Blood or needle phobia as a defence under the Road Traffic Act 1988

A man was charged with driving over the prescribed alcohol limit. Both specimens of breath contained less than 50 micrograms of alcohol per 100 ml and he refused to submit to a blood test. His defence was that he had a phobia of blood and that he should have been allowed to claim to replace the breath specimens with a specimen of urine. Evidence that he had a phobia was accepted by the prosecution. A woman was arrested on suspicion of driving whilst unfit through drink or drugs. She was charged with refusing to provide a specimen of blood. It was her defence that she had a phobia of needles. Evidence that she had a phobia was not accepted by the prosecution. In both cases the court was asked to decide whether or not the forensic medical examiner had been seriously wrong in deciding that there was no medical reason for refusing a specimen of blood. The man was acquitted and the woman was found guilty. These cases are used to describe the law relating to blood or needle phobias and to suggest how such cases should be approached by the police and forensic medical examiners.     

Desensitizing a pilot with a phobic response to required helicopter underwater escape training

INTRODUCTION: A systematic desensitization program designed to help aircrew who have a phobic anxiety of the Helicopter Underwater Escape Training (HUET) has been developed. CASE PRESENTATION: A student pilot presented with a severe phobic anxiety of the HUET course--a result of a being trapped underwater on a marine survival training course. A treatment team was assembled and concluded his phobia could be treated by a systematic desensitization method. An exposure matrix of graded difficulty of in/underwater escapes was performed over 2 d. The student reported that his confidence increased and anxiety reduced as he became accustomed to being strapped into a seat in the escape trainer while wearing increasingly difficult levels of equipment which increased the difficulty of escape, such as taking away nasal protection and goggles. At the end of Day 1, he was able to jettison the exit door/hatch while inverted underwater with a facemask and dressed in a simple coverall. At the end of Day 2, without nasal protection, inverted underwater, wearing full military equipment, he was able to cross the cabin, jettison the exit door, and successfully escape. DISCUSSION: A systematic desensitization treatment program can be used to successfully treat aircrew for phobia of the helicopter underwater escape trainer.     

Prevalence of psychiatric disorders in a mandatory screening program for infection with human immunodeficiency virus: a pilot study

Ninety-five randomly selected human immunodeficiency virus (HIV)-seropositive Air Force personnel were psychiatrically examined during a routine medical evaluation. Of the 95, 95% did not have acquired immunodeficiency syndrome and were largely asymptomatic; 61.1% had clinical axis I diagnoses, which included simple phobia, adjustment disorders, hypoactive sexual desire disorder, alcohol use disorder, major depression, and organic mental disorders; 30.5% had personality disorders. Significantly higher frequencies (p less than 0.05) of simple phobia and hypoactive sexual desire disorder were noted with knowledge of HIV seropositivity. Disorders that occurred more commonly than in age-matched Epidemiologic Catchment Area (ECA) participants included: simple phobia, antisocial personality disorder, alcohol abuse, and organic mental disorders. The high prevalence of major psychiatric illness in this sample supports the notion that screening for psychiatric illness, and counseling where indicated, should be integral to HIV screening programs.     

Applied tension treatment of vasovagal syncope during pregnancy

Vasovagal syncope is a common clinical problem that is often difficult and expensive to diagnose and treat. Applied tension is a behavioral treatment approach that has been demonstrated to be efficacious for the treatment of vasovagal syncope associated with injection phobia. The present case study evaluated the treatment of vasovagal syncope in a 41-year-old pregnant patient with injection phobia. The treatment included the use of applied muscle tension to increase blood pressure and prevent syncope during graduated exposure to increasingly greater anxiety-provoking stimuli. After completion of the treatment, the patient was able to undergo a blood draw and other medical procedures involving exposure to needles, with significantly reduced anxiety and no episodes of syncope. Applied tension is an effective and relatively inexpensive treatment for patients with vasovagal syncope related to injection phobia and may hold promise as a treatment for other types of syncope.     

