GROUP PSYCHOTHERAPY FOR CRIMINAL OFFENDERS—A Program for Parolees Under Social-Psychological Coercion

Selected prisoners, most of them with severe character disorders, are permitted to serve the remaining portion of their sentence on parole in the community on condition that they be patients in psychotherapy at a psychiatric clinic created in 1953 for this purpose. Nearly all the patients begin without personal motivation for such treatment. Attendance has been attained because parole officers are assigned to the task of enforcing attendance.Coercion can bring these reluctant patients to expose themselves to treatment, but staff members then have the task to overcome hostility, combat extensive rationalizations, and transform an initially poor rapport into patient participation in working through major personality change.This clinic provides an interesting laboratory for the development of a psychiatric treatment program for adults who have not responded well to a great variety of forms of correctional care.     

Palliatieve zorg op een chronische psychiatrische afdeling voor ouderen

Elderly, psychiatric patients admitted to a long-stay ward become physically ill and die. Which care can be offered on the ward and which cases require transferring a patient to specialized psychiatric-medical wards or a hospice? We studied 40 cases of death by malignancy in a clinic for elderly, long-term admitted psychiatric patients. Transferring the patient to such a ward was never indicated. Our population appeared to have a lack of awareness of their illness and expressed very few physical complaints. The possibilities of curative treatment of the malignancy were limited; the emphasis of the treatment was on palliative care. Because of the intensive support given on the patients ward the patients were able to die in peace. Deep sedation was never required.     

Paths to psychiatric care in Hong Kong

The pattern of psychiatric consultation in Hong Kong is examined among 226 patients at a public outpatient clinic and 56 patients at a private psychiatric clinic. The approach to psychiatric services is marked by lengthy delay during which patients get help from their family members or close friends. Arrival at the present psychiatric clinic was diverted through other medical resources, primarily Western-style medical services, and to some extent, traditional Chinese medicine. Individual routes were diverse, characterized by frequent switches among resources especially in the private sector. The nature of the patients' presenting complaints as well as the conceptualization of their initial complaints were multi-faceted, including both psychological and somatic factors. The overall consultation pattern of patients in Hong Kong is compared with other studies on Chinese and Western patients. Questions are raised for further analysis.The study was funded by the United Board for Christian Higher Education in Asia Faculty Research Grant made through Chung Chi College of The Chinese University of Hong Kong.     

Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): enhancing the assessment and treatment of psychiatric conditions

Aim In the current healthcare system primary care physicians (PCPs) have, in effect, become the primary psychiatric care physicians (PPCPs) for many of their patients. Being the PPCP in an already busy and stressful medical industry presents additional time management and treatment challenges to successfully manage patients' medical and psychiatric needs. The aim of the study was to ascertain PCPs' psychiatric assessment and treatment practices and to determine the extent to which PCPs have a need for using a structured psychiatric assessment tool.Method We sent 300 PCPs a survey to examine their psychiatric assessment and treatment practices. A one-page questionnaire was used to inquire about PCPs' psychiatric care practice habits including types of conditions treated, psychiatric medications prescribed, assessment methods used, interest in using a structured assessment tool and referral sources used. Sixty-eight usable surveys (23%) were returned.Results PCPs identify approximately one-third of their patients as mental health patients. They are treating a wide range of psychiatric conditions and prescribing a variety of psychiatric medications. The vast majority are using traditional clinical interviewing as their primary method of psychiatric assessment. However, the majority were willing to use a structured psychiatric assessment tool.Conclusion PCPs are serving a useful role in providing psychiatric treatment to many of their patients. Using a more structured psychiatric assessment method in practice could ultimately strengthen the assessment and treatment of psychiatric conditions in primary care settings.     

