Patterns of patient contact with psychiatric services

Summary Case Register data were utilised to compare the patterns of contact with psychiatric services made by patients from a single geographical area in London admitted to a teaching hospital, a mental hospital, or a psychiatric unit in a general hospital during the early part of 1969. Patterns of care during individual episodes were clearly different in the settings studied, but the duration of care was similar in each case. Similar lengths of time were spent during a three year period in contact with local services by patients whose index admission was to the different hospitals. The results suggest that management policies may affect the kind of contact which patients have with psychiatric facilities without any marked general effect upon the overall duration of that contact.     

Session-by-session report of low frequency Kleinian psychoanalysis: establishing analytic contact with a borderline patient

There is virtually no literature regarding the psychoanalytic treatment of patients with less than three times a week frequency other than those articles that include the word psychotherapy in the title. Even though more lenient positions are taken in public forums and between colleagues, there is still a vast political distance between what is considered kosher psychoanalysis and "that other procedure." The leading publication for psychoanalysis worldwide, the International Journal of Psychoanalysis, now includes articles on psychoanalytic psychotherapy. It is remarkable, but never mentioned, to notice how the cases and clinical process written about are usually indistinguishable from the cases and clinical process in all the other articles concerning psychoanalysis. This author presents material based in the belief that if a consistent pattern of transference analysis has taken place along with regular exploration of phantasy and defense, then, regardless of frequency, analytic contact can take place. This treatment is then regarded as psychoanalysis. In other words, psychoanalysis becomes defined by clinical process rather than external criteria. This article examines the establishment of analytic contact with a borderline patient within a twice-a-week, on-the-couch, Kleinian framework.     

Confabulation in a patient with fronto-temporal dementia and a patient with Alzheimer's disease

This paper describes two patients, O.I. and B.Y., with a confabulatory syndrome. O.I. was diagnosed with probable fronto-temporal dementia, whereas B.Y. met the criteria for probable Alzheimer's disease. O.I., but not B.Y., was impaired on tests of frontal/executive functions, and performed better than B.Y. on clinical tests of memory. Both patients confabulated in episodic/autobiographical memory tasks and in personal future planning tasks. B.Y. confabulated also in a semantic memory task. It is argued that the pattern of confabulation and the cognitive profile shown by the two patients is explained better by the hypothesis proposed by Dalla Barba and co-workers (Dalla Barba et al., 1997b) than by current theories of confabulation.     

Proximal paraparesis due to aortic dissection extending into bilateral carotid arteries in a patient with Loeys-Dietz syndrome

The authors report a 66 year-old female with past medical history relevant for thoracic abdominal aneurysm who presented with a complaint of chest pain radiating into her neck. The physical examination was significant for the distinctive facial features of wide spaced eyes and V-shaped uvula. Thoracic CT scan revealed a type I aortic dissection which warranted immediate surgical repair. On post-op day one she was noted to be confused and was found to have acute bilateral lower extremity paraparesis with proximal predominance. Furthermore, her left radial artery line had no pulse waves and no brachial, radial, or ulnar pulses could be detected with Doppler ultrasound. Emergent head CT scan revealed bilateral postcentral gyri infarctions and the thoracic CT scan demonstrated extension of the dissection into the aortic branches, including the left brachial and the bilateral carotid arteries. Consequently, surgical brachial artery repair ensued. In the interim, a repeated head CT scan demonstrated new ischemic infarcts involving the bilateral frontal lobes. Anticoagulation was not indicated due to the high risk of bleeding at surgical site. Genetic testing confirmed the presence of a mutation in the TGFBR2 gene at exon 5. Loeys-Dietz syndrome is an autosomal dominant disease caused by heterozygous mutations in the genes encoding type I or II transforming growth factor-β (TGF-β) receptor. Loeys-Dietz syndrome manifests with aggressive vascular pathology. This case underscores the importance of recognition of this spectrum of clinical and pathologic manifestations to identify and manage Loeys-Dietz syndrome.     

Awareness of being a patient and its relevance to insight into illness in patients with schizophrenia.

