life, ability to make appropriate treatment decisions, and treatment compliance, thus affecting survival.

Conclusion

It is highly important in surgical practice to observe patients carefully and appropriate preoperative anxiety management to avoid the bothersome intraoperative and postoperative results of preoperative anxiety. The measurements of preoperative anxiety should be made as routine procedures. The anxiety levels that will be determined in these routine procedures could facilitate the determination of the premedication doses to be given and prevent to postoperative complications.

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Legionellosis- A Mini Review - Juniper publishers

Journal of Case Studies - Juniper Publishers

Mini Review

Legionellosis is the term used to describe clinical manifestations of infection caused by the Legionella bacteria. It includes Legionnaires disease (LD), focal non-pulmonary infections and Pontiac fever. LD is a type of bacterial pneumonia, while Pontiac fever is a several days long non-pneumonic, febrile, influenza like illness associated with exposure to Legionella spp. That resolves spontaneously. Legionnaires disease was first described during an outbreak at a convention of the American legion in Philadelphia in 1976 [1]. Twenty-nine of 182 cases were fatal. Extensive epidemiologic work led to identification of the bacterium.

The legionella spp. is small gram-negative rods with fastidious growth requirements. More than 58 different Legionella spp. have been described, about half of which have been reported to infect humans [2]. Legionella pneumophila (Lp) is the most commonly encountered species. Lp contains at least 16 different serogroups. Lp serogroup 1 is the most common clinical isolate. The most common non Lp species isolated from humans are L.longbeachae, L.micdadei, L.bozemanae, and L.dumoffii [3]. These constitute less than 5% of culture -proven cases in North America. This bacteria needs special growth medium which contains Iron, L-cysteine, α-ketoglutarate, and charcoal-containing yeast extract agar buffered with an organic buffer (BCYEα agar).

Legionella bacteria are found in natural aqueous environment, in lakes, streams and costal oceans. Warm water (25°C-40°C) supports its growth [4]. Free living amoebas in the same waters support the intracellular growth and survival of Legionella. Almost all cases of LD results from this bacteria growing in water heaters, warm water baths, warm water plumbing systems and air conditioning and other types of cooling towers. Rain puddles in tropical regions, tsunami related water exposure, and windshield viper fluid are few other reported sources of infection. One exception to water as risk factor is that Llb, which is mainly transmitted through soil contact, especially from potting soil. LD is initiated by inhalation of aerosolized Legionella bacteria. After bacteria enter lung they are phagocytosed by alveolar macrophages. Bacteria prevents fusion of phagosome to lysosomes or endosomes, thus avoiding acidification and degradative enzymes. After sufficient intracellular replication, the bacteria kill the macrophage and then rephagocytosed by other macrophage. This process recruits other inflammatory cells leading to pneumonia [5].

Pathogenesis of Pontiac fever is not known with certainty. It is believed that PF is caused by inhalation of disease causing environmental aerosol derived from water containing microorganisms including Legionella bacteria. The incubation period of LD is between 2-10 days and for PF 4 hours- 3 days [1]. Person-to-person transmission of either LD or Pontiac fever does not occur. Legionella spp. is ubiquitous in environment. However, disease is not that common. Legionella is causative organism of only 0.5-10% hospitalized cases of community acquired pneumonia, an average value is probably 2% even in the geographic regions with excellent diagnostic capabilities [6]. Male gender, cigarette smoking, chronic heart or lung disease, diabetes, end stage renal failure, organ transplantation, immunosuppression, some forms of cancer and old age are well known host risk factors. Also important are environmental and bacterial factors such as relative bacterial virulence, bacterial aerosol stability, organism growth conditions and factors that facilitate the spread of bacterium from contaminated water to host, such as wind direction, relative humidity and aerosol formation.

LD is one of cause of bacterial pneumonia. Sometimes it is characterized by fever with pulse-temperature dissociation, myalgia, few pulmonary symptoms, nonproductive cough, diarrhea, confusion, hyponatremia, hypophosphatemia, and elevated liver enzymes. This symptom complex, however, is neither specific nor frequent enough to allow differentiation of LD from other common causes of community acquired pneumonia [7]. LD starts with prodrome of headache, muscle aches, and anorexia. Fever accompanies these symptoms. Cough may develop hours to days after onset of prodrome. Careful examination always demonstrates findings of pneumonia including focal rales and patchy infiltrate to dense focal consolidation on Chest X ray.

Diagnosis of LD requires high degree of suspicion and keen consideration of epidemiology. Various laboratory tests can be sued including sputum culture, urine antigen testing, immunofluorescent microscopy, paired serum antibody and molecular amplification techniques. Culture requires special media; hence laboratory needs to be informed about this. Yield of sputum culture varies between 20%-95%. Many clinical laboratories have neither expertise nor ability to properly perform these specialized cultures. Urine antigen testing has revolutionized the diagnosis. It is easy to perform and has fast turnaround time. The average sensitivity of this test is in the range of 70% to 80% [8]. Big caveat in using urine antigen is that it detects Lp serogroup 1 and poorly sensitive for other Lp serogroups. Hence negative test should be taken with grain of salt. Urine antigen test can be positive for months after the initial infection.

Legionella bacteria are intracellular, this means antimicrobials which are concentrated intracellularly are going to be more efficacious. The macrolides, quinolones, and tetracyclines all meet these criteria. Prospective, adequately sized clinical trials of antimicrobial therapy for LD have not been performed. In absence of these, decisions about antimicrobials must be made on the basis of experimental animal and cell culture studies [9]. For mild pneumonia in immunocompetent host first choice antibiotics include: Azithromycin 500mg daily for 3-5 days, Levofloxacin 500mg daily for 7-10 days, ciprofloxacin 500 twice a day for 7-10 days, moxifloxacin 400mg daily for 7-10 days or clarithromycin 500mg twice a day for 10- 14 days. Second choice for these patients will be Doxycycline 200mg loading dose followed by 100mg twice a day for 10-14 days or Erythromycin 500mg four times a day for 10-14 days [9,10].

