An activity therapy group with children in an in-patient psychiatric setting

This article describes a short-term activity discussion therapy group for severely disturbed children in an inpatient psychiatric unit. Major themes of the sessions are reported as well as clinical vignettes that assist in clarifying techniques and demonstrating the efficacy of these techniques. Co-leaders include a resident psychiatrist, a nurse, and a mental health worker; supervision is provided by a social worker. The group described is on-going at the New York Hospital-Cornell Medical Center (Westchester Division) in the inpatient children's psychiatric unit. In summary, staff report that group members tolerate group activities better and exhibit more socially acceptable interactions.     

Safety considerations in the psychiatric setting

Safety in the psychiatric setting involves many aspects of facility design, renovation, operations, training, and administrative control. Through the application of a systematic hazard-control program, risks may be identified and action taken to reduce or eliminate the potential for accidental or self-inflicted injuries. This paper addresses specific aspects of the hazard-control process and its application at The Sheppard and Enoch Pratt Hospital, Baltimore, Maryland.     

Anticoagulation therapy in a psychiatric setting

Many new psychotropic medicines have the potential to interact with oral anticoagulants. It is well known that warfarin has a narrow therapeutic index and many drug interactions. Although more interest has been evolving around drug interactions between drugs like warfarin and psychotropic medications within the same class (i.e., SSRls), the data is still incomplete. Careful monitoring should be performed when suspected interacting drugs are introduced or discontinued. Also, advances have occurred in both the indications for anticoagulation and how therapy is monitored. Warfarin was recently approved for secondary prophylaxis after myocardial infarction. Newer agents for anticoagulation such as low molecular-weight heparins have been introduced. The international normalized ratio has replaced prothrombin time as the standard monitoring parameter for warfarin therapy. Armed with the proper informatioN. the psychiatrist can make appropriate decisions regarding the management of thromboembolic disease while treating the patient in a psychiatric setting.     

Hallervorden-Spatz disease in a psychiatric setting

Neurodegenerative disorders of sufficient severity to be lethal are also likely to generate psychiatric symptomatology. At times, behavioral changes may predate neurologic manifestations, whereas at other times disturbances in mental status and physical functioning may coexist. In either situation, accurate assessment and appropriate treatment may prove challenging. The case of Hallervorden-Spatz disease reported here illustrates this difficulty; the authors present it to highlight the general issues that often arise in this group of illnesses. In this patient, as well as in three of his relatives, initially subtle neurologic signs were preceded by and then intermingled with significant and sometimes severe symptoms of depression. The authors emphasize the importance of attending to the neurologic symptom picture and family history in order to more appropriately assess the psychiatric manifestations of the disorder. Knowledge of neurodegenerative illnesses, even those as admittedly rare as Hallervorden-Spatz disease, can facilitate accurate and prompt diagnostic assessment, guide treatment strategies (including avoidance of inappropriate interventions), and help to more realistically define outcome expectations.     

Clinical characteristics and psychiatric comorbidity in males with exhibitionism

BACKGROUND: This study was constructed to detail the demographic and phenomenological features of males with exhibitionism. METHOD: Male subjects with DSM-IV exhibitionism were administered a semistructured interview to elicit demographic data and information on the phenomenology, age at onset, and associated features of the disorder. Subjects also underwent structured clinical interviews to assess both Axis I and Axis II comorbidities. Data were collected from September 2003 to March 2005. RESULTS: Twenty-five males with exhibitionism (mean +/- SD age = 35.0 +/-13.1 years [range, 14-68 years]) were studied. The majority of subjects were single (60% [N = 15]) and heterosexual (80% [N = 20]). The mean +/- SD age at onset for exhibitionism was 23.4 +/-13.1 years. All subjects reported urges to expose themselves with little control over these urges. Exposing oneself while driving was the most common expression of the disorder. Twenty-three (92%) suffered from a current comorbid Axis I disorder (major depressive disorder, compulsive sexual behavior, and substance use disorders were most common), and 40% (N = 10) suffered from a personality disorder. Suicidal thoughts were common (52% [N = 13]), and many (36% [N = 9]) had been arrested for exhibitionism. CONCLUSION: Exhibitionism appears to be associated with high rates of psychiatric comorbidity and impairment. Research is needed to optimize patient care for men with this disorder.     

Police-registered offenses and psychiatric disorders among young males

OBJECTIVE: To study associations between crime and psychiatric disorders among adolescent males in a representative population-based cohort study. METHOD: The sample includes 2,712 Finnish boys born in 1981. Information on criminality consists of offenses registered in the Finnish National Police Register 1998-2001. Crime was classified according to frequency and type (drug, violent, property, traffic, and drunk driving offenses). Information on psychiatric diagnoses between 1999 and 2004 was collected from the Finnish National Military Register. RESULTS: Of the 2,712 boys, 22% had a crime registration during the 4-year period, and 10% had at least one psychiatric disorder according to the Military Register. Those with psychiatric disorders accounted for 49% of all crimes. Of those with more than five crimes (n = 98), 59% had psychiatric diagnoses. After adjusting for other crime types and childhood socio-economic status, property crime was independently associated with several diagnoses: antisocial personality (APD), substance use (SUD), psychotic, anxiety, and adjustment disorders. Drug offending was independently associated with APD, SUD, and psychotic disorder, and traffic offenses with APD. CONCLUSIONS: Youth crime is predominantly associated with antisocial personality and substance use disorders. Crime prevention efforts should focus on boys showing a risk for antisocial and substance use problems. In particular, property, drug, and repeat offenders need mental health and substance use assessment. There is a need to develop integrated mental health and substance use treatment services for young offenders within or alongside the criminal justice system.     