Regional cerebral perfusion in cardiovascular reflex syncope

Little is known about the regional cerebral perfusion in subjects with presyncope or syncope, and the impact that autonomic nervous dysfunction has on it. Seven subjects with cardiovascular vasodepressor reflex syncope were studied. A baseline test was performed with the patients standing in the 70° upright position, while the passive head-up tilt table test with and without isoprenaline infusion was employed for provocation. Regional cerebral perfusion was assessed by means of single-photon emission tomography with technetium-99m labelled V-oxo-1,2-N,N ₁-ethylenedylbis-l-cysteine diethylester (baseline, and during blood pressure decline in the provocation test) and the autonomic nervous function by means of spectral analysis of heart rate variability (baseline, and before blood pressure decline in the provocation test). Every subject showed an abrupt decline in blood pressure in the provocation test (five with presyncope and two with syncope). The systolic and diastolic blood pressures decreased significantly (P<0.001) between the baseline and the provovation study time points (radiopharmaceutical injection and lowest systolic blood pressure). Mean cerebral perfusion as average count densities decreased upon provocation as compared with baseline (190±63 vs 307±90 couts/voxel, respectively,P=0.0013). Hypoperfusion was most pronounced in the frontal lobe. These results suggest that cerebral perfusion decreases markedly during presyncope or syncope with systemic blood pressure decline in subject with cardiovascular vasodepressor syncope. Furthermore, the autonomic nervous function remains unchanged before the systemic blood pressure decline.     

Clinical and electroencephalographic features of carotid sinus syncope induced by internal carotid artery angioplasty

BACKGROUND AND PURPOSE:Carotid sinus syncope may occur acutely during internal carotid artery angioplasty (CA). We performed this study to investigate the clinical, electroencephalographic (EEG), and hemodynamic features of carotid sinus syncope induced by CA.MATERIALS AND METHODS:Between 1992 and 2003, clinical, EEG, and cardiovascular monitoring was performed in 359 consecutive patients undergoing CA.RESULTS:Carotid sinus reaction (CSR) and syncope occurred in 62.7% and 18.6% of the procedures, respectively. CSR and syncopal spells were classified into cardioinhibitory, vasodepressor, and mixed type. Syncope occurred more frequently in patients with cardioinhibitory CSR (P < .001). The odds ratios for the risk of syncope in patients with cardioinhibitory CSR and vasodepressor/mixed CSR were 6.9 and 1.4, respectively. Sixty-one patients had cardioinhibitory syncope; 7 had the vasodepressor/mixed type. Thirteen spells were not related to cardiovascular disturbances. This last syncope subtype was significantly associated with brain hemodynamic disturbances, including a decrease in cerebral vasoreactivity (P = .04) and the absence of function of both communicating arteries (P = .03). Convulsive movements resembling supplementary sensorimotor seizures occurred in 79% of patients who experienced syncopal spells. EEG changes were more prominent in patients with cardioinhibitory syncope.CONCLUSIONS:Syncope occurs frequently in patients undergoing CA and can be misdiagnosed as seizures. The most frequent mechanism was a cardioinhibitory response. Cerebral hemodynamic disturbances may play a crucial role in the pathophysiology of syncope with normal sinus rhythm and normotension. Moreover, direct depression of the CNS following carotid sinus distension is likely to be involved.

Carotid sinus reaction (CSR) is one of the most common complications of internal carotid artery angioplasty (CA). It may occur due to an abnormal response to a baroreflex related to an overstretch of the carotid sinus caused by the dilating balloon. Accordingly, the occurrence of CSR is usually accompanied by vasodepressor reactions, including bradycardia, asystole, and hypotension. McIntosh et al¹ previously reported abnormal cardioinhibitory responses in 80% of all CSRs and abnormal vasodepressor responses in 5%–10% of patients.Carotid sinus hypersensitivity is most commonly found in men, at an older age,² as well as in the presence of arterial hypertension, diabetes mellitus, ischemic heart disease,³ and carotid stenosis.⁴ It follows that patients undergoing CA may have high rates of carotid hypersensitivity. Therefore, CSR may occur acutely during CA and is often accompanied by the appearance of neurally mediated reflex syncope.^5–8To the best of our knowledge, no previous study has examined the prevalence of loss of consciousness during CA procedures. We performed this study to investigate the clinical, electroencephalographic (EEG), and hemodynamic features of carotid sinus syncope induced by CA.     

Head-up tilt test for recurrent syncope in pilots

Syncope is defined as a sudden temporary loss of consciousness and postural tone that is associated with spontaneous recovery. Vasovagal or neurocardiogenic syncope is a common and usually benign cause of syncope. The mechanism may be cardioinhibitory, vasodepressor, or both. Diagnosis is usually made by a typical patient history with a definite trigger. Although vasovagal syncope is considered a benign condition, its occurrence in an aviator is worrisome, especially if recurrent and without a definite trigger. The head-up tilt test (HUTT) is used as a vasovagal syncope challenge test. A drop in BP and asystole during HUTT suggest a tendency to recurrent vasovagal syncope. We describe two military aviators with recurrent episodes of vasovagal syncope, one with definite triggers and one without. Both had positive HUTTs. The aviator with trigger-defined vasovagal syncope was disqualified from high-performance platforms due to his positive HUTT. The second case was disqualified from all platforms, irrespective of his HUTT result, because a definite trigger was not definable for all his syncopal episodes.     

