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Medical management of frailty: confessions of a gnostic.

Geriatric Medicine is concerned chiefly with the care of frail elderly people, especially when they become ill. Physicians face special challenges in dealing with such patients, who tend to have multiple interacting medical and social problems, impaired function, altered pharmacokinetics and pharmacodynamics, atypical disease presentations and to be affected by polypharmacy. The joy of geriatrics is in systematically meeting each of these challenges, but the techniques that geriatricians use to do so must not be kept secret. More must be done to encourage all physicians to use these techniques in caring for frail elderly people who are ill.

Aged↗

Differences and similarities between violent offenders and sex offenders.

OBJECTIVES: To investigate differences and similarities between violent offenders and two types of sex offenders, rapists and child molesters, in terms of their personality, the nature of the victim, the role of alcohol, and their confession to their crime. METHOD: Thirty-six adult sex offenders, 23 child molesters, and 32 violent offenders were compared on personality measures, their relationship with the victim, the presence of alcohol intoxication, their confession rate and retraction at trial, and the reasons they gave for having confessed to the police. RESULTS: Child molesters and adult sex offenders (rapists) were significantly more introverted than the violent offenders. The child molesters had higher social desirability scores than the other groups, they tended to assault relatives and friends, they were rarely intoxicated while committing the offense, and they had strong internal need to confess to the police. Rapists and violent offenders were more commonly intoxicated during the commission of the offense; the former tended to assault acquaintances, where violent offenders most commonly assaulted strangers. Exactly half of the rapists retracted their confession when the case went to trial; in contrast none of the other offenders retracted their confession. CONCLUSIONS: The results show that there are significant differences as well as similarities between the three groups of offenders, which have implications for assessment and treatment.

Adolescent↗

Psychology brings justice: the science of forensic psychology.

In this paper the focus is on one aspect of forensic psychology: the development of psychological instruments, a social psychological model and assessment procedures for evaluating the credibility of witnesses and police detainees during interviewing. Clinically grounded case work and research has impacted on police interviewing and practice, the admissibility of expert psychological testimony and the outcome of cases of miscarriage of justice. After describing the research that laid the foundations for advancement of scientific knowledge in this area, a brief review is presented of 22 high-profile murder cases where convictions based on confession evidence have been quashed on appeal between 1989 and 2001, often primarily on the basis of psychological evidence. The review of the cases demonstrates that psychological research and expert testimony in cases of disputed confessions have had a profound influence on the practice and ruling of the Court of Appeal for England and Wales and the British House of Lords. The cases presented in this paper show that it is wrong to assume that only persons with learning disability or those who are mentally ill make unreliable or false confessions. Personality factors, such as suggestibility, compliance, high trait anxiety and antisocial personality traits, are often important in rendering a confession unreliable. Future research needs to focus more on the role of personality factors in rendering the evidence of witnesses and suspects potentially unreliable.

Forensic Psychiatry↗

'If you pay, we'll operate immediately'.

OBJECTIVES: To study the attitudes of health care staff in four postcommunist countries towards taking gifts from their clients--and their confessed experience of actually taking such gifts. DESIGN: Survey questionnaire administered to officials including health care staff, supplemented by focus-group discussions with the general public. SETTING: Ukraine, Bulgaria, Slovakia and the Czech Republic. PARTICIPANTS: A quota sample of 1,307 officials including 292 health care staff, supplemented by stratified national random samples of 4,778 ordinary members of the public and in-depth interviews or focus-group discussions involving another 323. MAIN MEASUREMENTS: Explicit justifications and willingness to accept offers, reported frequency of offers, and personal confessions to accepting "money and expensive presents" as well as smaller gifts. RESULTS: Health care staff were far more inclined than the average official or public servant to accept "money or an expensive present" if offered, far more inclined to justify asking clients for "extra payments", and far more inclined to confess that they had actually taken gifts from clients recently. Judged by their own confessions, hospital doctors were only rivalled by traffic police and customs officials for taking money or expensive gifts from their clients. CONCLUSIONS: Poor pay does not explain why doctors so often took large gifts from their clients. Moral self justification, opportunity, and bargaining power are much more effective explanations.

Attitude of Health Personnel↗

Bernfeld's "The facts of observation in psychoanalysis": a response from psychoanalytic research.