Psychopathological symptoms in patients with primary hyperaldosteronism--possible pathways

A close comorbidity between endocrine diseases and psychopathological symptoms has been described in the literature. Until now only a few studies have reported about an increased anxiety and depressive symptoms in patients with primary hyperaldosteronism (PHA). The exact pathways of psychiatric comorbidities have not been totally clarified yet, although the renin-angiotensin-aldosterone-system has gained more attention in research on anxiety and depression. There are several structures and factors, which could mediate anxiety or a depressive symptomatology. Additionally a possible influence of the standardised treatment with a mineralocorticoidreceptor (MR) antagonist or adrenalectomy should be investigated as they have been shown to affect mood. Psychiatric comorbidities are not only an additional burden in these patients, but as depression and anxiety are additional risk factors in patients with cardiovascular diseases. Possible pathomechanisms in the relation between PHA and psychiatric symptoms should be more closely investigated. For the clinical practice a regular screening for psychiatric comorbidities and an adequate treatment are required.     

An Examination Of Factors Related To The Parole Survival Of American Indians

Abstract

This paper examines the parole survival of American Indians and non-American Indians released from a Western state prison. In order to determine whether the parole outcome exists independent of the ethnicity of the parolee, six pre-prison, prison and post-prison experiences were statistically associated with the parole outcome. The analysis reveals that the parole survival of the offender is in large part independent of ethnicity. Since the objective measures, or the experiences of the offenders, fail to explain the differences in the parole survival rates, the research suggests that attention should be focused on the activities of judges, parole boards and the parole officers in the field, for they have a great deal of discretion in the determination of parole survival.     

DELINQUENCY IN WOMEN

From observation of some 1,000 women who were committed to a California correctional institution because of felonious offense it was concluded that:1. Delinquency results from certain identifiable factors, particularly basic defects in early family relationships, various aberrant psychological states including many forms of mental illness; physical illness or injuries, particularly those producing brain damage and resulting in abnormal psychological conditions; general environmental factors, and specific environmental factors.2. Certain personality-types and certain life-environmental situations appear to be associated with certain patterns of offenses.3. Correction and rehabilitation may be achieved to a greater degree as correctional institution treatment programs are increasingly implemented with psychiatric personnel, and as increased guidance and support are made available through parole divisions.     

Delinquency in women

From observation of some 1,000 women who were committed to a California correctional institution because of felonious offense it was concluded that:1. Delinquency results from certain identifiable factors, particularly basic defects in early family relationships, various aberrant psychological states including many forms of mental illness; physical illness or injuries, particularly those producing brain damage and resulting in abnormal psychological conditions; general environmental factors, and specific environmental factors.2. Certain personality-types and certain life-environmental situations appear to be associated with certain patterns of offenses.3. Correction and rehabilitation may be achieved to a greater degree as correctional institution treatment programs are increasingly implemented with psychiatric personnel, and as increased guidance and support are made available through parole divisions.     

Attitudes to the psychiatric outpatient clinic.

Fifty patients were interviewed before their first ever appointment at a psychiatric outpatient clinic about their attitude to the forthcoming visit. Many did not know that it was a psychiatrist they were to see at the hospital. Widespread misconceptions about the nature of a psychiatric consultation were uncovered. Many felt the referral carried an implicit threat of social stigma. Patient''s misconceptions were relieved, and only 13% subsequently failed to attend the clinic compared with 30% of a control group.     

Psychological impact of traumatic injuries: what the surgeon can do.

In their treatment of accident and assault victims, plastic surgeons have unique opportunities to identify and refer patients with posttraumatic stress symptoms. This article describes brief assessments that surgeons or their clinic staff can use to evaluate traumatically injured adults and children for trauma-related psychological symptoms. An immediate postinjury evaluation (within 10 days of the trauma) consists of 11 questions to determine the presence of the following risk factors for posttrauma maladjustment: panic during or immediately after the trauma, reexperiencing symptoms, avoidance, sleep disturbance, injury from an assault, previous trauma and psychiatric history, and blaming someone else for the injury. The seven follow-up interview questions assess reexperiencing symptoms, avoidance, trauma-related phobias, depression, irritability, and increased substance use, all of which, if present, suggest psychological impairment. Questions recommended for the evaluation of younger children assess changes in play and recreational activity, sleep disturbance, night terror, aggression, irritability, avoidance, emergence of new fears, and loss of recently acquired developmental skills. The assessments require less than 2 minutes and are easily integrated into the hospital or clinic examinations of these patients.     