Assessment of left ventricular volume by an ambulatory radionuclide monitoring system during head-up tilt in patients with unexplained syncope: Relation to autonomic activity assessed by heart rate variability

BACKGROUND: Decreased left ventricular volume during head-up tilt plays an important role in triggering syncope in patients with neurally mediated syncope. However, precise changes in left ventricular volume during head-up tilt have not been well investigated. This study was conducted to test the hypothesis that the decline in left ventricular volume during tilt could trigger ventricular mechanoreceptor activation. METHODS AND RESULTS: To investigate the mechanisms of tilt-induced syncope, we measured the temporal changes in left ventricular volume, ejection fraction, cardiac output, and heart rate variability indices during head-up tilt in 25 patients with syncope of undetermined etiology. Eleven patients had a cardioinhibitory response (CI group), 7 patients showed a vasodepressor response (VD group), and 7 patients demonstrated a negative response (NG group). Before syncope, ejection fraction increased most in the CI group, the left ventricular end-diastolic volume declined most in the VD group (VD group, -11.0% +/- 3.3%; CI group, -2.8% +/- 4.8%; NG group, -3.4% +/- 2.2%; P <.005), and the high-frequency spectra increased most in the CI group (CI group, 25.0% +/- 21.0%; VD group, -4.1% +/- 11.7%; NG group, -5.3% +/- 12.7%; P <.01). The vasodepressor response was dependent on left ventricular volume, whereas the cardioinhibitory response was related to the vagal activity reflected by high-frequency spectra. CONCLUSIONS: The precise evaluation of left ventricular volume by an ambulatory radionuclide monitoring system combined with a heart rate variability analysis is considered useful for clarifying the pathophysiology of neurally mediated syncope.     

Vasodepressor syncope induced by lower body negative pressure: possible relevance to +Gz-stress training--a case report

We present a case report of vasodepressor syncope with brief sinus pause in a 26-year-old male subject following a graded lower body negative pressure (LBNP) challenge culminating at -70 mm Hg. Cessation of the LBNP protocol resulted in the return of heart rate and blood pressure activity to pre-challenge levels. Sinus arrest during central hypovolemic stress has been noted in the literature. Its potential in rare cases during exposure to high levels of LBNP should be noted as increasing numbers of investigators utilize presyncopal LBNP testing to assess the orthostatic responses of pilots and astronauts.     

Phobic fear of flying in aircrews: epidemiological aspects and comorbidity

BACKGROUND: Phobic fear of flying may affect aircrew members during any phase of their flying careers. Symptoms are beyond voluntary control and may lead patients to avoid flying and seek medical advice. METHODS: Of 1101 psychiatric files from our institute for 1985-2002, 150 represented cases of fliers who suffered from phobic fear of flying. Data collected from those files included assessment of fear-evoking situations, type of aircraft, class of aircrew duties, aircraft accident history, past medical history, age, and associated psychiatric comorbidity. RESULTS: We compared a group of 56 pilots with 94 other aircrew members. Results included 143 cases of flight phobia behavior and 7 cases of anxiety about parachuting. Flight phobia was less frequent among pilots (37.4%) than the other aircrew members (62.6%). We found a history of aircraft accident to the patient or an acquaintance in 25% of the cases. Observed comorbid psychiatric disorders (54%) consisted of depressive disorders (22%), anxiety disorders (16%), and personality disorders (7.4%). Fixed-wing pilots and aircrews members had a higher incidence of depression than did rotary-wing pilots and crewmembers (p < 0.05). Rotary-wing pilots and crewmembers had a higher rate of anxiety disorders (p < 0.05). DISCUSSION: Flight phobia encompasses a wide spectrum of clinical origins that may lead pilots or other aircrew members to refuse to fly. We recommend a careful psychiatric evaluation and close follow-up to adequately diagnose fliers with flight phobic reactions, as well as establishing adequate medical and/or psychological treatment.     

Treatment of gas mask phobia.

