Between a psychiatric diagnosis and a familial diagnosis

If the idea of a biopsychosocial model is not going to be merely a phrase, then every clinical diagnosis and therapeutic vision need to consider the familial issues. Taking the family issues into consideration has evident gains; it allows for a better understanding of the patient and allows for actions which reduce the risk of a relapse of illness. The fact that such issues are not part of the therapeutic armament, despite the effectiveness of psychoeducation, is bewildering: on one hand the families are not always invited to co-operate, on the other hand--they often give up this co-operation. In such a situation, the relation between the patient's family and the personnel needs analysis, especially common, often unconscious emotions and prejudices. They can form a dysfunctional 'knot', which does not allow for a therapeutic alliance to be formed. How to come out from such an impasse and make a common positive alliance? Paradoxically, the therapeutic possibilities are bigger when--especially in the initial phase of treatment--the psychiatrist "is able to not know" and is capable of listening into the patient's family perspective, and has an interest in the 'family story'. It is only after the knowledge on the family is gained and the family perspective is accepted, that the deconstruction of that part of the family's story that forms the problem and a common search for "positive changes" are possible. Although it may not appear to be so, such an ordeal can be very difficult for the psychiatrist who is used to controlling the situation through psychiatric theory and diagnosis, psychiatric language and the psychiatric institution. The issue presented appears to be part of a universal dilemma: what is the range of "the language power" of the psychiatrist and when is the sharing of this power with the patient and the family beneficial for the therapy.     

Impact of a family-centred approach on a couple living with a brain tumour: a case study

The diagnosis of a malignant brain tumour can be devastating for both patients and their families. Despite neurological and cancer treatment advances, there has been little progress in extending life expectancy for these patients. Cassileth et al. (1985) suggest that of all types of cancer, brain tumours cause the most psychosocial repercussions for the family. The brain tumour clinical nurse specialist (CNS) is in a strategic position to intervene with families along the continuum of care by using a family-oriented approach which can facilitate their adaptation to this health problem. The present case study will describe the illness experience of one couple where a member had a brain tumour. The process of assessment, interventions and outcomes will be highlighted. The CNS utilized the Calgary Family Assessment Model (CFAM) (Wright & Leahey, 1984) and Calgary Family Intervention Model (CFIM) (Wright & Leahey, 1994) to guide her work with this family. An example of an intervention was the illness narrative approach. In this approach the concepts of illness experience, perceptions, beliefs and support were used as part of the therapeutic modality which served to enhance the coping strategies of the couple and decreased their crisis situation. This collaborative style of nursing promoted the well-being throughout the illness trajectory of both the family and the CNS.     

Diagnostic agreement between a doctor and a nurse for psychiatric disorders: a pilot study

The objective of the study was to examine inter-rater agreement for psychiatric disorders by means of a structured interview performed by a psychiatrist and a nurse. Sixteen psychiatric inpatients with a mean age of 38.9+/-12.9 years were assessed independently by a psychiatrist and a nurse using a structured psychiatric interview, Strukturert Psykiatrisk Intervju for Allmennpraksis (SPIFA). For most diagnoses, agreement was substantial to perfect (kappa = 1 for the diagnoses major depression, generalized anxiety disorder, obsessive-compulsive disorder and substance abuse). Fair to moderate kappa values were found for personality disturbances and dysthymia. The results of this study indicate that after adequate training nurses can perform structured psychiatric interviews with a high inter-rater agreement.     

Melatonin: a clock-output,a clock-input

In mammals, the circadian system is comprised of three major components: the lateral eyes, the hypothalamic suprachiasmatic nucleus (SCN) and the pineal gland. The SCN harbours the endogenous oscillator that is entrained every day to the ambient lighting conditions via retinal input. Among the many circadian rhythms in the body that are driven by SCN output, the synthesis of melatonin in the pineal gland functions as a hormonal message encoding for the duration of darkness. Dissemination of this circadian information relies on the activation of melatonin receptors, which are most prominently expressed in the SCN, and the hypophyseal pars tuberalis (PT), but also in many other tissues. A deficiency in melatonin, or a lack in melatonin receptors should therefore have effects on circadian biology. However, our investigations of mice that are melatonin-proficient with mice that do not make melatonin, or alternatively cannot interpret the melatonin message, revealed that melatonin has only minor effects on signal transduction processes within the SCN and sets, at most, the gain for clock error signals mediated via the retino-hypothalamic tract. Melatonin deficiency has no effect on the rhythm generation, or on the maintenance of the oscillation. By contrast, melatonin is essential for rhythmic signalling in the PT. Here, melatonin acts in concert with adenosine to elicit rhythms in clock gene expression. By sensitizing adenylyl cyclase, melatonin opens a temporally-restricted gate and thus lowers the threshold for adenosine to induce cAMP-sensitive genes. This interaction, which determines a temporally precise regulation of gene expression, and by endocrine-endocrine interactions possibly also pituitary output, may reflect a general mechanism by which the master clock in the brain synchronizes clock cells in peripheral tissues that require unique phasing of output signals.     

