Adult attachment style. II: Its relationship to psychosocial depressive-vulnerability

Background A range of studies show adult attachment style is associated with depressive-vulnerability factors such as low self-esteem, poor support and childhood adversity. However, there is wide inconsistency shown in the type of insecure style most highly associated. Few studies have examined attachment style in relation to clinical depression together with a range of such factors in epidemiological series. The present study uses an interview measure of adult attachment which differentiates type of attachment style and degree of insecurity of attachment, to see: (a) if it adds to other vulnerability in predicting depression and (b) if there is specificity of style to type of vulnerability. Method Two hundred and twenty-two high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. The Attachment Style Interview (ASI) differentiated five styles (Enmeshed, Fearful, Angry-dismissive, Withdrawn and Standard) as well as the degree to which attitudes and behaviour within such styles were dysfunctional (‘non-standard’). Attachment style was examined in relation to low self-esteem, support and childhood experience of neglect or abuse, and all of these examined in relation to clinical depression in a 12-month period. Results The presence of any ‘non-standard’ style was significantly related to poor support, low self-esteem and childhood adversity. Some specificity of type of style and type of vulnerability was observed. Logistic regression showed that non-standard Enmeshed, Fearful and Angry-dismissive styles, poor support and childhood neglect/abuse provided the best model for clinical depression. Conclusion Non-standard attachment in the form of markedly Enmeshed, Fearful or Angry-dismissive styles was shown to be associated with other depressive-vulnerability factors involving close relationships, self-esteem and childhood adversity and added to these in modelling depression. Accepted: 21 September 2001     

Adult attachment style as mediator between childhood neglect/abuse and adult depression and anxiety

BACKGROUND: There has been little prospective investigation of the relationship between adult attachment style and clinical levels of anxiety and major depression. This paper seeks to address this, as well as examining the potentially mediating role of adult insecure attachment styles in the relationship between childhood adverse experience and adult disorder. METHODS: 154 high-risk community women studied in 1990-1995, were followed-up in 1995-1999 to test the role of insecure attachment style in predicting new episodes of anxiety and/or major depressive disorder. The Childhood Experience of Care and Abuse (CECA) and the Attachment Style Interview (ASI) were administered at first interview and the Structured Clinical Interview for DSM-IV (SCID) administered at first and follow-up interview. Major depression and clinical level anxiety disorders (GAD, Social Phobia or Panic and/or Agoraphobia) were assessed at first contact and for the intervening follow-up period. RESULTS: 55% (85/154) of the women had at least one case level disorder in the follow-up period. Only markedly or moderately (but not mildly) insecure attachment styles predicted both major depression and case anxiety in follow-up. Some specificity was determined with Fearful style significantly associated both with depression and Social Phobia, and Angry-Dismissive style only with GAD. Attachment style was unrelated to Panic Disorder and/or Agoraphobia. In addition, Fearful and Angry-Dismissive styles were shown to partially mediate the relationship between childhood adversity and depression or anxiety. CONCLUSION: In order to correctly interpret lifespan models of adult psychiatric disorder, it is necessary to test for mediating factors. Attachment theory provides a framework for explaining how dysfunctional interpersonal style arising from early childhood perpetuates vulnerability to affective disorders. This has implications for intervention and treatment to break cycles of risk.     

The opinion of caregivers on aspects of schizophrenia and major affective disorders in a Nigerian setting

Background In Nigeria the burden of caring for persons with severe mental disorders rests largely on families whose attitudes to these conditions have not been explored. Objectives To assess the opinion of relatives of 75 schizophrenics and 20 major affective disorder cases on aspects of the disease and compare with the responses of relatives of cancer, infertility and sickle cell disease (SCD) cases. Method Caregivers were assessed using a burden questionnaire that contained items on etiological beliefs and attitudes to illness. Results The responses of relatives of the two psychiatric illness groups were similar. The single most important etiological factors were that “it is Satan's work” (35.8 %) and “it is a natural illness“ (23.2 %). Other factors were “genetic” (9.5 %), “witchcraft” (10.5 %) and “curse by enemies” (10.5 %). This was similar to the opinion of cancer and infertility caregivers; but different from SCD where the most important causative factors were “genetic” (41.5 %) and “natural” (21.5 %). Psychiatric caregivers had higher frequency of anger and stigma. Over two-thirds of psychiatric caregivers felt glad caring for the patient and would not like the patient institutionalized. Most families were thought to be supportive and there was an impression that caring had made family emotional ties closer. Conclusions These families were tolerant and would cooperate with health authorities. Causative models are influenced by available knowledge and practices in the culture. To actualize the potential of families to play useful community psychosocial roles, there is a need for public mental health literacy and welfare support. Accepted: 10 July 2001     