UNDERGRADUATE PSYCHIATRIC EDUCATION—Senior Medical Students Study Patients with the Clinical Team

A course in psychiatry for senior medical students, designed to give all members of the class some direct experience, particularly in therapeutic interviewing as well as in total psychiatric study of patients by the clinically integrated work of medical specialists, psychiatric social workers, and clinical psychologists in collaboration with psychotherapeutically trained and experienced psychiatrists is conducted in the following manner: A third of the class, about 25 students, is divided into four sections of six or seven members, and each section attends five hours one forenoon a week for approximately three months. Each student, after an initial demonstration interview by the instructor, sees weekly the same two clinic patients alone, for 45-minute individual interviews, followed by a one and a half hour supervisory session. After this a 50-minute seminar or treatment review conference is followed by a similar period for writing records of interviews and summaries of the therapeutic work. Of four seminars, two are conducted by the psychiatric faculty, and one each by the social worker and the psychologist. Each student reads a written summary of all his interviews with one patient for discussion by his colleagues in the section and by the faculty from all three disciplines.     

Low self-esteem and psychiatric patients: Part II - The relationship between self-esteem and demographic factors and psychosocial stressors in psychiatric patients

BACKGROUND: The objective of the present study was to identify the effects and relative importance of demographic factors and psychosocial stressors on self-esteem of psychiatric patients. METHOD: The present study was carried out on a consecutive sample of 1,190 individuals attending an open-access psychiatric outpatient clinic. Patients were diagnosed according to DSM III-R diagnostic criteria following detailed assessments. At screening, patients and controls completed two self-esteem questionnaires, the Rosenberg self-esteem scale and the Janis and Field Social Adequacy scale. In addition, a large amount of demographic and psychosocial data was collected on all patients. RESULTS: Significantly increased self-esteem was observed with an increase in age, educational achievement and income. Employed patients showed significantly higher self-esteem compared to unemployed patients. Female patients had a significantly lower self-esteem compared to male patients. The self-esteem of psychiatric patients did not vary significantly with their marital status. No relationship was detected between acute stressors and the self-esteem of psychiatric patients, although severe enduring stressors were associated with lower self-esteem in psychiatric patients. CONCLUSION: The results of this large study demonstrate that the self-esteem of adult psychiatric patients is affected by a number of demographic and psychosocial factors including age, sex, educational status, income, employment status, and enduring psychosocial stressors.     

Salient components of a comprehensive service for eating disorders

Eating disorders are challenging and difficult to treat, because of the necessity of a multidisciplinary treatment team for effective outcomes and the high mortality rate of anorexia nervosa. An adequate initial assessment and evaluation requires a psychiatric assessment, a medical history and medical examination, a social history and an interview of family members or collateral informants. A comprehensive eating disorder treatment team includes a psychiatrist coordinating the treatment and appropriate medical physician specialists, nutritionists, and psychotherapists. An adequate outpatient eating disorder clinic needs to provide individual psychotherapy with cognitive behavioral techniques specific for anorexia nervosa and bulimia nervosa, family therapy, pharmacological treatment and the resources to obtain appropriate laboratory tests. Eating disorder patients requiring inpatient care are best treated in a specialized eating disorder inpatient unit. A cognitive behavioral framework is most useful for the overall unit milieu. Medical management and nutritional rehabilitation are the primary goals for inpatient treatment. Various group therapies can cover common core eating disorder psychopathology problems and dialectical behavior therapy groups can be useful for managing emotional dysregulation. Residential, partial hospitalization and day treatment programs are useful for transitioning patients from an inpatient program or for patients needing some monitoring. In these programs, at least one structured meal is advisable as well as nutritional counseling, group therapy or individual counseling sessions. Group therapies usually address issues such as social skills training, social anxiety, body image distortion or maturity fears. Unfortunately there is s paucity of evidence based randomized control trials to recommend the salient components for a comprehensive service for eating disorders. Experienced eating disorder clinicians have come to the conclusion that a multidisciplinary team approach provides the most effective treatment.     