In severe cases or immunocompromised host treatment of LD includes using Azithromycin 500mg daily for 5-7 days or levofloxacin 500mg daily for 7-10 days or 750mg daily for 5-7 days. Second lie drugs for these severe cases include Ciprofloxacin 750mg twice daily for 14 days or moxifloxacin 400mg daily for 14 days or Erythromycin 750-1000mg IV four times a day for 3-7 days followed by 500mg four times a day for total of 21 days or Clarithromycin 500mg IV twice a day for 3-7 days followed by 500mg twice a day for total of 21 days. Failure to respond to specific therapy for LD should bring into question the validity of the diagnosis, the possibility of coinfection or superinfection. No human vaccine exists for LD, and prior infection does not prevent reinfection [11]. Antibiotic prophylaxis prevents LD and should be considered during nosocomial epidemics and for high-risk population before control of an epidemic. Engineering modifications and maintenance of water supply systems is important to prevent contamination of water with Legionella. Disinfection of water distribution systems and surveillance for Legionella contamination should be a routine practice to prevent disease transmission from contaminated water. 

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Psychotherapy in the Service of the Lonely - Juniper Publishers

Nursing & Health Care - Juniper Publishers

Abstract

Both loneliness and psychotherapy have been well researched and described. The present paper examines the interaction between them; the salient features of psychotherapy, the needs of the lonely, and the use of the therapeutic process in helping the lonely survive and emerge from their ordeal, emotionally strengthened and spiritually enriched.

Keywords: Level of Internet Use; Students; Selected College

Introduction

The Therapeutic Relations in Psychotherapy

In his book The Road Less Travelled, Peck [1] suggested that "Entering psychotherapy is an act of the greatest courage" (p. 53). Psychotherapy, at least in the Western culture, is associated with emotional pain and "disturbed" patients (or clients) of psychologists and psychiatrists. Normally, psychotherapy does involve a trained and, hopefully, skilled therapist who attempts to help the clients alleviate their problems. However, the therapist also seeks to contribute to his client s further growth and development through the interaction and relationship that develops between them. The therapeutic relationship is so central to the therapist s practice, that its overall form and structure is often accepted without seriously considering the idea that "the relationship may have a structure beyond its temporal, physical and financial boundaries" Schamess [2]. It unfolds according to its own dynamics and the roles of its participants, and over time, the bond that develops between client and therapist becomes intimate and close, as well as therapeutically beneficial.

Whereas in non-therapeutic relationships both participants are open about themselves and vulnerable (a mutuality which serves to strengthen their bond), according to Schamess [2] only the client is expected to do the "risky revealing” in psychotherapy That being said, it does not have to diminish form the intimacy between the two participants. The therapist can greatly contribute to that intimacy by being truly interested in and caring about the client, and by being genuine, showing warmth and fully accepting the client. Psychotherapy, not unlike non-therapeutic intimate relationships is bi-directional, though the participants' roles and behaviours differ. In non-therapeutic relationships, we can find relationships where participants promote dependence in their partners, or engage in a leader-follower pattern of interaction, while in other relations partners may encourage their loved one to grow and develop. In psychotherapy, the therapist is expected to structure the relationship in such a way that it aims, first and foremost, to help the client alleviate his problems. We should point out that during psychotherapy some of the therapist s needs are met as well, despite it being focused on the client. This may include increased esteem, learning about human nature and behaviour, being seen helpful, and being financially remunerated Rokach [3] While it is assumed that the therapist is a reasonably secure person and that his life is not bleak or desolate, the client on the other hand may be [and frequently is] a lonely and alienated individual. When they interact, the therapist attentively listens to the client, sympathizes with him, and endeavours to understand how he feels; therapists are supposed to always remain even keeled and does not turn his back on the client because he cannot stand the outpouring. In other words, the therapist may be construed as an almost ideal confidante by the client. Small wonder then that often times the emotional feelings involved in therapy rise to a crescendo where either or both parties may be frustrated by the fact that the hour has to end and that both parties must go on to their private lives, perhaps not to see each other for an entire week Klopfer [4].

Intimacy, while welcomed in therapy, may become an issue if the therapist and client are of the opposite sex Rokach [3]. It is not unusual--or unexpected--to find a female client who glamorizes her male therapist (or vice versa) and fantasizes about him becoming her lover. She may then offer herself to him sexually, directly and bluntly or covertly, in an attempt to deepen their intimacy and through it receive increased attention, acceptance, approval, and closeness to him (see also Holroyd, Lerman, Forer & Greenberg, 1983). The traditional psychoanalytic model refers to it as transference, while a therapist who has similar feelings toward his client is said to be experiencing counter-transference. I believe that it may be a mistake to attribute all of the client's sexual daydreams and emotional responses to his or her neurotic distortion of the therapist-client relationship see also Klopfer [4]; Rogers [5]; Szasz [6]. It is suggested that what the client feels and thinks about the therapist is not as unreal as the psychodynamic approach maintains. Though some of the client's feelings toward the therapist may be of a transference nature, it is quite reasonable to conclude that the feelings the client has for the therapist are genuinely directed at the human being behind the helper's title. Lonely clients feel their loneliness to be painful and yearn to escape from behind the walls they feel surrounded by Peck [1]. And, as many have discovered, "the experience of falling in love allows us this escape--temporarily- from the place in we may feel confined to. The essence of the phenomenon of falling in love is a sudden collapse of a section of an individual's ego boundaries, permitting one to merge his or her identity with that of another person" Peck [1] p. 87. It is, indeed, possible for therapist and client to genuinely fall in love with each other as a result of true feelings of love, as a consequence of transference, or possibly as a combination of the two" Klopfer [4] p. 39.

