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PubMed1981

Diagnosing borderline personality. A pilot study using multiple diagnostic methods.

The research described in this paper stemmed from the hypothesis that borderline personality organization can be differentiated from neurotic and psychotic levels of personality organization by means of three structural criteria: degree of identity integration, level of defensive operations, and capacity for reality testing. In order to elicit these criteria, the "structural" interview has been developed that focuses on the "here-and-now" patient-interviewer interaction. The patient's responses to the interviewer's attempts to clarify, confront, and interpret various aspects of the patient's interview behavior provide the basis for judgments as to the patient's structural diagnosis. Specifically, the paper reports a study of the differential diagnosis of 48 hospitalized patients in which structural diagnoses of borderline or psychotic personality organization were made according to this diagnostic interview approach. These diagnoses were compared with ones obtained from Gunderson's Diagnostic Interview for Borderlines, with psychological test diagnoses, and with clinical diagnoses based on past history and current illness. Results show substantial convergent agreement among all of the diagnostic methods and support the utility of the structural interview. In most discrepant cases, other methods reflected disagreement among themselves despite the diagnoses obtained from the structural interview, suggesting that there are some cases difficult to classify by any means. Further analysis suggests that the structural interview may be eliciting a different dimension of personality functioning in arriving at borderline diagnoses than do the other methods studied. The results also indicate that borderline structural diagnoses refer to patients described clinically as having severe character pathology, and do not overlap with patients described as having schizophrenic disorders. The structural interview appears to warrant further study, and, at the same time, shows promise as a research tool in further studies of structural diagnosis and its relevance for prognosis and treatment.

Adolescent↗
PubMed1995

The psychotherapeutic treatment of suicidal adolescents.

The therapeutic work with a suicidal adolescent begins with the therapist's recognition that there are a multitude of causes for suicidal behavior and that the risk of a serious suicide attempt lies in the patient's feeling of desperation about his situation, the feeling that he faces intolerable pain due to shame or embarrassment, degradation, guilt or loss. The patient can not assess whether his view of his situation is realistic or not, and he is unable to conceive of alternative solutions. The therapist must throw the patient a lifeline to give him hope of escaping from his belief that he is trapped in a world of unending pain. That lifeline may be an active intervention in the life of a patient, reality testing of the patient's perceptions that he is trapped, or both. The choice of interventions is based on an exploration of the psychodynamic and psychopathological constellations that have caused the patient to feel so trapped. Patients, in their anguish, will resort to extremes of coercion and manipulation; the therapist must be able to tolerate and work with these behaviors. The therapist must maintain his belief that he can find ways to help the patient, while accepting the possibility that some day he might fail. He can succeed only if he is prepared to fail. Meeks (1984) summed up his article on suicidal adolescents in the following way: Success in the therapy of these youngsters does not depend on brilliant insights as much as on persistence, patience, and a sustained hope for the future. The treatment process may become a demonstrated proof that the therapist can stand to feel the patient's feelings and live the patient's painful existence, without giving up on life or the patient [p. 5].

Adolescent↗
PubMed1994

Sectorial automatism: a further development.

This article deals with surprising delinquent behaviour of a limited kind--in time and nature. This delinquent behaviour manifests itself during actual life stress conditions where in the person's past there is evidence of psychotraumatization. The author offers an etiological theory concerning the medicine of behaviour and psychosomatics. The application of this theory to consider delinquency an important branch of behavioural sciences and medicine is concretized, updated and the evolution of the concept towards a sectorial approach becomes the main topic of the present work. A sector of faulty interaction between the individual with a psychotraumatic history and the environment is activated during life stress conditions, and may lead to behavioural or psychosomatic disturbances. Case histories are presented, concretizing the sectorial faulty behaviour following an impaired reality testing and impulse control in a vulnerable field of interaction with the environment. The legal implications are discussed, in the light of an inconsistent mens rea, offering at the same time a judicial psychiatric rehabilitation model. The advantages of this approach, which has been developed during the past seven years, are mentioned. A continuous interprofessional dialogue between judges and psychiatrists has made possible this rather enlightened attitude towards this special kind of delinquent behaviour promoting rehabilitation instead of unnecessary social ostracism or 'social death'.

Adolescent↗
PubMedDate not supplied

[Crohn disease--addiction--neurosis: comparison of ego functions].

25 neurotic patients, 25 alcoholics, and 25 patients suffering from Crohn's disease were rated with a german adaption (by Streeck) of Bellak's Ego Function Assessment scales. Crohn's disease patients showed personality characteristics similar to those of patients suffering from psychosomatic illnesses. Ego function disturbances could be found with respect to Introspection as a subfunction of Reality Testing, Creativity and Capacity for Abstraction as a subfunction of Thought Processes. The results indicated a remarkable heterogeneity of the Crohn's-patient group as well as possible influences of gender-specific personality differences in that group.

Adult↗
PubMed1977

A psychogeriatric activity group in a rural community.