Crisis debriefing of a jury after a murder trial

The importance of crisis debriefing for those involved in major accidents, violent crimes, and natural disasters has been demonstrated. Similar debriefing may be warranted for jurors exposed to disturbing material in criminal cases. The authors describe a debriefing session for jurors after the murder trial of a man whose truck had collided with a school bus, killing 27 people. The graphic evidence of the accident, the high levels of emotion of the survivors and the victims' relatives, and the intense community and national attention to the trial placed the jurors under considerable stress. The debriefing enabled the jurors to express their feelings of anger, guilt, and frustration and to begin to accept their role in the event.     

Magnetic localization of a dipolar current source implanted in a sphere and a human cranium

Magnetic fields produced by a dipolar source implanted in a spherical conductor and a human cranial specimen were measured in the magnetoencephalogram (MEG). The location of the source was accurately computed in the spherical conductor from the identified magnetic field extrema using equations for a current dipole in a sphere. This same method was insufficient for localizing the source in a human cranium, where magnetic field maps appeared as distortions from the classical dipolar pattern. A more complete computer modeling procedure was used, adjusting for the non-spherical dimensions of the recording matrix on the cranium. By fitting the gradient of computer simulated fields to those measured outside the cranium, the accuracy of source localization was substantially improved. The greatest distortion of the extracranial magnetic field was an inequality in the measured amplitude of the two extrema, produced by an increased distance and angle of the MEG probe when recording over the lower face and ear. However, gross heterogeneities in the resistance of the skull due to a craniectomy and an implanted insulating balloon had a negligible effect on the extracranial magnetic field pattern.     

Portrait of a sadist as a young man

Treatment of chronically violent patients poses problems for the therapist in a number of ways. Institutional demands, concern for one's personal safety, and psychotic transferences are common. This case details the treatment of one young violent offender.     

Psychiatric referrals from a renal unit: a study of clinical practice in a British hospital

Renal patients referred for a psychiatric opinion were compared with patients from the same unit who had never seen a psychiatrist. Overall the referrals had more psychiatric symptoms, but syndrome profiles of the two groups were very similar. In diagnostic terms, the referrals differed in having a range of adjustment disorders characterised by changes other than simple mood disturbance. There were relatively few major mental illnesses. Three other factors were associated with referral: youth, absence of a confiding relationship; and currently receiving haemodialysis. Most referrals were managed with short term non-intensive therapies, and there was little need for psychiatric in patient care. Psychiatric disorder did not influence survival. The significance of these findings for renal unit psychiatry is discussed.     

Detecting errors in a scoring program: a method of double diagnosis using a computer-generated sample

This paper discusses a new method for locating errors in diagnostic computer scoring programs for structured clinical interviews. It was proposed as a test of the accuracy of the scoring program for the Composite International Diagnostic Interview, version 1.1. The proposal was to create an independent scoring program in a different computer language but serving the same criteria. Both programs were then applied to the same large set of valid (i.e., logically consistent) computer-generated test cases, and differences in diagnostic assignments reviewed. The method described can identify the program steps that account for the sources of the errors. Corrections can be made and the programs run again on new sets of test cases until discrepancy-free results are achieved. While this method cannot discover errors that are repeated in the two programs, it does discover more of the errors in a scoring program than we have previously been able to identify. This technique provides a systematic and rigorous approach to assuring the accuracy of scoring programs based on established algorithms. Accepted: 28 August 1997     

Urethral extrusion of a peritoneal catheter in a patient with a neobladder: a rare complication of shunt insertion

The insertion of a ventriculoperitoneal shunt (VPS) is considered the standard of care for several forms of hydrocephalus. Abdominal complications are most common with this procedure, comprising up to 30% of all shunt-related problems. Conversely, visceral perforation or extrusion of the shunt apparatus is rare. Herein we report a rare complication of VPS insertion in which the peritoneal catheter was spontaneously extruded through the urethra of a patient with a neobladder. We further discuss the pathogenesis, diagnosis, and treatment of this condition.     