How psychiatric patients perceive the public's stereotype of mental illness

Background: It is well established that the general public has devaluating attitudes towards psychiatric patients. In order to avoid rejection, many of these patients develop coping strategies, such as withdrawal and concealing their treatment history. These efforts are in themselves stressing, which might have negative consequences for the course of the disorder. It is not clear, however, how many and which patients do actually perceive the public's stereotype as threatening and, therefore, expect rejection. Method: Ninety psychiatric patients and a sample of 1042 persons of the Austrian general population were asked whether they agreed with five devaluating statements about mental patients contained in a questionnaire developed by Link et al. Matched pairs comparisons and multiple logistic regression were employed in order to find out whether patients agreed with these statements to the same extent as the general population did. Results: For the statements that most people believe that psychiatric patients are “less intelligent”, “less trustworthy” and “taken less seriously”, patients thought significantly less often than the general population that most people devalue mental patients. For two statements (“personal failure”, “think less of”) no difference was found. Conclusions: It seems that some psychiatric patients are less convinced than the general population that most people devalue psychiatric patients in specific respects; these patients might fear rejection less than other patients do. Those who actually fear rejection might need antistigma assistance more urgently than the first group. Accepted: 31 October 2002 Correspondence to Dr. Marion Freidl     

Attachment patterns are associated with symptomatology and course of schizophrenia in male inpatients

The authors tested the hypotheses that the insecure attachment styles of adult patients with schizophrenia are associated with (a) diagnosis, (b) psychopathological syndromes, and (c) course of the disorder. Thirty schizophrenic and 30 age-matching control males answered a self-report questionnaire tapping secure, avoidant, and anxious/ambivalent attachment styles. The patients were diagnosed using the Structured Clinical Interview for DSM-IV (M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1995), and their symptoms were quantified using the Positive and Negative Syndrome Scale (PANSS; S. R. Kay, A. Fizhbein, & L. A. Opler, 1987). Patients with schizophrenia did not significantly differ from nonpatient controls in secure style mean scores, but they exceeded the latter in both avoidant and anxious/ambivalent style scores. There were no significant correlations between secure attachment style and any PANSS symptom dimensions, whereas avoidant style correlated positively with both positive and negative syndromes, and anxious/ambivalent style correlated only with positive syndrome. Compared with patients with secure style, those with insecure attachment styles were younger at onset of the illness and had longer psychiatric hospitalizations. The preliminary results suggest that the insecure types of attachment, in particular the avoidant style, are associated with schizophrenic symptomatology and course of the illness in male inpatients. Further studies using a longitudinal design on extended samples are needed to determine the direction of causality in the composite relationships among the distinct attachment styles, psychopathology, and course of schizophrenia.     

The use of the ADI-R as a diagnostic tool in the differential diagnosis of children with infantile autism and children with a receptive language disorder

Children with infantile autism and children with a specific receptive language disorder often show similar behavioural problems, making the differentiation between these two diagnostic categories difficult. The purpose of this study is to evaluate the usefulness of parental information in the differential diagnosis of the two types of disorders mentioned above. Sixteen children with a receptive language disorder and 11 children with infantile autism participated in the study. All children had normal non-verbal IQs. The ADI-R (Autism Diagnostic Interview-Revised) was performed with all children. The results showed that the ADI-R items reflecting behavioural features at pre-school age (age range 4–5 years) were better suited to differentiate the groups than the items reflecting behavioural features at the time of the investigation (mean age: 9 years). The items on the dimension “Reciprocal social interaction” and “Communication and language” discriminated the groups better than the items of the dimension “Restricted interests”. According to the ICD-10 algorithm of the ADI-R one child with autism and one child with a receptive language disorder were falsely classified. These false classifications were mainly due to a distorted parental perception of the child's behaviour. The ADI-R is a useful tool in the differential diagnosis of developmental disorders. Accepted: 27 April 2001     