Three senior students in occupational therapy and a faculty member collaborated with a community mental health center in implementing and conducting an Outreach Activity Group for socially isolated, psychogeriatric clients residing in an outlying rural community. The students gained experience in five areas: learning the structure, functions, and funding of a community program; identifying the role and function of occupational therapy in community-based mental health; making use of administrative and consultative role functions; leading a group; and, with other health professionals, identifying ways to lessen the problems faced by the psychogeriatric client in the community. The group was helpful in maintaining the psychogeriatric client in the community by promoting self-esteem, self-expression, new interests, constructive use of leisure time, reality testing, interpersonal relationships, and perceptual motor stimulation.

Aged↗
PubMed1996

Psychotic symptoms in primary care.

BACKGROUND: Psychotic symptoms include a variety of disturbances in perception, reality testing, speech, and behavior. We examine the prevalence, distribution, treatment, and functional impairment associated with psychotic symptoms in primary care patients. METHODS: Data are drawn from a recent study of adult primary care patients (N = 1001) in a large, urban, prepaid group practice. At the medical visit, patients completed a questionnaire that probed demographic characteristics, health status, and mental health care utilization. Following the visit, patients received a telephone-administered, structured psychiatric interview that included 11 psychotic symptoms. Medication prescription data were also available. Comparisons are presented of patients with and without psychotic symptoms. RESULTS: Thirty-seven (3.7%) patients reported one or more psychotic symptoms, most commonly a belief that others were spying on or following them (n = 16). As compared with patients without psychotic symptoms, a larger proportion of the patients with psychotic symptoms reported mental health-related work loss (54.1% vs 17.9%, P < .0001), suicidal ideation (21.6% vs 2.6%, P < .0001), major depressive disorder (32.4% vs 6.3%, P < .0001), bipolar disorder (29.7% vs 1.2%, P < .0001), and several other mental disorders. An antipsychotic medication had been prescribed during the previous 17 to 20 months for only two (5.4%) of the patients with psychotic symptoms. CONCLUSIONS: Psychotic symptoms were relatively common (3.7%) in this practice and were strongly associated with functional impairment and affective, anxiety, or substance use disorders. Primary care physicians are encouraged to examine patients with these mental disorders for the presence of psychotic symptoms.

Adult↗
PubMed1996

The relation of Cotard's syndrome to delusional misidentification.

A case of Cotard's syndrome with face processing deficits is described. The phenomenology of Cotard's syndrome may be an expression of underlying visual processing deficits, including abnormalities in face perception processing. Phenomenologic and neurobiologic characteristics of this case are similar to those found among delusional misidentification syndromes. This similarity suggests areas for further study that may lead to a better understanding of the relation of phenomenology to neurobiology in Cotard's syndrome.

Capgras Syndrome↗
PubMed1997

Revisiting foundations of autonomy and beneficence in genetic counseling.

Respect for autonomy of clients and helping clients to achieve the good they desire are now recurring themes in genetic counseling literature. In professional discourses on the clinical encounter involving genetic counseling these ideas are frequently employed in a manner which suggests that a client enters the conversation lacking only some technical information needed to make a decision. However, decision-making autonomy is developed and sustained over a lifetime through dependencies on social partners; including with the genetic professional. In an operational sense autonomy is reflected in the capacity of a client to do informed analytical work, to engage in reality testing of alternative decisions, and to do moral testing of decisions. The counselor's role can extend to assisting the client in developing the skills needed for the tasks of moral deliberation. This work develops a theoretical framework for conceptualizing autonomy of clients and the resulting relationship between counselor and client. This framework is more foundational than current debates about the relative merits of directive versus nondirective counseling, and points toward a relationship between counselor and client which differs from that implied by either of these two traditional relational paradigms.

Beneficence↗
PubMed1998

Practice parameter for the use of red blood cell transfusions: developed by the Red Blood Cell Administration Practice Guideline Development Task Force of the College of American Pathologists.

A practice parameter has been developed to assist physicians in the therapeutic use of red blood cell transfusions. The developers of this parameter used the best available information from the medical literature, as well as clinical experience and the extensive reality testing required by the College of American Pathologists for approval. In acute anemia, a fall in hemoglobin values below 6 g/dL or a rapid blood volume loss of more than 30% to 40% requires red blood cell transfusions in most patients. However, tissue oxygenation provides a better indication of physiologic need in situations where invasive monitoring provides this information. When these data are not available, heart rate and blood pressure measurements and the nature of bleeding (active, controlled, uncontrolled) supplement the hemoglobin value in guiding the transfusion decision. In sickle cell disease and thalassemias, red blood cells are transfused to prevent acute or chronic complications. Red blood cell transfusions are used in chronic anemias unresponsive to pharmacologic agents based on the patient's symptoms. Guidelines must be altered for neonates who require an increase in hematocrit to above 0.30 to 0.35 when respiratory distress is present. Indications for red blood cell transfusion for the pregnant or postpartum patient are similar to those for the nonpregnant patient. Risks of transfusion, particularly transmissible disease and incompatibility, remain but have been reduced. Thus, red blood cell transfusion continues to be a powerful therapeutic tool when used judiciously and carries less risk than in the recent past.