The Therapist

Commenting on the essence of psychotherapy, and referring to the role the therapist plays in the change and growth of the client, Peck [1] noted that it is impossible to truly understand another without letting that person within yourself. In my experience as a clinical psychologist, that process affects not only my clients, but me as well. As a therapist, I am have the very privilege of being allowed into other people’s worlds. I am invited to become closer to them than they would, perhaps, allow even their most intimate friends. Consequently, I witness their pain and assist them in addressing it. The client, naturally, needs to be committed to therapy, for it to succeed. For the duration of therapy the therapist is required to make the same kind of commitment to the client. This commitment entails understanding and supporting whatever stage the client is at, and he must be willing to grow and learn from the client. Psychotherapy requires courage of the therapist; courage to risk change, make interpretations, suggestions and observations; courage to extend oneself, and courage to be, at times, different and unconventional. Most importantly, the therapist must strive to nurture the therapeutic relationship by making room for the client within himself. And that very commitment is, in my experience, one of the most rigorous, demanding and all-consuming requirements a therapist has to fulfill Rokach [3]. Although I do not care for all my clients in an identical manner, I have never yet treated anyone who I did not care about or for. At times, I am blessed to work with those I consider unique; people whose characteristics I highly value, and whom I would certainly choose to befriend had we met "on the street". However, psychotherapy is a unique alliance which is confined to a specific time and place, and which is governed by strict ground rules. Its very existence depends on, and focuses upon the client.

The therapeutic relationship is established and carried out in order to help the client and not to fulfil the therapist's needs. Consequently, although I may yearn to remain a close friend with a client, to see that person grow and develop, and thus continue to enjoy the enriching relationship which I had with him or her, I cannot do so. It has been rare that I have kept in contact after therapy was terminated, and if I do so, it was on a casual basis, rather than as a close friend. I read once that every love relationship involves therapy, and every psychotherapy includes love. Peck [1] observed that "The essential ingredient of successful, deep, and meaningful psychotherapy is love" (p. 173). Love, as we understand it, calls for a continuous and close alliance. However, being a therapist means being ready to suffer, sacrifice, and give of oneself, not only while sharing the client’s pain and sorrow during therapy, but also by not submitting to the heart's desire to continue and enjoy the company of a person I became close to in my office.

Much has been written about therapist burnout i.e. Figley [7]; Bagel [8]; Bride [9]; Rothschild [10]; Steele et al. [11]. However, very little, if anything, has been written about psychotherapy as a lonely journey for the therapist. I find it difficult, and at times painful, to say goodbye to a client which, most probably, I will never see again. No other relationship is so teasingly painful. In therapy, two people interact so closely, growing and learning from one another, only to depart when the relationship is ripe for a more balanced and enriching experience. Over the 40 years that I have worked with clients, I have had two "wishes" concerning my clients. One was to let them know that I would like to remain their friend following completion of therapy. In so doing, however, I would selfishly declare that I am now focusing attention on my needs after catering mainly to theirs. In other words, I would be saying, I would like to be your friend and remain so not necessarily because it is therapeutic and beneficial for you, but because I like and value you, and because this is something that I want and need. As I mentioned earlier, I have yet to follow through. My other ‘wish’ is quite different, and has to do with wishing that I could offer psychotherapy in a detached, mechanical way so as to prevent closeness and mutual fondness from forming. This being so far removed from the essence and spirit of psychotherapy, and from the manner in which I practice it, that I could not possibly realize that wish either, nor would I want to. That means that the profession in which I have chosen to specialize can be a painfully lonely one.

Helping the Lonely

Since loneliness is not a unidimensional phenomenon, treatment is frequently multifaceted as well. For example, loneliness that follows the death of a loved one often requires resolution of the grief process as a prerequisite to the alleviation of loneliness and formulation of new social relationships Lopata et al. [12]; Rokach [13]. On the other hand, loneliness which follows a divorce may necessitate treatment that is initially directed at feelings of interpersonal inadequacy and insecurity and only then can the loneliness be addressed Weiss [14]. "Many of the problems and much of the pain I felt came from trying to resist my loneliness. The moment we begin to build a wall against it, we have already lost... before we can look at our loneliness, we must stop trying to resist it. We must stop blaming husbands or wives, children or bosses for our feelings of loneliness and [the] alienation in our lives. Schultz [15] p. 169. This quote describes precisely what many lonely clients do; they run away, hide or deny their loneliness, ashamed to admit that they are in pain, or frightened of the stigma which is attached to loneliness Moustakas [16]; Rokach [17,18]. However, if they do finally talk about their loneliness, they often go on a rampage, blaming everyone around them for it. My purpose is to, initially, empower the client to recognize and admit that he is lonely, his loneliness, and take full responsibility for it. Once that has been done through nurturing within the therapeutic relationship, the client is on her way to lessening the pain.

Having been, once, asked how do I help the lonely, I replied that I see myself as a father or a friend who is attempting to teach a child to swim while the child is terrified to even approach the water. That analogy, for me, encapsulated the trust the child must first have in order to place his hand in his father's. The courage the child needs to approach the water, and the effort they will both need to invest in order to teach the child the series of co-ordinated movements that will allow him to float and move in whatever direction he chooses, and eventually, be able to swim. Friedman [19] observed that while paying attention to the community one lives in, is part and parcel of what sociologists and social workers, psychologists are commonly trained in the language of individual self-interest, and thus focusing on the client's community ties and belonging may pose a challenge. Examining the client s ties to the community and helping to cultivate a strong sense of belonging are important, but often overlooked therapeutic goals when that therapy is offered by psychologists. To begin with, it should be mentioned, reminded us Friedman that the therapeutic alliance can serve as a way of belonging which can be nurtured and developed. Especially for people who experience difficulty in connecting with others, and who are lonely, the experience of belonging that takes root in therapy, may be a significant achievement for them and be further extended to their lives outside of therapy. Thus, a close, intimate therapeutic alliance is the cornerstone of a fruitful therapy, and a way to help the client feel belonging and a connection to a caring individual. Doherty [20] maintained that therapists can educate clients about the need for a community by providing an accepting and supportive connection in the therapy room. He, eloquently declared that "there is no fundamental contradiction between pursuing personal needs and promoting the welfare of the community. When we promote clients' positive involvement in the community, we promote their own well-being as well” (p. 100). Friedman argued, with a lot of conviction that what is needed is a sort of a holistic approach which together with helping the client explore his inner self also be aware of the outer realm.