Quieting response training: Treatment of psychophysiological disorders in psychiatric impatients

Self-regulation methods incorporating biofeedback are known to be useful in the treatment of psychophysiological disorders in psychologically normal patients. In this study, the effectiveness of Quieting Response (QR) training for the treatment of secondary psychophysiological complaints in psychiatric inpatients was assessed. Ten male and 27 female inpatients with a variety of secondary psychophysiological diagnoses were accepted into the study. Severely disturbed, confused, or depressed patients were excluded. All patients received QR training, which integrated EMG (electromyogram) and thermal feedback with breathing, progressive relaxation, and autogenic exercises. Daily practice of a 15-minute sequence of exercises was encouraged, and a 6-second reinforcement exercise was presented for use whenever an annoyance was encountered. No other therapeutic modalities were employed. Patients were followed for up to 2 years, and outcome was assessed with a multifactor quartile system. Rate of success at final follow-up for the inpatients (51%) was found to be equivalent to that of outpatients coming to the clinic with primary psychophysiological diagnoses (55%) and was not related to psychiatric diagnosis or nature of presenting complaint. Stepwise discriminant analysis indicated that older, less depressed individuals were more successful. Inpatients differed from nonpsychiatric patients only in the number of additional sessions received. Only one minor incident of increased psychopathology was observed. It was concluded that QR training was as effective for treating secondary psychophysiological disorders in all but the most severly disturbed inpatients as it was for the outpatient clinic population.This paper was presented at the Twelfth Annual Meeting of the Biofeedback Society of America, Louisville, Kentucky, March 1981. This project was funded in part by the van Ameringen Foundation. The authors gratefully acknowledge the contributions of Jane Archer and Jonathan Boren to the project.     

Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level

Physical disorders are, compared to the general population, more prevalent in people with severe mental illness (SMI). Although this excess morbidity and mortality is largely due to modifiable lifestyle risk factors, the screening and assessment of physical health aspects remains poor, even in developed countries. Moreover, specific patient, provider, treatment and system factors act as barriers to the recognition and to the management of physical diseases in people with SMI. Psychiatrists can play a pivotal role in the improvement of the physical health of these patients by expanding their task from clinical psychiatric care to the monitoring and treatment of crucial physical parameters. At a system level, actions are not easy to realize, especially for developing countries. However, at an individual level, even simple and very basic monitoring and treatment actions, undertaken by the treating clinician, can already improve the problem of suboptimal medical care in this population. Adhering to monitoring and treatment guidelines will result in a substantial enhancement of physical health outcomes. Furthermore, psychiatrists can help educate and motivate people with SMI to address their suboptimal lifestyle, including smoking, unhealthy diet and lack of exercise. The adoption of the recommendations presented in this paper across health care systems throughout the world will contribute to a significant improvement in the medical and related psychiatric health outcomes of patients with SMI.     

PSYCHIATRIC INPATIENT SERVICES IN GENERAL HOSPITALS

Traditional asylum care of psychiatric patients leads to the isolation, confinement, and restraint of the patients, and to isolation of psychiatric practice from the rest of medicine. Modern psychiatric advances have demonstrated the disadvantages to both patients and their families of such isolation, confinement and restraint. It is in the best interests of patients and professional workers that inpatient psychiatric services be continuous with, and contiguous to, other medical services and to rehabilitation services of all kinds.Examination of currently available information reveals a shortage of psychiatric beds in California, particularly for diagnosis and brief treatment. Thus, not only is there a need to develop psychiatric inpatient facilities, but also an opportunity to develop them along several different lines. Since both the Hill-Burton Act (federal) and the Short-Doyle Act (state) give financial assistance to only those psychiatric services established in general hospitals or affiliated with general hospitals, this requirement calls for examination in the light of experience with services so operated.At first, the Short-Doyle Act was perceived as a panacea for the psychiatric ills of the state. Now it is beginning to be recognized as one method of providing additional mental health resources, rather than the exclusive method. As more short-term cases are treated in local, tax-supported, psychiatric units in general hospitals, an impact can be expected on the state hospital program.In its administration of the Short-Doyle Act, the Department of Mental Hygiene attempts to respond to community needs as locally determined. It tries to insure local option and encourage local responsibility while furthering high standards of staffing and of service.     