This article presents the development of the Awareness of Being a Patient Scale (ABPS), a 25-item self-report scale to measure the awareness of schizophrenic patients. Awareness is defined in terms of a patient's psychological attitude toward the psychiatric situation, and is to be evaluated from the standpoint of Parsons' sick-role concept by assessing the recognition of the need for treatment and acceptance of the treatment situation. It is hypothesized that awareness is a factor in the motivation to receive treatment. Closely related to the awareness is the insight into illness, a clinical construct comprising a patient's understanding of psychotic illness and symptoms. There also seems to be an overlap between them. However, the difference is that awareness principally pertains to a patient's perspective, not addressing the precise understanding of illness and symptoms, while the frame of reference in assessing insight is from the viewpoint of psychiatry. In examining properties of the ABPS, it is demonstrated that the ABPS has satisfactory reliability, favorable concurrent validity, and significant value in discriminating between long-term stable outpatients and recently admitted and long-term hospitalized patients. This study indicates that the awareness of being a patient has clinical importance and the ABPS is an efficient means of measuring such awareness.     

Barognosis in a patient with hemiataxia

Barognosis was tested in a patient who had a lesion of the right cerebellar hemisphere. While blindfolded, he used each hand to estimate the mass of given test loads, alternating hands between trials. He moved each load sinusoidally, comparing it with the previous one. The period of oscillation was found to be a linear function of the mass. With each load, the period of oscillation was longer when he used the ataxic hand. On 23 of 59 comparisons between loads, the patient reported incorrectly. Ninety-one percent of the errors were in the direction of loads feeling heavier when the ataxic hand was used. To explain these results, it is proposed that (1) the perceived magnitude of a load depends on the corollary discharge, and (2) cerebellar damage may reduce the accuracy of the corollary discharge.     

Establishing therapeutic contact with schizophrenics: a supervisory approach

The beginning resident in psychiatry often finds schizophrenic inpatients to be noncompliant with the standard therapeutic approaches. This can present a significant supervisory challenge. An approach that views the schizophrenic as deficient of "good" objects and emphasizes the resident's capacity to form ordinary human relationships is discussed as a means of establishing therapeutic contact.     

Approach to a patient with blepharoptosis

Blepharoptosis or drooping of upper eye lid is a common, but non-specific sign of neurological diseases which sometimes could herald a life-threatening disorder. First, the diagnosis of ptosis should be established by considering four clinical measurements: palpebral fissure height, marginal reflex distance, upper eyelid crease, and levator function test. The diagnostic categories of ptosis are scheduled as pseudo-ptosis, congenital, and acquired ptosis. Acquired causes include mechanical, myogenic, neuromuscular, neurogenic, and cerebral. Each category with diseases presenting with ptosis was described in detail. Considering some features, such as involvement of other cranial nerves, extraocular muscle, pupil size and reactivity, and unilateral or bilateral presentation of ptosis, could help to narrow the differential diagnosis.     

Epileptic seizures in a patient by immersing his right hand into hot water

We report on a 22-year-old assistant cook, presenting with seizures evoked by immersing his right hand into hot water of 40-46 degrees C. His seizure pattern consisted of either simple partial seizures of a tingling sensation arising in the right hand and marching to the right shoulder or a similar attack evolving to a complex partial seizure. Video-EEG monitoring recorded habitual seizures originating from the left centro-temporo-parietal region, compatible with lesions seen on brain magnetic resonance imaging. He responded well to antiepileptic drug treatment and wearing gloves while working in the kitchen. In this patient, hot water of 40-46 degrees C could maximally stimulate skin warm thermoreceptors in the right hand whereby afferent impulses subsequently activated the epileptogenic focus, adjacent to or in the sensory cortex, and elicited seizures.     

Acute paresthesia in a patient with migraine

Ergot-containing medications are widely used to treat migraine patients in some countries but nowadays intoxication is only reported rarely. We report a 35-year-old woman who presented with acute paresthesia of the extremities. An angiogram revealed diffuse vasospasm of the femoral arteries bilaterally and the right brachial artery. History taking disclosed a possible interaction between ergotamine and macrolide antibiotics. The patient’s symptoms improved rapidly after discontinuation of the offending medication and administration of vasodilators. This report aims to remind physicians that catastrophic adverse effects can develop through unrecognized drug interactions, even with widely prescribed medications given in safe dosages. The importance of a detailed drug history and knowledge of drug interactions cannot be overemphasized in the diagnosis of ergotism.     

Botulism in a patient with jejunoileal bypass

A 45-year-old woman was diagnosed as having the unclassified form of botulism. Her intestines may have been predisposed to colonization with Clostridium botulinum because of a jejunoileal bypass procedure that had been done several years earlier. One other similar case has been reported.