Therapy is seldom neutral, and moreover it reflects and reproduces cultural norms. Cushman [21], thus, argued that by valorising the isolated individual, we may actually strengthen the problems that the client is struggling with. Since the therapy we offer, and our interactions with the client reflect our values, beliefs, and background - it is imperative that psychotherapists become aware and adopt the view that belonging to and building a community is a fundamental ingredient of well-being Blow and Timm [22]. Attending psychotherapy has not been condoned in the North American society for a long while. At the dawn of the 20th century it changed and many more are attending therapy and hiding it less. And still, therapy is offered in confidentiality to the individual, the couple or the nuclear family, but the rest of the community is not represented except by the dialogue between client and therapist. Morgan [23] indicated that this point is addressed by Narrative therapists who encourage their clients "to re author their lives” (p. 2) in order to create newer and more appropriate 'stories’ which may include or even focus on one's community and connections. At times, family members, friends or even work colleagues may be invited into the therapy sessions to celebrate the client's accomplishments and or to simply bear witness to the creation of new stories Freeman and Combs [24].

While the therapeutic relationship has been established, strengthened, and is supportive and empowering of the client, and when working with individuals, we address the pain that one feels being lonely, especially for a long time, and feeling deeply stressed and saddened by it. Some clients attempt to distance themselves from the pain and thus tend to supress, or even deny that they are lonely and experience the accompanying negative feelings and cognitions. Facing their loneliness, admitting to themselves that they, indeed, experience it and not run away is the first step. We then attempt to understand the nature of one’s loneliness. Is it a transient one influenced by events in the client's life, or is it a chronic, long term, experience that is more troublesome and requires a concerted effort to resolve. The reasons for the loneliness that the client experiences need to be examined and understood, for only then addressing it can be possible. The next step is empowering the client to explore ways to address the loneliness. One approach to that empowering is addressing possible learned helplessness that the client may exhibit, and which prevents a free and courageous exploration of coping strategies. We also highlight the importance of a steady and committed approach, which while it may not always succeed, the client will persevere and have the inner conviction that she can diminish her loneliness and reduce its pain. Some writers Moustakas [25]; Rokach [13,18] suggested that loneliness, just like pain, can be a beneficial force in one’s growth and development. Firstly, it directs us to look inwardly (an experience which the extroverted way of life in North America does not encourage), helps us take "personal stock,” and evaluate our relationships, goals and our priorities. Loneliness, just like the effects of intense fire on gold, can clear and purify our understanding of who we are and what we want out of life. After experiencing the intense pain of loneliness, suggested Moustakas [25] we may emerge knowing that our resources for coping and living are appropriate, discover new capabilities within ourselves, gain a better understanding of the wondrous and beautiful things in nature and the universe, and learn anew to fully appreciate human contact, intimacy, and love. I aim to help my clients realize it and renew their hope for more fruitful human interaction and personal fulfillment. Group approaches to loneliness are, naturally, somewhat different in that the group members can serve as an invaluable source of insight, support, direction, and ‘quality control’ of the client’s journey in addressing his loneliness. Group members, in addition to their support of the client in-group, may also provide friendship outside of the group and encourage the person to explore relationships, friendships, and social intercourse.

Cognitive Strategies: Deshawn Besse [26] reviewed the self-deprecating manner in which the lonely perceive themselves, commonly feeling inferior, unattractive, less socially skilled or overall worthless. One of the consequences of such a point of view is that they tend to perceive the world as negative and others as not trustworthy or accepting Luhmann et al. [27]. Being so unhappy with themselves and their surroundings, the lonely who may want to connect with others, may also be quite hypervigilant which further impacts their negative perceptions of the world and viewpoints about others. These biases, may intensify their loneliness, confirm their negative view of the world and of others Cacioppo and Hawkley [28]. The lonely, consequently, often believe they are helpless and incapable of changing their situation, believing their loneliness is the result of personality characteristics (such as, for example, shyness or low social competence) rather than circumstances and traits that may be more malleable Heinrich and Gullone [29,30]. In light of this vicious cycle, treatment strategies that were suggested included educating the lonely of the connection of their negative and unrealistic thoughts and how they may be contributing to their current situation.

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Prescribing Trends in the outpatient Department in A Rural Hospital in Bangladesh - Juniper Publishers

Complementary Medicine & Alternative Healthcare - Juniper Publishers 

Abstract

This study was carried out to find the medicine-prescribing pattern in outpatient department of Medicine, Surgery, Gynecology and Obstetrics in government and private hospitals in Faridpur city, Bangladesh. To see the patterns of prescriptions of 250 patients were collected over a period of three months and analyzed for the average number of drugs per prescription, number of drugs prescribed per prescription, most common diagnosis, most commonly prescribed antibiotics, most commonly prescribed groups of drugs, percentage of drugs prescribed by generic names, percentage of drugs prescribed from Essential Drug List (EDL) of Bangladesh. The average number of medicines per prescription was 4.14 and 48.8% patients were prescribed up to 3 medicines. Only 37.I6% drugs were prescribed from EDL of Bangladesh. Percentage of encounters with an antiulcer ant, a NSAID and a multivitamin & mineral prescribed were 29.25%, 18.15% and 9.84% respectively.

It was evident that 73.6% [184] of the prescriptions contained antibiotics. Cefixim and ciprofloxacin were found to be the most preferred antibiotics in physician’s prescriptions survey. The diseases, which were seen in the studies, include cough, typhoid, diarrhea, nausea, chronic UTI, RTI, fever and rhinitis. The result of the present survey indicates that antibiotics are widely and inappropriately practiced without following standard guidelines. This is an alarming condition in the health sector of Bangladesh and therefore, the respective authority should take necessary steps to minimize the harmful effects of antibiotics.