Antiepileptic drugs: a case report in a pregnancy with a neural tube defect

While receiving lamotrigine, a patient pregnant with triplets suffered a double fetal neural tube defect. Plasma homocysteine, folate, vitamins B12 and B6 (pyridoxal phosphate), and red cell folate levels were measured in samples while she was receiving folic acid therapy for 1 month during the second trimester of pregnancy. Some mutations were sought, involved in homocysteine metabolism and linked with the folate metabolism. Her results were compared with those of a pregnant woman with normal triplets and with those of 58 pregnant women, with a normal pregnancy. Results indicated a decrease in vitamin B12 and B6 values in plasma in the patient, and a genotype AG (polymorphism A66G) was observed, but was not found in the pregnant woman with normal triplets. Even if lamotrigine therapy is not known to be associated with significant changes in red cells or in serum folate, periconceptional folic acid supplementation is counseled for women, along with periconceptional B12 and B6 vitamin supplementation when their plasma values are decreased.     

Stepping Stones Triple P seminars for parents of a child with a disability: a randomized controlled trial

Parents of children with a developmental disability require tailored parenting support, as their families have special needs and are at risk of increased burden. The aim of this study was to evaluate the efficacy of the Stepping Stones Triple P seminars, a brief group intervention for parents of a child with a disability. There were two seminars that presented parenting strategies to improve both child behavior and parenting variables implicated in the development and maintenance of child problem behavior. Fifty-three parents participated in this randomized controlled trial. Each had a child, aged two to ten, with a disability. The results indicated significant reductions in child behavior problems, the use of dysfunctional parenting styles, and parental conflict reported by parents in the intervention group compared to a waitlist group. The results were maintained at 3-month follow-up and there was evidence of a sleeper effect for parenting confidence. This study demonstrated that the seminars provide a promising intervention for parents of children with a disability. Limitations and implications for future research are also discussed.     

Training a retarded child as a behavioral teaching assistant

After baseline observations were made of the classroom disruptive behavior of three retarded children, a behavior modification program was initiated. Hector, a 14-yr-old boy with an IQ of 42 distributed candy reinforcers to the best behaved pupils in a class for the severely retarded. The two most distruptive children in the class were made targets for behavior modification by Hector, who was first required to earn the privilege of being a teaching assistant by behaving well in his own classroom. Hector's appropriate behavior increased when he was reinforced by serving as a “helper” and the target children behaved more acceptably through the behavior modification program even though the reinforcers were delivered by a peer.     

Why Doesn't a Family Member of a Person With Advanced Dementia Use a Substituted Judgment When Making a Decision for That Person?

OBJECTIVE: The objective of this study was to identify what standard of decision making a family member uses when making medical decisions for their relative with advanced dementia. METHODS: Thirty family members of patients with advanced dementia from an Alzheimer disease center and a suburban long-term care facility were interviewed using a semistructured interview. All interviews were audiotaped, transcribed, and analyzed using qualitative data analysis techniques. RESULTS: Family members were split almost evenly in the standard they used when making medical decisions for their relative: substituted judgment (43%) or best interests (57%). However, few who used the substituted judgment standard viewed it as distinct from best interests. Instead, both standards were taken into consideration when making medical decisions. In addition to not having discussions about healthcare preferences, the reasons for not using a substituted judgment included: the need for family consensus, unrealistic expectations of the patient, the need to incorporate their relative's quality of life into the decision, and the influence of healthcare professionals. Family members who did not have discussions about healthcare preferences identified various barriers to the discussion, including waiting too long, avoiding the topic, and the patient's denial of dementia. CONCLUSION: These data suggest several reasons why surrogate decision-makers for persons with advanced dementia do not use the substituted judgment standard and the potential value of interventions that would allow patients with early-stage dementia and their family members to discuss healthcare preferences.     