Factors influencing nurse-patient interaction in the acute psychiatric setting: an exploratory investigation

Nurse-patient interaction in acute psychiatric in-patient facilities has been the subject of much discussion in the literature and remains a contentious issue. How and why nurses interact with patients in the acute care setting requires definition within the current dynamic environment of mental health service provision. Factors which impact on the manner in which nurses care for patients also require investigation. This article presents the findings of a collaborative research study that investigates factors that influence nurse-patient interaction in the acute psychiatric setting. Ten nurses on the study ward were given opportunity, through semi-structured interviews, to outline and describe the factors perceived to influence nurse-patient interaction. Factors identified as influencing interaction included the ward environment, something always comes up, nurses' attributes, patient factors, instrumental support and focus of nursing. Issues which emerged from the study provide managers and clinical nurses with an opportunity for generating new possibilities for nurse-patient interaction. However, these issues must be addressed in a sensitive way that takes into account the complex and dynamic nature of acute care settings.     

Asperger's disorder in the emergency psychiatric setting

Asperger's syndrome (AS) is a pervasive developmental disorder that may be unrecognized, especially if signs of other psychiatric disorders coexist. The objectives of this paper are: 1) to ascertain the prevalence of AS in the emergency psychiatric setting; and 2) to describe features of AS which may help to differentiate these patients from patients with psychotic disorders. Among 2500 patients admitted to a psychiatric intensive care unit, 5 (0.2%) received a diagnosis of AS, for the first time. Besides impairment of social interaction, common features were the following: male gender, left handedness, obsessive-compulsive symptoms, cognitive hyper-abilities, violent behavior, sense of humor, low WAIS total score, high WAIS verbal/performance score ratio, unusual, restricted interest and clumsiness. Comorbid schizophrenia is difficult to rule out in these patients. Psychotic symptoms should not be overvalued in making the diagnosis when specific features of AS are present.     

Problem patients in a psychiatric inpatient setting

Summary A total of 26 psychiatric inpatients (5.8% of all admissions) in an intensive treatment unit were identified as problem patients by nursing personnel. Reasons for such identification were behavioral pathology of the patient, difficulties of the staff in the relationship with the patient, and insufficient therapeutic progress, and the use of inappropriate therapeutic methods. Compared with a control group, the problem patients were psychotics or personality disorders. They presented more behavioral pathology, were prescribed more medication, and experienced decisively longer hospitalizations, although they profited less from their hospitalization. Follow-up investigation revealed that the majority did not earn their own living, otherwise they were no more poorly socially adapted than the discharged controls. The suicide proneness of problem patients was high. In the treatment of these patients the necessity of adapting the therapeutic standards and expectations is of the utmost importance.     

Children and adolescents in the psychiatric emergency setting.

Emergencies in child and adolescent psychiatry are not uncommon, occur in a variety of settings, and require referral to resources offering different levels of care. Clinicians must be familiar with basic tenets of emergency assessment and treatment whether practicing alone in a rural area or as part of an interdisciplinary team in a busy urban hospital. Recommendations for future research include gathering more extensive epidemiologic data and data regarding practice patterns nationwide and conducting more psychopharmacologic research into the management of patients with acute agitation, aggression, and violence. In addition, outcome data to support provision of necessary inpatient and outpatient services must be collected. The development of successful strategies to prevent psychiatric emergencies in children and adolescents is equally important.     

Post-traumatic stress disorder in the forensic psychiatric setting

The objective was to assess the prevalence of post-traumatic stress disorder (PTSD) in offenders who undergo forensic psychiatric evaluation (FPE), compare differences with regard to the prevalence of PTSD between immigrants and Swedes, compare psychiatric comorbidity and offenses between PTSD and non-PTSD patients, and compare various instruments and questionnaires when assessing the level of PTSD symptoms. Twenty-five immigrants and 25 Swedes were studied consecutively. The Clinician-Administered PTSD Scale (CAPS), Impact of Event Scale-22 (IES), Post-traumatic Symptom Scale (PTSS-10), and Structured Clinical Interview for DSM-IV (SCID)-PTSD were administered. In the immigrant group, 60 percent had PTSD, compared with 12 percent of the Swedes. Subjects with PTSD scored higher on IES-22 and PTSS-10 than those without PTSD. Considering the number of sexual and violent offenses together, the proportion of these types of offenses was higher in the PTSD group than in the non-PTSD group.     

Precipitants of violence in a psychiatric inpatient setting

Data gathered from the medical record and in interviews with staff and patients in an inpatient psychiatric setting at a Veterans Affairs medical center were used to examine events preceding 73 episodes in which patients were placed in four-point restraints. The behaviors leading to restraint included physical aggression, verbal threats, and threats with an object as a weapon. These behaviors were more likely to relate to external situations than to the patient's internal psychiatric symptoms. Staff were most frequently the target of patients' aggression, and patients were more likely to view the events leading to restraint as conflict with staff. No differences in the subsequent number of restraint episodes or hours in restraints were found between patients with positive and negative responses to the index restraint episode.