Keywords: Prescribing pattern; Essential drug; Antibiotic; Faridpur city; Rational use of drug

Introduction

Knowledge of risk perceptions has demonstrated to be vitally important in understanding how individuals and societies manage the risks of daily life. In medicine perceptions of drug risks are probably to influence patients’ treatment decisions, their compliance with treatment regimens, their views on the acceptability of adverse reactions and the drugs that cause them, and their attitudes toward government regulation of medications. Understanding perceptions is a prerequisite for designing better communication materials for patients and the general population [1]. The drug use process can be separated into four fundamental components, namely: prescribing, dispensing, administration/ uptake and outcome (efficacy/safety) [2]. The evaluation of medication use is vital for clinical, educational and economic purposes [3]. Monitoring of prescriptions and drug utilization study could distinguish the related problems and give feed backs to the prescriber in order to make awareness for the rational use of drugs [4]. It is therefore necessary to define the prescribing pattern and target the irrational prescribing habit for sending a remedial message [5]. Therefore, the present study has been undertaken to observe the prescribing patterns of Antibiotics and the usage of these agents in different types of patients with different types of diseases in Faridpur City of Bangladesh

Materials and Methods

Study area, duration of research project and data collection process. A cross-sectional study was conducted in order to evaluate prescription pattern of antibiotic drugs in patients with various infectious diseases. On the basis of inclusion and exclusion criteria prescriptions were collected from all patients (both male and female) attended the outpatient (OPD) at government and private hospitals in Faridpur city. The study was carried out over 90 days period of April 15th, 2018 to July 15th, 2018. A total of 250 patients were included in the study. New patients attending the outpatient department of Medicine, Surgery and Gynecology and Obstetrics in government and private hospitals in Faridpur city during the study period were considered for analysis. Follow up visits during the study period were included and were counted as separate visits. Patients visiting the emergency department or who got admitted during OPD visit were not included in the study. The average number of drugs per prescription, number of drugs prescribed per prescription, most common diagnosis, most commonly prescribed antibiotics, most commonly prescribed groups of drugs, percentage of drugs prescribed by generic names, Percentage of prescriptions with injectable preparations., percentage of drugs prescribed from Essential Drug List (EDL) of Bangladesh, The data was expressed as percentage, mean and total numbers

Results

Total number of 250 medical case records were collected, scrutinized and analyzed for drug prescription. The majority of the patients were male 157 (62.80%) and 93 (37.2%) patients were female with 14.80% of them aged between 18-50 years Table 1.

Among 250 patients, we found that majority of the patients were victim of gastrointestinal tract infection (51.2%). Other patients suffered from orthopedic disorder (26.0%), respiratory tract infection (8.0%), ENT infections (8.0%) and urinary tract infection (6.8%) respectively. These data are shown in Table 2.

In this research project, A total of 1036 individual drugs were prescribed for 250 drug encounters, giving an average of 4.14. The range of drugs per encounter varied from 1-7. There was not a single prescription wherein no drug was prescribed. Moreover, very few drugs were prescribed by generic name (1.93%). These data are represented in Table 3

Total number of drugs in our prescription was 1036. Among these, the most prescribed drugs were of acid related preparations (29.25%). Then the second most prescribed drugs were antibiotics (28.09%) Table 4.

At least one antibiotic was prescribed in 184 (73.6%) of the 250 encounters and 77 prescription contain single antibiotic with other drugs. The most prescribed antibiotic was of cefixime 67 (23.02%). Then the second most prescribed antibiotics ciprofloxacin (17.87%) Table 5.

Among 1036 drugs only twenty drugs (1.93%) were prescribed by generic names. It was also seen that out of 250 prescriptions only 385 drugs (37.16%) were prescribed from the EDL of Bangladesh Table 6.

The present study also shown that omeprazole 58% and multivitamin with mineral 52% were prescribed among essential and non-essential drugs. The five most commonly prescribed drugs, which were included within or excluded from the EDL [6] of Bangladesh Table 7.

Discussion

A prescription that is given by a doctor or physician is taken as an indication of the doctor or physician’s attitude towards the disease and the role of drugs in its treatment [7]. The central priority of health care system is providing the right medicine to the right people at the right time [8]. The source of data in these study 250 medical cases was collected and the percentages of male and female patients were 62.80% and 37.20%. Most of the patients were above 50 years old. Similar results were obtained from the previous study, which was conducted by Khan et al. [9]. This prospective study was conducted on 4800 patients who visited the OPD and IPD of ENT department of Teerthanker Mahaveer Medical Hospital and Research Centre of North India. Their result indicated that higher percentage of male person suffering from different infections.

We observed that in the data of this research project, most of the patients were suffering from gastrointestinal disorders (51.20%) and orthopedic disorder (26.00%). It is important to note that drugs should be prescribed in their generic names to avoid confusion. In this study the average number of prescribed drugs were 4.14 and drugs were prescribed by generic name is 1.93%. It also showed that 80.08% patients were given three or more drugs. The variation in results may be due to difference in characteristics of health care delivery system, morbidity and mortality characteristics in the population. Since, WHO has recommended that average number of drugs per prescription should be 2.0 [10], the results of the study reflect polypharmacy which may lead to adverse drug reactions, increase the risk of drug interactions, dispensing errors, decrease adherence to drug regimens and unnecessary drug expenses.

Antiulcerant drugs, 207 prescriptions (69%) were found and the omeprazole [148 prescriptions (49%)] was the most commonly prescribed of this class. The present observation remarked that 73.60% prescription contained antibiotic drugs along with other drugs. Among 41.85% prescription contained single antibiotic drug and 58.15% contained two antibiotic drugs. No prescription contained more than two antibiotic drugs. Prescriptions among which antibiotics that lie under Cefixime, Ciprofloxacin were most commonly prescribed. Similar results were obtained from the previous study, in Iran (61.9%) [11]. In another study by Biswas et al revealed that mostly prescribed drugs were also antibiotics (49.22%) [12]. According to WHO 15- 25% of prescriptions with antibiotics are expected, where infectious diseases are more prevalent [13]. In a 3rd world developing country like Bangladesh, prevalence of infectious diseases is higher than the developed countries. That is why; in this study the antibiotic utilization rate was higher than that of developed countries. However, this result does not indicate that the prescription pattern was better than in other countries.