Gilles de la Tourette Syndrome in a child with congenital deafness

We present the case of a 10-year-old boy, Sam, with congenital deafness and Gilles de la Tourette Syndrome (GTS). GTS is characterised by multiple motor tics and one or more vocal tics that wax and wane. Due to his deafness Sam never developed vocal language but instead used sign language from the age of four. His tic disorder rapidly accelerated from the age of seven over a six-month period and soon sign language was incorporated into tics as complex “vocal” tics. Bursting out “words”in sign language would also occur in front of people unfamiliar with sign language and often with an obscene content although this was not evident to someone not trained in sign language. To our knowledge this is the first reported case of a congenital deaf child with GTS. The case presented here supports previously published work that the intentional share of the tics in GTS is very small. This case also questions former theories on which regions and circuits of the brain are involved in GTS. Accepted: 16 May 2001     

Diagnostic assessment of communicative and interactive behaviours in children with autism and receptive language disorder

 Children with autism and children with a severe specific receptive language disorder both show clear deficits in communicative language skills and in social relationships. In this study the usefulness of the Autism Diagnostic Observation Schedule (ADOS) in the differential diagnosis between these two groups of developmentally impaired children is assessed. 11 children with early infantile autism and 20 children with a specific receptive language disorder participated in the study. 18 children with an expressive language disorder were used as a control group. The ADOS was individually administered to all children by the same examiner. The results showed that on most of the ADOS measures the autistic children were clearly more deviant than the language impaired children. There were no significant differences between the two groups of language impaired children. Eight out of 11 autistic children reached the defined cut-off values on the measures “language and communication” and “social interaction” of the ADOS algorithm, whereas only three autistic children did so on the measure “stereotyped behaviour”. None of the language-impaired children reached the cut-off values on more than one measure. The ADOS allowed for good assessment of certain types of behaviour. However, to confirm the diagnosis of infantile autism, additional information from parents is required. Accepted: 15 February 2000     

DSM-IV Conduct Disorder symptoms in adolescents as markers of registered criminality

A nationwide sample of 1,079 Norwegian adolescent psychiatric in-patients, 581 males and 498 females, were followed up after 11–33 (mean 23.2) years. On the basis of detailed records from index hospitalisation they were re-diagnosed and retrospectively scored on 14 of the 15 behaviour items listed as diagnostic criteria for conduct disorder in DSM-IV. The patient list was linked to the national criminal registry, and 48 % were found to have a criminal record. The ability of the 14 behaviour items to identify overall and specific kinds of registered criminality was investigated. In males, “stealing” was the strongest marker for overall and violent crime. “Having forced someone into sexual activity” was a strong marker for later sex offences. In females, “running away from home” was strongly associated with overall and violent registered criminality. ROC curves were constructed to test the sensitivity and specificity of the sum of conduct disorder behaviour items fulfilled in the identification of individuals with registered criminality. The area under the curve was 0.81 (95 % c. i. = 0.78–0.85) in males and 0.75 (95 % c. i. = 0.71–0.80) in females. A cut-off at 3 criteria fulfilled seemed optimal in males and somewhat high in females. Accepted: 17 May 2001     

Substance abuse in schizophrenia. A Singapore perspective

Background Most of the information on the prevalence and patterns of substance abuse in patients with schizophrenia has been from studies conducted in North America and Europe and data from Asian countries are conspicuously lacking. This study was undertaken with the aim to identify the prevalence and patterns of substance abuse among patients with first-episode schizophrenia in the city-state of Singapore. Methods All new patients with a diagnosis of first-episode schizophrenia or schizophreniform disorder who were seen in one calendar year in the only state mental institute in Singapore and its affiliated outpatient clinics were evaluated for a lifetime history of substance use. Results In a sample of 272 patients, 201 (73.6 %) were abstainers, 43 (15.8 %) had “mild” substance use and 28 (10.3 %) had “heavy” use patterns. Alcohol was the most frequently abused substance. The substance users were more likely to be males and were more likely to have a criminal record than abstainers. Conclusions To our knowledge, this is the first study that examines the co-morbidity of substance abuse in schizophrenia in an Asian population. Our findings once again highlight the fact that patients with schizophrenia are at a high risk for substance abuse. Accepted: 20 February 2002     