An Emergency Psychiatric Service in a General Hospital

The same extensive range of general hospital facilities should be allocated to emergency psychiatric illness as are available for other medical conditions. During the study herein reported, for every three medical consultations in the emergency ward of a large general hospital, two psychiatric consultations were requested. Over a two-year period when 24-hour coverage by psychiatric consultants was instituted, such assessments increased from 148 to 340 (during the first four months of each year); the increase in police referrals was outstanding, rising from 16 to 105. The general wards of the hospital assumed greater responsibility for further medical treatment, while committal to the mental hospital declined. Many more psychiatric patients could have been treated in the general hospital if facilities had been available. The development of an emergency psychiatric service is not an easy process and co-ordination with other psychiatric resources is required. Residents in training face situations in the emergency ward which are not encountered in any other aspect of their clinical experience.     

Consultation-liaison scheme for self-poisoned patients in a general hospital.

In a prospective clinical trial 276 self-poisoned patients consecutively admitted to hospital were randomly allocated to medical teams or to psychiatrists for an initial psychiatric assessment and a decision about "disposal." Junior doctors and nurses received instruction in this work. While awaiting the outcome of the trial the randomisation was continued for 13 months and 729 allocations were made altogether. Physicians requested psychiatric opinions for roughly one in five of their patients. In other respects medical teams performed similarly to psychiatrists. Provided that due attention is given to teaching junior staff and to ensuring that psychiatric treatment and social-work support are available once patients have been assessed, such a consultation-liaison scheme could be adopted in other hospitals. This would help to change unfavourable attitudes towards self-poisoned patients and contribute to the general training of doctors and nurses.     

Transactions of the One Hundredth Annual Meeting of The Canadian Medical Association: Part II

The purpose of this retrospective study was to compare (1) regular methadone withdrawal treatment and (2) prolonged methadone withdrawal treatment in 105 and 71 voluntary patients respectively, who attended the Narcotic Addiction Foundation (N.A.F.) between 1959 and mid-1964. Treatment consisted of individual counselling and medical care for all, and only residential care and psychiatric assessment for selected cases. The number of treatment sessions and the details of drug therapy are described.One hundred and fifty-three of 176 patients (87%) were interviewed approximately one to five years after the first clinic contact. Forty-three per cent showed some overall improvement in their behaviour. Rehabilitation was defined as change in a specific area—drug use, work, criminal behaviour, community associations, friendship patterns and family relationships—rather than in terms of abstention from drugs only. Age affected comparative results.     

An Operant Intra-/Extra-dimensional Set-shift Task for Mice

Alterations in executive control and cognitive flexibility, such as attentional set-shifting abilities, are core features of several neuropsychiatric diseases. The most widely used neuropsychological tests for the evaluation of attentional set-shifting in human subjects are the Wisconsin Card Sorting Test (WCST) and the CANTAB Intra-/Extra-dimensional set shift task (ID/ED). These tasks have proven clinical relevance and have been modified and successfully adapted for research in animal models. However, currently available tasks for rodents present several limitations, mainly due to their manual-based testing procedures, which are hampering translational advances in psychiatric medicine. To overcome these limitations and to better mimic the original version in primates, we present the development of a novel operant-based two-chamber ID/ED "Operon" task for rodents. We demonstrated the effectiveness of this novel task to measure different facets of cognitive flexibility in mice including attentional set formation and shifting, and reversal learning. Moreover, we show the high flexibility of this task in which three different perceptual dimensions can be manipulated with a high number of stimuli cues for each dimension. This novel ID/ED Operon task can be an effective preclinical tool for drug testing and/or large genetic screening relevant to the study of executive dysfunction and cognitive symptoms found in psychiatric disorders.