The WHO recommended target for injection exposure is 10% or less [14]. In this study, the percentage of prescription with an injection encountered was 2.32% which is less than in Nepal (3.1%) [15], Zimbabwe (13%) [16] and India (13.6%) [17]. so, the observed proportion of injectable drugs prescribed may be considered acceptable according to WHO recommendations. Minimum use of injections is preferred, and this reduces the risk of infection through parenteral route and cost incurred in therapy [15]. It also showed that out of 250 prescriptions 102 (40.80%) had at least one multivitamin and multimineral prescribed which was not enlisted in EDL. The justification for this practice is not clear. However, some patients and doctors believe that the multivitamin supplement may induce or enhance the patient’s appetite or relief from weakness. In this study, the percentage of drugs prescribed from EDL of Bangladesh was 43.16%. The possible reason for this lower value could be the prescribers lacking the understanding the importance of essential drug concept. The low rate of prescribing from EDL of Bangladesh may be also contributed by excessive use of multivitamin and multiminera, antiulcerant (Ranitidine) and antihistamine [Cetirizine HCl], which are not enlisted in EDL of Bangladesh. So that the higher percentage of non-essential drugs in this study is responsible for inappropriate use of medicines.

Conclusion

Physician is often considered to be God and therefore when a doctor gives an antibiotic to a patient, it is taken without question. However, a doctor is often pressurized to give antibiotics for a variety of reasons. It could be due to the pressure of making a patient well as soon as possible, or the fear of losing patients to another doctor. Patients often demand powerful treatments, and then there is the industry pressure and incentive schemes, and, most importantly, the doctor`s own clinical judgment skills. To be fair, many doctors work with inadequate and unreliable investigational facilities. This may promote the use of combination antibiotics and defensive medicine. From the result of this study, it can be concluded that inappropriate drug prescribing, inappropriate use of drugs and irrational prescribing of antibiotic are major problems. Therefore, there is a need strict enforcement and adherence to existing regulations regarding antibiotic practices. To overcome these problems, the drugs control authorities should be better equipped and more vigilant to cope with the present situation. Health professionals and drug manufacturers should be more committed in order to achieve the goals of the National Drug Policy of Bangladesh. 

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Two Methods of Policing: Will the Resources of the Police Officers and the Local Communities be Spiraling Upwards or Downwards? - Juniper Publishers

Forensic Sciences & Criminal Investigation - Juniper Publishers

Abstract

From the viewpoint of Swedish vulnerable areas this article focusing on the potential consequences of two methods of policing (Zero-tolerance and boundary-relation) from the perspective of factors connected with officers’ health, professional work performance, and the effect on the resources of the local community such as work against crime. The authors put forward different patterns of loss of resources that result from officers stressful and traumatic experiences. The article further discuss the effects on society connected to signs of loss of resources in the areas of health, such as cynicism, and performance. The two methods of policing play very different parts in whether resources will be lost or gained when the officers approach the local community. Reflecting the principles of Sir Robert Peel wherein the good relations between the police and the public is emphasized as the basis of effective policing.

Keywords: Occupations; Mutilation; Witnessing; Shootings; Dealing; Normalcy; Exposure

A Heightened Need for Resources of Officers

It has long been established that working as a police officer is associated with stress and health problems Habersaat et al. [1]. When compared to other occupations, a heightened level of risks with regard to on duty actions resulting in ill-health or injuries has been documented Mayhew [2]. These risks included also an elevated frequency of threats. Consequently, Violanti [3] has compared US police officers day to day work with warfare: “The police officer is expected to be combat-ready at all times...[facing] a continual sense of danger from an unknown enemy...While the Vietnam veteran was at war for a minimum of nine months, police officers alternate between the violence of the street (e.g., shootings, witnessing death and mutilation, dealing with abused children) and the normalcy of civilian life on a daily basis.”

The different contexts of potentially traumatic exposure

Regarding the Swedish Police force an increased exposure for on duty risks documented by Mayhew [2] from the perspective of 61 s.c. vulnerable areas having been defined. Out of these 29, were named “specially vulnerable areas”. Both varieties of vulnerable areas are together described in terms of low socioeconomical status, high criminal activity, and high level of narcotic related crimes NOA, 2015, & 2016 [4]. From research findings, it has also been suggested a dynamic or circular process where in these areas increased rates of crime undermine both the informal as well as the formal local control. Under more favorable circumstances, these local control conditions would regulate or abate deviant behavior whereas the wearing out instinctively of both varieties of control instances consequently allows crime to advance Klinger [5].

Methods on offer

The different work methods pertaining to how the police officers handle their tasks in the vulnerable areas are of greatest importance. Two well-known and defined methods can be described as representing two different rationales where one is more leaning towards zero-tolerance and the other more towards a balance between setting boundaries and building relations to the local community. Similar to both methods is that working in these areas expose the police officers to high frequencies of stressful events. This including effects from the above two different work methods on the police officers and thereby also on the community is here in the center of attention of the authors.

The work method of zero-tolerance is a strategy based on repeated activities targeting even minor crimes and focusing on order-maintenance Bratton et al. [6], Greene [7]. Through this method, the frequency of interactions between citizens and police officers are aimed to be very high. Moreover, the interaction between the two parts can be described as having a negative tone where one part (police officers) is to take control over the other part (citizens). This logically also implies increasing the likelihood of traumatic encounters.

In the other work method setting boundaries (including arrests and punishments), there is a balance between the building of relations to the local community and singular citizens. The stressful negative interactions between police officers and citizens are mixed with positive interactions between the two parts. This is a work method more in tune with Sir Robert Peel’s principles where the relations between law enforcement and the public are emphasized as the base of effective policing Peel [8].

Potential Health Effects from Specific Demands and Resources

When regarding those two work methods with the focus on both possible health effects on police officers and its indirect effects on society; stress is an important factor to examine. Stress in general has been shown to generate negative effects both physical and psychological Ohira et al. [9]. Being a police officer is associated always with presenting one of the most stressful occupations often resulting in physical as well as psychological ill health Habersaat et al. [1], Maguen et al.[10], Berg et al.[11] showed that both frequency and severity of job stress among police officers was associated with anxiety symptoms and burnout. Moreover, these authors found that the frequency, not the severity, of stress factors was associated with cynicism.