Many soldiers develop feelings of claustrophobia when wearing a protective mask. In the battlefield environment of today, it is essential that soldiers be able to tolerate gas masks. This article briefly reviews the historical use of gas masks in the U.S. Army. Two cases of treatment of gas mask phobia are described. Behavioral therapy techniques useful for treatment are summarized.     

Radiation: facts, fallacies and phobias

There is frequent debate in the media and the scientific published reports about the use of radiation for diagnosis and treatment, the benefits and risks of the nuclear industry, uranium mining and the storage of radioactive wastes. Driving this debate is increasing concern about reliance on fossil fuels for power generation for which alternatives are required. Unfortunately, there is generally a poor understanding of the relevant basic sciences compounded by widespread irrational fear of irradiation (radiation phobia). Radioactivity, with special reference to uranium and plutonium is simply described. How radiation affect tissues and the potential hazards to individuals and populations are explained. The origins of radiation phobia and its harmful consequences are examined. Whether we like it or not, Australia is heavily involved in the uranium industry by virtue of having one-third of the world's known reserves, exports of which are worth approximately $470m annually. As this paper has been written as simply as possible, it may also be of interest to readers who may have had little scientific training. It may be downloaded from the web using references provided in this article. It is concluded that ignorance and fear are major impediments to rational debate on radiation issues.     

股骨下段骨折合并的血管神经伤早期修复

目的：总结股骨下段骨折合并的血管神经损伤处理的经验教训,以降低伤残率。方法血管伤７８例,神经伤３７例,其中１９例系血管神经同时受伤。血管伤分别行血管减压和扩张,血管修补,血管吻合,血管移植术,神经损伤分别行解除压迫,神经吻合,神经移植术,结果血管伤７８例,６９例恢复血运,９例截肢,神经伤３７例,除９例截肢外,４例未恢复神经功能外,其余全部恢复神经功能。结论对血管神经损伤,要及时准确地做出诊断,及时     

Systematic desensitization of a phobia for flying with the use of suggestion.

This case study describes the successful treatment of a phobia for flying in an active-duty United States Marine helicopter crew chief by using systematic desensitization. Systematic desensitization is briefly described as a treatment technique which incorporates relaxation exercises paired with the visualization of anxiety-producing images--in this case, images associated with flying. The patient and the therapist constructed a hierarchy of 32 items which were then rank ordered from least to most anxiety producing with the first item being "Ordering parts to repair a helicopter" and the last item being "A routine helicopter landing". Treatment consisted of having the patient visualize the scenes from the list while achieving a state of deep relaxation. The patient was unique in that he possessed an extraordinary ability to experience olfactory, tactile, auditory, and kinesthetic cues as well as vivid visualizations when imagining the items. The patient moved to the next item on the list only after he could feel relaxed while visualizing the previously anxiety-arousing scene of the preceding item. After progressing through the entire list, the patient initiated an actual helicopter flight. The patient participated in a 6-month follow-up helicopter flight with the therapist and experienced an appropriate, manageable level of anxiety. The presentation concludes with a brief discussion concerning the protential usefulness of routinely incorporating relaxation exercises into flight training as a preventative approach to anxiety- and stress-related illness frequently found in aviators.     

心理素质训练对新兵心理健康状况的影响

目的 探讨心理素质训练对新兵心理健康状况的影响.方法 200名新兵随机分为两组:干预组(n＝100)在新兵集训期内全程参加心理素质训练,对照组(n＝100)在新兵集训期内未参加心理素质训练.采用SCL-90及应对方式量表对两组新兵在集训前后进行团体测量,并在集训结束后1个月时对干预组新兵心理素质训练效果进行主观评价.结果 干预组在集训后除恐怖和精神病性无显著降低外,其他各SCL-90因子分均显著下降;对照组在集训前后除躯体化外各SCL-90因子分均无显著差异.两组比较除躯体化、恐怖及精神病性外,其他各因子集训前后差值干预组均显著大于对照组(P＜0.05).干预组集训前后应对方式中退避和合理化无显著改变,但更多地运用解决问题、求助等应对方式,自责、幻想则显著减少;对照组集训前后应对方式无显著变化.两组比较,除退避和合理化外各应对方式差值干预组均显著大于对照组(P＜0.05).结论 心理素质训练有助于改善新兵心理健康状况和应对方式,可降低军事心理应激水平.     