Sleepwalking violence: a sleep disorder, a legal dilemma, and a psychological challenge

OBJECTIVE: The purpose of this article is to further an understanding of the psychological state when aggression follows an episode of partial arousal from early non-REM sleep during which some areas of the brain appear to be functioning as in waking while others appear to remain in a state of sleep. To illustrate this, the author examines a case of homicide for which the defense argued lack of responsibility due to sleepwalking. METHOD: A review of the forensic literature on sleepwalking aggression and sleep studies suggests that these fall into one or both of two DSM-IV-TR diagnoses: sleepwalking disorder and sleep terror disorder. The new case, which would meet criteria for an overlap disorder in which sleepwalking is followed by sleep terror, is compared to one previously published. RESULTS: These findings support sleepwalking violence as a distinct overlap disorder with common disturbed psychological functioning during and for a period up to 1 hour following an aggressive episode. CONCLUSIONS: Research clarifies the pathology of this disorder and highlights the need to both refine the differential diagnosis and test the efficacy of treatment protocols.     

The resident as a teacher: a neglected role

Residents are frequently requested to take on teaching responsibilities, especially with medical students, but they receive little formal preparation for this role. This paper reviews some of the problems residents may face when teaching and describes a training workshop designed to enhance the teaching skills of residents. The workshop is based around a simulated teaching event that focuses on the organizational and practical, as well as didactic tasks involved in supervision of a clinical clerk. Such a workshop helps the resident to identify and prepare for some of the problems they may encounter and provides them with an opportunity to develop new skills that will improve the quality of their teaching.     

A coinsidence,a chance or a misfortune? Hangman's fracture

William R. Francis and Bassam El-Effendi shared a common ground: they were the first individuals to classify Hangman's Fractures. Interestingly, although they were unaware of each other, they classified and published their findings in the same year, published in the same edition of the same journal (but on different pages). This new classification system was a chance for notoriety for El-Effendi, yet it was a misfortune for Francis. Both physicians graduated in 1973 (from different universities). Also fellows at different universities in 1981, they were also both unaware they studied the same topic. Coincidentally, their paths crossed in the same edition of a journal where their studies were published in the same year, which was unprecedented in the literature. One classification scheme is well-known while the other is almost completely unheard of for no apparent reason other than chance for one and misfortune for the other.     

Testing a maintenance model for eating disorders in a sample seeking treatment at a tertiary care center: a structural equation modeling approach

Fairburn et al (Fairburn, CG, Cooper, Z, Shafran, R. Behav Res Ther 2003;41:509-528) proposed additional maintenance mechanisms (ie, interpersonal difficulties, mood intolerance, low self-esteem, and perfectionism) for some individuals with eating disorders in addition to core eating disorder psychopathology (ie, overevaluation of eating, weight, and shape and their control). This is the first study to both elaborate and test this maintenance model as a structural model. Adults seeking treatment of an eating disorder (N = 1451) at a specialized tertiary care center were included in this cross-sectional study. In the first part of the study, diagnostically heterogeneous participants (n = 406) were randomly selected to test a structural model based on the maintenance model. In the second part of the study, remaining participants (n = 1045) were grouped according to eating disorder diagnosis to test for invariance of the structural paths of the final model across diagnoses. Overall, the structural model with core and additional mechanisms fit the data well and, with 1 exception, represented maintenance processes for each of the diagnostic groups. Treatment models based on both core and additional maintenance factors for those seeking therapy at a specialized tertiary care center may result in improved treatment outcomes for these patients with eating disorders.     

Coadministration of a beta-adrenergic antagonist and a tricyclic antidepressant: a pilot study

After a 7-day washout period, 16 subjects suffering from unipolar depression were randomly assigned to either desipramine (DMI) or DMI plus propranolol treatment for 21 days. Both groups showed a significant improvement in their scores on the Hamilton Rating Scale for Depression (HRSD) after 21 days of drug treatment. However, there was no significant difference in the improvement in HRSD scores between the two groups. The results of this pilot study support the need to reevaluate the popular belief that propranolol induces or worsens depression.     

Intraparenchymal Pericatheter Cyst as a Complication of a Ventriculo-Peritoneal Shunt in a Premature Infant

A ventriculo-peritoneal shunt is a standard surgical management for hydrocephalus, but complications may impede the management of this disease. Obstruction of the catheter is one of the most common complications and manifests clinically in various ways. Intraparenchymal cyst development after shunt malfunction has been reported by several authors, but the underlying mechanism and optimal treatment methods are debatable. The authors report a case of intraparenchymal cyst formation around a proximal catheter in a premature infant after a ventriculo-peritoneal shunt and discuss its pathogenesis and management.