Recurring trauma of police officers means a psychological sensitization effect that was identified by Regehr et al. [12]. Sensitization was manifested as an ongoing (prolonged) psychological response after stressful exposure. In turn, the amelioration of the stress response was related to awareness of access to social support if needed. Cynicism is, in itself, a long-recognized sign of burnout Maslach [13]. Cynicism refers to being distrustful of others sincerity or integrity and beliefs regarding others as motivated purely by self-interest (Oxford dictionary, on line). The cynicism that is referred to in this article is regarded in line with Maslach [14] as a state rather than as a personal trait thereby connected to attitudes, behavior, and cognition Dean, Brandes, & Dharwadkar [15]. In general, cynicism is found to have negative impact on interpersonal relations and work performance Leiter et al. [13]. Leiter and Maslach discussed the premise that even though there are strong correlational links between the three subscales of the Maslach Burn out Inventory (MBI) these patterns does not fully mirror the person centered reality of the match between on one hand and the individual employee and the organizational conditions on the other. They therefore employed a latent profile design with large samples of participants and hypothesized profiles of firstly a total of the three dimension (Overextended, Disengaged/Cynisism and Ineffective) meaning the BurnOut (BO) score profile and MBI, secondly the separate existence of the three MBI dimensions and thirdly a healthy profile named Engagement.

Furthermore, the person-centered BO scores were analogously examined together with also different dimensions of the work organization. e.g. workload or resources. Concerning the profile of disengagement or cynicism this showed to be the closest to the total score profile of BO consequently also closer than the separate Exhaustion score. Interestingly, the cynicism profile was not distinguished by high work load. However, cynicism occurred in a unique organizational context of low scores concerning the three dimensions of resources doing the job (reward, community, fairness, professional network etc), low scores regarding social context at work (e.g. civility or incivility from manager or co-worker) and satisfaction with work (e.g. accomplishment or overall satisfaction with work). Leiter et al. [13] suggested cynicism was a more central aspect of BO than fatigue, but also, in itself, a fork where the work process seemed to go wrong. Therefore, its “sources and outcomes“ (p 98) also need to be better understood.

Repeated exposure is sensitizing exposure

Researchers such as Regehr et al. [12] or Chopco et al. [16] examined the nature and consequences of repeated exposure to potentially traumatic situations in the policing profession. The findings of Regehr and colleagues (2007) concerning the consequences of recurring exposure to stressful situations are interesting while they are contra intuitive or challenging to notions about a protective effect from being psychologically accustomed to traumatic situations at work. Instead, when the researcher examined police officer’s individual history of traumatic stress exposure together with psychological and biological responses to acute stress, they found a very different storyline. Regehr et al. [12] used a police training video simulator and the simulator recounted a domestic violence situation. The situation included an injured (through harm) female victim, the ongoing presence of the perpetrator and the need for safety precautions regarding the officer herself or himself in the current situation.

From collected anamnestic data and from different recordings in conjunction with the simulated stressful situation the researchers found an outcome of psychological sensitization to stressful situations associated to the quantity of (repeated) exposure to traumatic stress in police officers. This prolonged psychological response to stress was not accompanied by a prolonged physiological response (concerning heart rate or cortisol measures). Instead, the physiological response of the repeatedly exposed officers did not differ from that of the lesser exposed officers. This latter finding may be elucidated by results reported by Ohira and colleagues (2011) on lack of parallelism between the psychological and the physiological responses in conjunction with chronic job stress. Expressed differently, what Ohira and colleagues (2011) observed was a psychophysiological dysregulation where the brain to a lesser extent exhibited control over the cardio vascular system in term of “accelerating it” during stress when compared to the more vital regulatory dynamics of a non-job-stress group.

Support from colleagues as resources

Moreover, a further important finding by Regehr et al. [12] was that the level of reported social support was negatively associated with to the reported level of stress all through the different stages of the experiment. This dynamic was the most pronounced for the period of measurement that was the furthest in time away from the simulated traumatic situation concerning subjective level of stress. While the main finding of repeated exposure being related to a prolonged subjective stress response, the researchers underline the importance of availability and maintenance of social support along with the policing career (Regehr et al., 2007). Essentially, the experimental condition suggested that the amelioration of the stress response did not rely on actual access to support or consolation; but rather on that support available if needed. In parallel, the phenomenon of disengagement or cynicism occur in a situation where civility from manager and/or co-worker is sparse and satisfaction with work is low (Leiter et al., 2016) this might give evidence of this event and an urgent need for a supporting atmosphere among colleagues must be put to the fore in order to protect the health of the officers

Varieties in post-traumatic development may undermine close relationships

In order to secure these needs in the light of trauma, mere cognitive post-traumatic growth (PTG) seemed not sufficient but needed to be complemented with active means or improved behavioral skills i.e. behavioral PTG. In turn, the results presented by Chopco et al. [16] themselves, indicated that the benefits of behavioral growth need to be further scrutinized while behavioral PTG but not cognitive PTG was positively associated with PTSD symptoms. Moreover, behavioral PTG was associated with relationship stress potentially undermining availability of social support. The researchers discussed behavioral PTG and relationship stress from the perspective of increased action orientation coping and a vicious circle deterring close relationships including communication about traumatic experiences in turn resulting in less cognitive processing and more symptoms of PTSD. This kind of process may also be confirmed by the finding that that behavioral PTG tended to increase with age in police officers.

Stress undermines the quality of professional performance

By definition, the workload tends to be higher in high crime vulnerable areas then in low crime areas. Thereby the workload is initially high independently of what work method is chosen when policing these areas. To temporarily leave a potential ameliorating effect from collegial support aside, stress is from experimental design known to narrow the understanding of the actions of fellow humans towards “making malicious” etc.. This tendency is termed “the fundamental attribution error”.