In his 1941 article, "The Facts of Observation in Psychoanalysis," Siegfried Bernfeld wrote that observing the sequence of events leading up to and following the patient's confessing a secret is important for psychoanalytic theory. The patient's confessing a secret is important for psychoanalytic theory. The patient's confessing a secret may follow a comment by the analyst that clears away the obstacles to the patient's confessing by creating an encouraging atmosphere and reducing the patient's shame or distrust. Bernfeld believed that the study of this sequence would be fruitful for the development of psychoanalysis. His article now seems prescient. Members of the San Francisco Psychotherapy Research Group have used formal empirical methods to study Bernfeld's thesis, and we have found strong support for his assumptions.

Humans↗

Child sexual abuse: a case study in community collaboration.

OBJECTIVE: This is an exploratory study that describes the process and outcomes of a Midwestern US community's approach to case management of child sexual abuse. METHOD: Data were abstracted from 323 criminal court files. Specific information gathered included child and suspect demographic data, law enforcement and CPS involvement, child disclosure patterns and caretaker responses, offender confession, offender plea, trial and child testimony information, and sentences received by offenders. Both case process and outcome variables were examined. RESULTS: In this community, criminal court records reflect a sex offense confession rate of 64% and a sex offense plea rate of 70%. Only 15 cases went to trial and in six the offender was convicted. CONCLUSION: Communities can achieve successful outcomes when criminal prosecution of sexual abuse is sought, but the child's testimony is not necessarily the centerpiece of a successful case. In this study, desired outcomes were a consequence of the collaborative efforts of law enforcement, CPS, and the prosecutor's office, which resulted in a high confession and plea rate.

Adolescent↗

Carbohydrate deficient transferrin: a marker for alcohol abuse.

OBJECTIVE: To assess the value of serum carbohydrate deficient transferrin as detected by isoelectric focusing on agarose as an indicator of alcohol abuse. DESIGN: Coded analysis of serum samples taken from patients with carefully defined alcohol intake both with and without liver disease. Comparison of carbohydrate deficient transferrin with standard laboratory tests for alcohol abuse. SETTING: A teaching hospital unit with an interest in general medicine and liver disease. PATIENTS: 22 "Self confessed" alcoholics admitting to a daily alcohol intake of at least 80 g for a minimum of three weeks; 15 of the 22 self confessed alcoholics admitted to hospital for alcohol withdrawal; 68 patients with alcoholic liver disease confirmed by biopsy attending outpatient clinics and claiming to be drinking less than 50 g alcohol daily; 47 patients with non-alcoholic liver disorders confirmed by biopsy; and 38 patients with disorders other than of the liver and no evidence of excessive alcohol consumption. INTERVENTION: Serial studies performed on the 15 patients undergoing alcohol withdrawal in hospital. MAIN OUTCOME measure--Determination of relative value of techniques for detecting alcohol abuse. RESULTS: Carbohydrate deficient transferrin was detected in 19 of the 22 (86%) self confessed alcohol abusers, none of the 47 patients with non-alcoholic liver disease, and one of the 38 (3%) controls. Withdrawal of alcohol led to the disappearance of carbohydrate deficient transferrin at a variable rate, though in some subjects it remained detectable for up to 15 days. Carbohydrate deficient transferrin was considerably superior to the currently available conventional markers for alcohol abuse. CONCLUSION: As the technique is fairly simple, sensitive, and inexpensive we suggest that it may be valuable in detecting alcohol abuse.

Alcoholism↗

Snoring and sleep architecture.

The purpose of this study was to examine whether snoring adversely affects sleep architecture and sleep efficiency, and thus may account for the frequent complaints of daytime tiredness and fatigue expressed by heavy snorers. We recruited eight self-confessed heavy snorers and six self-confessed nonsnorers. All subjects had full nocturnal polysomnography, including continuous monitoring of snoring, which was quantified by counting the number of snores per hour of sleep (snoring index), the number of snores per minute of snoring time (snoring frequency), maximal and mean nocturnal sound intensity (dBmax and dBmean, respectively). We found that even the self-confessed nonsnorers snored lightly, with significantly smaller frequency and index than the heavy snorers. Sleep architecture was similar in both groups. Distribution of snoring among the sleep stages differed for light and heavy snorers: light snorers snored uniformly throughout all sleep stages, whereas heavy snorers tended to snore more during slow-wave and REM sleep. Snoring frequency and snoring index were similar during all sleep stages in light snorers, but they were higher during slow-wave sleep in heavy snorers. Wakefulness time after sleep onset and sleep efficiency correlated significantly with the snoring index. We conclude that although snoring does not affect sleep architecture in general, it influences sleep efficiency and wakefulness time after sleep onset; this may have an adverse effect on daytime function of heavy snorers.