Well-being in Australia--findings from the National Survey of Mental Health and Well-being

Background: The National Survey of Mental Health and Well-being in Australia has provided a rare opportunity to investigate not only the sociodemographic distribution of well-being, but also how it is related to impaired mental or physical health, to specific groups of psychiatric disorders and disability in daily life. Methods: A national household sample of 10,641 individuals (response rate 78 %) representative of the adult population was interviewed with the Composite International Diagnostic Interview and completed scales measuring recent symptoms, disablement and well-being. The latter was measured by the single item Life Satisfaction Scale of Andrews and Withey (1976) expressed as percentage, with 100 % being “delighted”. Results: The mean score for the Australian adult population was 70.4 % (95 % CI 70.0, 70.8), which matches the proposed universal norm. Men and women had very similar mean scores. Well-being was higher in persons with tertiary education and in those owning or purchasing their homes. It was lower in persons with physical or mental disorders, particularly depression. For alcohol use, a U-shaped relationship was found, whereby well-being was lower both in abstainers and in heavy users. Multiple regression analysis showed that when adjustment is made for confounders, women had higher life satisfaction than men and that high life satisfaction became less common with age in men, but even more so in women. Life satisfaction was impaired for respondents with high psychological distress, especially in the unemployed, the divorced and those with tertiary education, whether or not their symptoms led to a CIDI-A diagnosis of depression. Conclusion: The correlates of well-being are essentially in the expected direction. Depressive disorder has a stronger association with low well-being than other psychiatric diagnoses. Of particular interest is the existence of a small number of persons with current anxiety or depressive disorders who report having high life satisfaction. This deserves further investigation. Accepted: 4 July 2002 Correspondence to Dr. Keith Dear     

Repetitive behaviors in autistic disorder

Introduction: Repetitive behaviors are common in autistic disorder, as in other developmental disabilities. Behaviors as diverse as stereotypies, cognitive inflexibility, and a need for sameness are grouped together under DSM IV classification, even though they are diverse in phenomenology, underlying neural circuitry, and possible clinical significance. In order to better define repetitive behaviors, we studied the relationship between such behaviors and chronological age, developmental level, estimated IQ, presumed mood state, severity of illness, as well as behavior reactivity to environmental stimuli, in a group of 121 consecutive autistic children, aged 2–4 and 7–11 years. Results: Younger autistic children displayed more motor and sensory repetitive behaviors. Older children had more complex behaviors. Children with higher IQ scores, likewise, demonstrated more complex repetitive behaviors. Most motor behaviors and self injury showed features of reactivity. Conclusions: Certain “repetitive” activities may not represent core features of autistic disorder and may be equivalent to normal motor and cognitive behaviors, as seen during typical development. Accepted: 28 August 2002 Correspondence to Mark T. Palermo, MD     

Young cases of schizophrenia identified in a national inpatient register--are the diagnoses valid?

Background: Psychiatric inpatient registers are often used in research in the Nordic countries. We aimed to investigate the validity of recorded diagnoses of schizophrenia in the Swedish National Inpatient Register, in cases of early age at onset. We also wanted to describe the accuracy of the diagnoses in cities/university clinics and country hospitals as well as in child and adolescent psychiatric clinics and clinics for adults. Method: One hundred cases with a diagnosis of schizophrenia, born 1973–1977, were randomly selected. The psychiatric records were scrutinised according to the criteria of DSM-IV. Results: Eighty-six per cent (95 % CI 78–93 %) fulfilled the DSM-IV criteria of schizophrenia syndrome and 76 % (95 % CI 66–86 %) fulfilled the “narrow” definition. There were no large differences in the accuracy of the diagnoses between regions or clinics. Conclusion: The proportion of “true” cases of schizophrenia is high in the Swedish National Inpatient Register. In addition, the results did not support large differences between clinics or regions although a larger sample size would be needed to test this formally. In comparison with earlier studies from the Nordic countries the validity seems to be quite stable over time, between different ages at onset and between Nordic countries. Thus, the registers are well suited to be used in schizophrenia research. Accepted: 17 June 2002 Correspondence to Ch. Dalman     