The attribution error phenomenon was examined by Kubota et al. [10] who found that the level of current stress was associated with the degree of making the attribution error and to a larger degree attribute action(s) to (uncivil) inherent qualities of the performer. This tendency could be explained by a three step model presented by Gilbert et al. [17] where under load (stress) the brain simplifies interpretation and excludes a demanding qualified third interpretative step of wider explanations (to actions). Moreover, the interpretations of actions (of others) relies on both higher and lower order cognitive functions, e.g. Arnsten [18] describes how higher order functions are vulnerable to stress and more or less ”shut down” from stress hormones. Consequently, this leaves the individual to make interpretations using his or her lower order cognitive functions meaning a fundamental attribution error tendency also not corrected by higher order cognitive resources. These effects could also shed light on the psychological functioning of cynicism and complement the perspective of professional burnout that also includes a dimension of reduced personal professional accomplishment as described by Maslach [13].

Furthermore, in the FBI Enforcement Bulletin article Graves [19] states that “Cynicism often adversely affects officers” productivity, impacts the morale of their colleagues, and chills community relations. It also tends to breed a poor quality of life for officers and their families.” When examining the s.c. zerotolerance work method that is based on a high frequency of citizen – police officer interactions it has been described as aggressive Green [7], Fischer [20]. By frequent interactions law enforcement overrule the tendency, otherwise often found in high crime areas, to only charge more serious deviances and accepting and letting go of not so serious deviances Klinger [5]. With a focus on police officers health the frequent interactions of zero-tolerance tend to lead to not only a higher level of stress but also to increased level of cynicism Berg et al. [11]. Research indicates also that officers working in high-criminal areas tend to show more cynicism than officers in other areas Sobol [21]. This can be understood out of a more general assumption that cynicism is associated with “tendencies toward negative, and often disparaging, behavior” Dean, Brandes & Dharwadkar [15].

Doing good

In the work method whereby setting boundaries is balanced with building relations the more negative stressful interactions associated with for example making arrests are mixed with more positive interactions with the citizens. Building relations between individuals is in general considered as having positive effects both for the individuals as well as for the society at large. For example, interpersonal relationship has been found to be associated with lower levels of psychological distress and the perceiving of fewer social constraints in challenging situations Danoff-Burg & Revenson [22]. It has also been shown that positive and fair interactions initiated by the police will enhance citizens’ willingness to cooperate and obey police Tyler & Fagan[23]. Mazerolle et al. [24] found that even short, respectful and fair interactions between police and citizens had positive effects on the citizens’ willingness to comply and cooperate with the police.

When observing the two work methods described above and their plausible direct effect on police officers and indirect effect on citizens and society it is rather clear that a mix of setting boundaries and building relations in the long run will be the most effective work method. Regarding the health of police officers, the balance between more stressful interactions in regard to for example arrests can be counterpoised by the more positive relationship building interactions thereby lowering the risk of risking development of cynicism among police officers. Moreover, a crucial side effect of this work method would be enhanced cooperation between police and citizen thereby creating a more effective policing and a safer society.

Discussion

Weitzer & Tuch [25] argued that citizens’ dissatisfaction with the crime rates in relation to their neighborhood high-crime area will influence their view of the police in a negative way. There are several findings that point to the importance of wellestablished relations between police and citizens and how those relations are built. The police have to build knowledge of the expectations of people in high-criminal areas Skogan [26]. There is the importance of how police are acting when interacting with citizens (procedural justice). Here respectful and polite are the leading words as citizens “tend to focus more on process than the outcome” Tyler TR [27].

As discussed earlier, police officer’s ability to form trust Andersson Arntén & Archer [28] and acting with respect Andersson Arntén et al. [29] may have profound effects on the society which points to the advantage of the balanced work method. Moreover, that same balanced work method is also beneficial as the result of an interaction between law enforcement and citizens is associated with who is initiating the contact. Rosenbaum et al. [30] found that when a contact between citizens and police were of a negative nature there was a tendency of citizens being less satisfied when the contact was initiated by the citizen itself. The authors discuss this propensity from the angle that expectations rather than outcome may predict the experience. A further suggestion may be that a healing dynamic or a positive spiraling process of building resources in the vulnerable communities needs as a first step to be initiated by the police in terms of relating in a caring way.

So, when a high rank officer of the Swedish Police on national TV SVT Aktuellt July 5th 2018 requested that the people living in the vulnerable and special vulnerable areas needed to take a considerably bigger responsibility for the criminal development in their neighborhood it was done despite research results [31]. To make residents in those areas be able to take a bigger responsibility starts with 1) An understanding and responds to the expectations of these residents regarding police and citizen encounters; 2) The building of good through police initiated interactions; 3) Building trust throw showing respect in all interactions even in situations including those characterized of setting boundaries and making arrests, and 4) Continuing police training to make this happen. Furthermore, this high rang officer seemed to be unaware of the conditions for health of police officers. Chopco et al. [16] relied on Deci and Ryans’ (2000), selfdetermination notion, and discussed traumatic experiences among police officers from the perspective of being a challenge to fundamental psychological needs of experiencing own competence, autonomy and relatedness.

In line with this, van der Werff et al. [32] found that resilience to severe stress among police officers was related to personal resources of increased structural connectivity of the brain tentatively meaning the use of higher order cognitive resources in regulating emotion. The resilient officers also rated less of a stance of acceptance when regulating cognition and emotion. Instead of accepting negative circumstances, those officers being the most resilient, showed more of genuine presence in terms of a suggested emotion and cognition regulating style of proactivity and willingness to change. The above logically promotes both resources of the local community and the health of officers. In parallel, cynicism also shines with its absence and all three fundamental human needs, not least ‘caring’ exemplifies relatedness in its most advanced form.

As a conclusion the authors would like to quote Tyler (2005)

“Public consent and support of law enforcement are two of the most critical tools on a police officer’s “belt.” People who believe that the police are performing their duties with professionalism and integrity are more likely to obey laws and support the system by acting as witnesses, for example.” 

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