心理干预对新兵心理健康状况的影响研究

 目的 探讨心理干预对新兵心理健康状况的影响.方法 采用症状自评量表,对1 113名新训队新兵进行心理测量,并根据统计学的聚类分析随机在症状组抽出47人,亚健康组抽出45人,健康组抽出38人进行心理干预.同时,分别对三组进行组内差异比较以及平均数差异比较.结果 在各组干预前后的比较中:症状组的恐怖因子没有差异,焦虑因子差异显著(P＜0.05),其余各因子差异十分显著(P＜0.01);亚健康组的敌对和恐怖因子没有差异,人际和抑郁因子差异显著(P＜0.05),其余各因子差异十分显著(P＜0.01);健康组的强迫和焦虑因子有十分显著的差异(P＜0.01),其余各因子则没有差异.在各组干预后平均数差异比较中,症状组的新兵心理健康水平改变的最高.结论 心理干预后新兵的心理健康水平有显著提高,是提高部队新征兵员心理健康水平的有效方法.     

Virtual reality exposure in the treatment of fear of flying

BACKGROUND: Recently, a growing body of research has appeared on different aspects of virtual reality exposure (VRE) therapy applied to the treatment of anxiety disorders. The purpose of this article was to review with a systematic methodology the evidences that support the potential effectiveness of this therapy in the treatment of fear of flying (FOF), a problem that significantly affects patients' social functioning and personal welfare. METHODS: Potential studies were identified via computerized search using the PubMed/Medline and Web of Science databases, and additional review of their references. Articles ranged from 1969 to 2007 and the keywords used in the search were: "virtual reality" and "fear of flying"; "virtual reality" and "flying phobia"; or "virtual reality" and "flight phobia." RESULTS: There were 40 studies using VRE in the treatment of FOF identified, mostly on the effectiveness of VRE therapy in group and case studies. Several components of the treatment protocols differed among the studies, which made the results comparison a challenging task. Nevertheless, controlled studies demonstrate that VRE treatment is effective with or without cognitive behavior therapy (CBT) and/or psychoeducation and that it is considered to be an effective component of the treatment of FOF. CONCLUSIONS: All studies that used cognitive and relaxation techniques in addition to VRE treatment were effective. More randomized clinical trials are required in which VRE therapy could be compared with standard exposure therapy. Thus, we suggest that CBT, psychoeducation, and VRE could be combined to treat FOF.     

内窥镜胸交感神经链切断术

目的　总结内窥镜胸交感神经链切断术治疗多汗症的经验。　方法　回顾性分析内窥镜胸交感神经链切断术治疗58例多汗症的结果,复习文献,总结此手术的临床应用。　结果　58例均治愈;出现气胸4例、代偿性多汗2例、肋间神经痛1例。　结论　内窥镜胸交感神经链切断术比较安全,除多汗症外还可用于雷诺病、灼性神经痛、社会恐怖症和心绞痛的治疗。     

Psychiatric disorders as they relate to aviation: the problem in perspective

The major causes of licence loss among pilots during 1965-81 are discussed in relation to the effect of recent changes in licensing practices, such as permission to use beta-blockers. Mental disorders comprised the second highest cause of licence loss during 1965-77 (13.0%) and remained at a high level during 1977-81 (14.7%). The age-related incidences of alcoholism, psychoses and neuroses, and idiopathic and reactive flight phobia are detailed.     

海上训练人员心理应激状态与个性特征的相关研究

目的：研究海上训练人员的心理应激状态与个性特征及相关性。方法：以海军某部训练的126名军人为训练组，平时状态的军人136名为对照组，采用症状自评量表(SCL-90)、艾森克个性测量问卷(EPQ)进行调查。结果：训练组中轻度的不良反应为人际敏感、强迫、敌对、躯体化、偏执等；较明显的心理健康问题为偏执、强迫、敌对、抑郁、人际敏感等。训练组躯体化、恐怖、阳性项目数、精神病性、敌对明显高于对照组，且EPQ精神质(P)分、神经质(N)分明显高于对照组。以EPQ各维度为自变量，以SCL-90总均分和各因子分为因变量，进行多元逐步回归分析，P进入SCL～90总均分及除敌对因子外的各因子方程；N进人SCL-90总均分及除躯体化、恐怖因子外的各因子方程；E进人人际敏感、抑郁方程。结论：训练人员心理卫生水平呈下降趋势，神经质、精神质个性特征易促发负性情绪，这些特征容易使个体在认知、情感、行为、适应等方面产生较多的心理健康问题。