Adult↗

Unreliable admissions to homicide. A case of misdiagnosis of amnesia and misuse of abreaction technique.

BACKGROUND: The past decade has witnessed a recognition that unsafe criminal convictions may be occasioned by unreliable confessions. AIMS: To present a case which illustrates the dangers of using abreaction interview techniques in a legal context and demonstrate the relevance of the memory distrust syndrome to an unsafe confession to murder. METHOD: We under took a detailed assessment of a person appealing against his original murder conviction, 'the appellant', and a careful scrutiny of all the relevant papers in the case. RESULTS: The appellant served 25 years in prison before his conviction was quashed as 'unsafe' on the basis of fresh psychological and psychiatric evidence. CONCLUSIONS: Amnesia for an offence had been misdiagnosed, and the use of repeated abreaction interviews had further confused both the appellant and the original court. At the Appeal Court, the advice was that the man had experienced a form of source amnesia which resulted in an unreliable confession.

Adult↗

Judgment, 29 December 1987.

The Court of Appeal of Santiago, Chile, held that, under Articles 111 and 481(4) of the Chilean Code of Penal Procedure, the confession of an accused will prove that person's participation in the crime only if it is corroborated by other means of proof and the confession is in conformity with the circumstances surrounding the crime. It acquitted the defendant, who had confessed to the crime of abortion, noting that the medical record stated that the abortion was spontaneous and that the physician could not affirm that there had been abortive manipulations.

Abortion, Illegal↗

Pediatric "body packing".

BACKGROUND: Recent events in the United States have led to increased security at national borders, resulting in an unexpected increase in drug seizures. In response, drug smugglers may begin using children as couriers, including using them as "body packers." OBJECTIVE: To look at the occurrence of body packing, the concealing of contraband within the human body, which is well documented in adults, in the pediatric literature. PATIENT REPORTS: Two cases of pediatric body packing, in boys aged 16 years and 12 years. Patient 1, a 16-year-old boy, presented with findings consistent with opioid intoxication after arriving in the United States on a transcontinental flight. His mental status improved after he received naloxone hydrochloride, and he subsequently confessed to body packing heroin. He was treated with a naloxone infusion and aggressive gastrointestinal decontamination. He ultimately passed 53 packets of heroin, one of which had ruptured. He recovered uneventfully. Patient 2, a 12-year-old boy, presented to the emergency department with rectal bleeding. He had recently arrived in the United States from Europe, and he confessed to body packing heroin. He was treated with whole-bowel irrigation and activated charcoal, and he subsequently passed 84 packets. He also recovered uneventfully. CONCLUSIONS: We report the first 2 cases of body packing in the pediatric literature and review the diagnosis and management of this clinical entity. Pediatricians should be aware that body packing, regrettably, is not confined to the adult population.

Adolescent↗

Evaluations of children who have disclosed sexual abuse via facilitated communication.

OBJECTIVE: To review the findings of interdisciplinary team evaluations of children who disclosed sexual abuse via facilitated communication. DESIGN: Case series. SETTING: Tertiary care hospital outpatient child sexual abuse program in central New York. PATIENTS: Between January 1990 and March 1993, 13 children who disclosed sexual abuse via facilitated communication and were referred to a university hospital child abuse referral and evaluation center. The range of previously determined developmental diagnosis included mental retardation, speech delay, and autism. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Medical records were reviewed for (1) disclosure, (2) physical evidence, (3) child's behavioral and medical history, (4) disclosures by siblings, (5) perpetrator's confession, (6) child protective services determinations, and (7) court findings. RESULTS: Four children had evidence of sexual abuse: two had physical findings consistent with sexual abuse, one also disclosed the allegation verbally, and one perpetrator confessed. CONCLUSIONS: These results neither support nor refute validation of facilitated communication. However, many children had other evidence of sexual abuse, suggesting that each child's case should be evaluated without bias.

Adolescent↗

Disclosure of HIV seropositivity.