The role of stress in the onset of depressive disorders

Background: We conducted the present study to evaluate the impact of stressful events on the onset of depressive disorders in a Spanish clinical sample, compared to a control group matched for age, sex, civil status and social class. We compared our results with those of other studies carried out with samples that were both clinically and culturally similar to ours. Method: Fifty depressed patients that were diagnosed with a depressive episode in the 6 months prior to the interview and 50 healthy controls were included in the study. Both groups were compared on the “Life Events and Difficulties Schedule” (LEDS). Results: Of the depressive patients, 68 % compared to only 18 % of the control individuals experienced at least one provoking agent in the 12 months prior to the onset of the symptoms. The risk of developing a depressive disorder was 9.7 % greater in subjects exposed to such provoking agents. Chronic difficulties are equally important to the genesis of depressive disorders as severe life events. No significant differences were seen between the two diagnostic subgroups of depressed patients in the accumulation of severe events, major difficulties or provoking agents. Conclusion: The results support the view that stress is a major factor in the aetiology of depressive disorders. The amount of stress suffered by the patients, however, was less than that found in our healthy sample. Important issues about the model of interaction between stress and depression are discussed. Accepted: 29 July 2002 Correspondence to L. Rojo     

Fear of intimacy in women: relationship between attachment styles and depressive symptoms

BACKGROUND: Preoccupied and fearful attachment have both been associated with depressive symptoms, but it is unclear which attachment style is primarily associated with major depression. While preoccupied attachment denotes a focus on relationships as a source of self-validation, fearful attachment involves an avoidance of relationships for fear of rejection. Present research aims to investigate the relative influence of fearful and preoccupied attachments on self-reported depressive symptoms within both a student and a clinical sample and to examine these associations separately for male and female participants. SAMPLING AND METHODS: All participants completed the Relationship Questionnaire and the Beck Depression Inventory. Study 1 assessed attachment ratings and self-reported severity of depression for 71 patients diagnosed with major depression. Study 2 similarly assessed 245 university students, and study 3 compared attachment ratings of the two samples. RESULTS: Both Pearson correlations and partial correlations were examined for both samples. Fearful attachment was associated with self-reported depression severity for females with depression, but attachment styles were unrelated to depression severity for males with depression (study 1). For female university students, both fearful and preoccupied attachment styles were significantly related to depression severity, but again there were no associations for male university students when partial correlations were utilised (study 2). Study 3 revealed significantly higher levels of fearful attachment for women with depression compared with female university students and no significant differences for males overall. CONCLUSIONS: For females, the avoidance of intimacy for fear of rejection was associated with a broad spectrum of depressive symptoms. Results highlight gender differences in depressive experiences, and have implications for research into the effects of fearful attachment on social support and the therapeutic alliance. Limitations to this study include the reliance on self-report measures of attachment and depression severity, the small number of male participants in the clinical sample, and the use of a cross-sectional rather than longitudinal design.     

Reliability and validity of a child-specific cross-cultural instrument for assessing posttraumatic stress disorder

 The Posttraumatic Stress Symptoms in Children (PTSS-C) was developed as a cross-cultural semi-structured interview to diagnose posttraumatic stress disorder (PTSD) and to identify PTSD-non-related posttraumatic stress symptoms in children after various traumatic experiences. The psychometric properties were studied in two different child populations in Iraqi Kurdistan (the survivors of the military operation “Anfal”, and the orphans), in a sample of Kurdistanian refugee children in Sweden, and in a comparison sample of Swedish children. The instrument yielded satisfactory internal consistency, high interrater agreement, and excellent validity on cross-validation with the Child Posttraumatic Stress Disorder Reaction Index (CPTSD-RI) and the Diagnostic Interview for Children and Adolescents (DICA) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Accepted: 14 March 2000     

Posttraumatic stress disorder in children after the military operation "Anfal" in Iraqi Kurdistan

 Five years after the military operation “Anfal” in Iraqi Kurdistan, 45 families were randomly selected among the survivors in two displacement camps. The Posttraumatic Stress Symptoms for Children (PTSS-C) and the Harvard Trauma Questionnaire (HTQ) were administered to the oldest child and the caregiver in each family, respectively. Posttraumatic stress disorder (PTSD) was reported in 87% of children and 60% of their caregivers. While childhood PTSD was only significantly predicted by child trauma score and the duration of captivity, it was neither predicted by maternal PTSD nor did it disappear after the reunion with the PTSD-free father. However, the small sample size makes the results hypotheses rather than conclusive. Accepted: 17 April 2000     