Deciding whether or not to disclose one's HIV-positive status to another person is an important decision: the way each person experiences and copes with the illness is reflected in this choice. We conducted a study of 174 patients (29.3% of women) to examine how the decision to disclose or conceal was made, as well as its subjective and social consequences. We discovered that only 3.5% of the individuals remained silent about their illness. Most spoke about it, regardless of how they had been infected or of the advice they had received to be discrete. The confession often did not bring them the relief they sought. Revealing one's HIV-positive status is not a sign of social responsibility, or of a special trust in someone, but rather a compulsive act to release suppressed tension. Individuals who do not confess need attention; their silence is a sign of their inability to adapt to their illness, as well as of their self-imposed exclusion from society.

Adaptation, Psychological↗

The potential conflict between clinical and judicial decision making heuristics.

The Gudjonsson Suggestibility Scale (GSS; Gudjonsson, 1984) was introduced as a tool for identifying suspects who are at risk of making false confessions. High GSS-scores indicate a greater risk of making false confessions. Recently, some authors have claimed that low GSS-scores can be used to support the credibility of recovered memories. This new application broadens the use of the GSS in two ways. First, low GSS-scores are considered to possess diagnostic value. Second, the GSS is advocated as a practical tool in clinical settings. This article critically evaluates such a clinical application of the GSS. Our main argument has to do with the incompatibility of basic clinical and judicial decision making heuristics. Psychotherapists, and other medical professionals, should base their decisions on different parameters than judicial professionals. Compared to judicial heuristics, clinical heuristics can be characterized as more empathetic, less critical, and less conservative. Given these differences, clinical conclusions (including those about the accuracy of recovered memories) cannot be easily translated into judicial decisions. If they do enter the judicial domain, these conclusions may lead to dubious forensic decisions.

Adult↗

A review and update on the practice of evaluating Miranda comprehension.

This article summarizes recent developments in constitutional law relevant to the Miranda warning. We describe the origins of the warning, concerns about the use of the Miranda warning, perspectives on the utility of the warning, and the relevance of the warning. We describe how the warning has changed over time, requirements for administering the warning, and procedures that police use in delivering the warning and obtaining confessions. We review case law relevant to "coerced" Miranda waivers and confessions, changes over time in the court's interpretation of what constitutes "coercion," use of the warning with special populations, and the recent focus in case law on individual factors that might impair Miranda comprehension. We review empirical research on factors associated with deficits in Miranda comprehension. We integrate case law rulings and empirical research into suggested approaches to forensic assessment of Miranda comprehension.

Adolescent↗

Criminal anticipation of DNA investigations resulting in mutilation of a corpse.

A corpse of a female was found in her apartment in a state of advanced putrefaction. Both hands were amputated, the external genitals were excised and the body parts had been removed from the scene. The subsequent investigations proved that the body parts had been severed post mortem. The cause of death was determined to be manual strangulation. A 33-year-old man later confessed that he had strangled the victim 9 days prior to discovery of the body and that he had had sexual intercourse post mortem. According to the confession, the rational motive for the subsequent mutilation was to eliminate biological stains (e.g. semen inside the vagina, epithelial cells below the fingernails from scratching) suitable for forensic DNA analysis. This constitutes a new type of defensive mutilation intended to prevent the identification of the perpetrator. An increase in the occurrence would be detrimental to the elucidation rate of homicides: in a total of 171 homicides investigated at this institute, DNA analysis of biological stains gave reliable evidence in 45 cases.

Adult↗

Child sexual abuse: relationship between sexual acts and genital findings.

A comparison was made between the findings observed during the examination of female victims of sexual abuse with the sexual acts to which the perpetrator confessed to have performed. In Shelby County, TN, during the calendar years 1985-1987, 30 individuals confessed to have sexually assaulted 31 girls. The mean age of the girls was 9.1 years, and that of the offenders was 30 years. In 18 of the 31 cases the offender admitted to vaginal penetration. Specific findings were observed in 11 of these 18 (61%) girls, compared with only 3 of 13 (23%) girls when penetration was denied. Although specific findings were more commonly observed when the perpetrator admitted to vaginal penetration, in 7 of 18 girls (39%) the examiner described normal appearing genitalia (n = 2), or nonspecific abnormalities only (n = 5). The author concludes that all complaints of sexual abuse must be considered potentially valid and should be investigated further, even if the physical examination fails to detect any abnormalities.

Adolescent↗