Child Maltreatment, Adolescent Attachment Style, and Dating Violence: Considerations in Youths with Borderline-to-Mild Intellectual Disability

One of the most salient developmental tasks of adolescence is the entry into romantic relationship, which often involves developing attachments to partners. Adolescents with a history of maltreatment have been found to be at greater risk of insecure attachments to romantic partners than non-maltreated adolescents, and the interaction of maltreatment and insecure attachment style has been linked to dating violence. The current study examined attachment styles and dating violence in child welfare-involved adolescents with borderline-to-mild intellectual disability (n = 40) and with average IQ (n = 116). Despite reporting similar experiences of childhood maltreatment, IQ was found to interact with avoidant attachment style to predict the degree of dating violence victimization and perpetration experienced by youth. It is suggested that an avoidant attachment style is a risk factor for all maltreated youth, and holds a particularly strong effect on youth with lower IQ levels. These findings highlight the need for developmentally appropriate attachment and dating violence interventions for maltreated youth.     

Association between physical illness and suicide among the elderly

Background Only a few small studies have explored the association between various physical illnesses and suicide in the elderly and they have produced inconsistent results. Thus, we undertook this larger study to more definitively assess the association between elderly suicide and physical illness. Methods This case-control study compared the proportion with physical illnesses among 822 cases who committed suicide with that among 944 controls who died due to motor vehicle accident at age 55 years or over in Alberta, Canada. Results Compared to the motor vehicle accident deaths, the elderly who committed suicide were more likely to have cancer, ischemic heart disease, chronic pulmonary disease, peptic ulcer, prostatic disorder, depression and other psychiatric illnesses. There was no significant difference in the proportion of cerebrovascular disease and diabetes mellitus between the case and control groups before adjustment of demographic and clinical characteristics. After adjustment of these variables, the elderly with any of the following illnesses were more likely to die by suicide than those without the illness: cancer (adjusted odds ratio [95 % confidence interval]: 1.73 [1.16–2.58]), prostatic disorder (excluding prostatic cancer, 1.70 [1.16–2.49]), chronic pulmonary disease among the married (1.86 [1.22–2.83]), depression (6.70 [4.72–9.50]) or other psychiatric illness (2.16 [1.68–2.76]). There was no evidence that ischemic heart disease, cerebrovascular disease, peptic ulcer and diabetes mellitus might be associated with suicide in the elderly. Conclusions Cancer, prostatic disorder, chronic pulmonary disease among the married and psychiatric illness appear to be associated with suicide among the elderly. Accepted: 17 December 2001     

Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors

Background. Adolescents in many countries show high rates of suicide attempts and repetitions of attempts as a common feature. Attempted suicide is the best predictor of future suicide. Repetition of attempts further increases the risk of suicide. The present study sought to identify patterns and risk factors for repetition of attempts in older teenagers. Methods. Data were collected by uniform procedures in a longitudinal follow-up study in seven European centres participating in the WHO/EURO Multicentre Study on Suicidal Behaviour. Information on attempted suicide in the 15–19-year age group during the period 1989–1995 was analysed. Results. A total of 1,720 attempts by 1,264 individuals over a mean follow-up period of 204 weeks (SD 108.9) were recorded. When life-table analysis was performed, 24 % of the individuals who had previously attempted suicide made another attempt within one year after the index attempt, compared with 6.8 % of the “first-evers”, with no major gender difference. Cox regression analysis revealed that previous attempted suicide (OR 3.3, 95 % CI 2.4–4.4) and use of “hard” methods (OR 1.5, 95 % CI 1.1–2.1) were both significantly associated with repetition of attempted suicide. Stepwise Cox regression analysis showed that a history of previous attempted suicide was the most important independent predictor of repetition (OR 3.2, 95 % CI 2.4–4.4). Conclusion. For young suicide attempters, follow-up and adequate aftercare are very important if repetition and risk of suicide are to be reduced. This applies particularly to those who have already made more than one attempt. Accepted: 19 February 2001