Adult↗
PubMed2003

Predictive DNA testing for glaucoma: reality in 2003.

As new genes and common mutations are identified, DNA testing can be offered. Like clinical testing used in glaucoma, such as IOP, tonography, disc measurements, nerve fiber layer analysis, and the various methods of visual field analysis, well-designed studies are needed to be able to interpret clearly the meaning of abnormal results. To use DNA testing to identify individuals at high risk for glaucoma, it is necessary to have solid evidence with sensitivity and specificity parameters, genotype-phenotype correlations, and information on prevalence and penetrance. These data will have to be replicated in several studies using large, population-matched control groups. Mass screening of glaucoma patients for Myocilin mutations may be worthwhile if 3% to 5% of glaucoma patients will be positive. For comparison, screening all cases of colon cancer for gene mutations involved in hereditary nonpolyposis colorectal cancer is considered feasible and desirable with a yield of only 3%. Recent research has shown the value of early treatment of glaucoma. The cost effectiveness of genetics screening will need to be weighed against the cost of conventional screening and the benefits of early treatment considered. Within glaucoma pedigrees with known mutations, DNA mutation-positive individuals will need more frequent clinical screening, whereas DNA mutation-negative individuals will need less frequent follow-up. It is likely that, for every positive-mutation glaucoma case identified, there will be on average two siblings and two children to test. In addition to the laboratory costs, the costs of counseling, and, in particular, the availability of suitably trained individuals who can correctly interpret these test results, must be considered. The risk and benefits of these measures must be calculated and then balanced with the long-term visual outcome of such a strategy. How could genetic testing alter management in glaucoma? If a family member in a Myocilin pedigree with a severe mutation is negative for the mutation, that individual's risk changes from 50% to that of the general population (ie, -2%), and the frequency of clinical screening can be reduced. There are ethical issues involved in testing, particularly in children, but testing would seem justified in congenital, developmental, and juvenile glaucoma. Issues related to insurance may affect the decision making of some patients. A further consideration, which may regrettably become important in the future, is that of intellectual property and patent issues pertaining to glaucoma gene discovery. In addition to clinical evidence of the value of predictive DNA testing, it is incumbent on those working in the field to evaluate the acceptability of testing to patients and their family members. The authors' experience to date is that predictive DNA testing in glaucoma is well supported in suitable families. As with predictive DNA screening in other ophthalmic conditions, issues relating to insurance, ethics, and confidentiality need to be taken into consideration. Although many of the more recently described genetic associations of POAG require more thorough evaluation, Myocilin gene testing can and should be offered for young-onset severe glaucoma cases with a positive family history.

DNA↗
PubMed1993

A speculation on perversion and hallucination.

This study develops a new explanation for the loss of reality in perversion. It is a speculative effort, and draws heavily on Freud's metapsychology. I have reviewed Freud's concept of the experience of satisfaction, and have described tests of reality implicit in the experience. Freud did not put these forward as reality-tests, but this they logically become from his own arguments. These reality-tests can be shown to be at work in the perverse solution to overwhelming anxiety. In particular, the pervert exploits them to create body or motor hallucinations or delusions which serve to deny castration anxiety and other concomitant traumatic situations.

Anxiety↗
PubMed2003

Learning curves and impact of previous operative experience on performance on a virtual reality simulator to test laparoscopic surgical skills.

BACKGROUND: The study was carried out to analyze the learning rate for laparoscopic skills on a virtual reality training system and to establish whether the simulator was able to differentiate between surgeons with different laparoscopic experience. METHODS: Forty-one surgeons were divided into three groups according to their experience in laparoscopic surgery: masters (group 1, performed more than 100 cholecystectomies), intermediates (group 2, between 15 and 80 cholecystectomies), and beginners (group 3, fewer than 10 cholecystectomies) were included in the study. The participants were tested on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) 10 consecutive times within a 1-month period. Assessment of laparoscopic skills included time, errors, and economy of hand movement, measured by the simulator. RESULTS: The learning curves regarding time reached plateau after the second repetition for group 1, the fifth repetition for group 2, and the seventh repetition for group 3 (Friedman's tests P <0.05). Experienced surgeons did not improve their error or economy of movement scores (Friedman's tests, P >0.2) indicating the absence of a learning curve for these parameters. Group 2 error scores reached plateau after the first repetition, and group 3 after the fifth repetition. Group 2 improved their economy of movement score up to the third repetition and group 3 up to the sixth repetition (Friedman's tests, P <0.05). Experienced surgeons (group 1) demonstrated best performance parameters, followed by group 2 and group 3 (Mann-Whitney test P <0.05). CONCLUSIONS: Different learning curves existed for surgeons with different laparoscopic background. The familiarization rate on the simulator was proportional to the operative experience of the surgeons. Experienced surgeons demonstrated best laparoscopic performance on the simulator, followed by those with intermediate experience and the beginners. These differences indicate that the scoring system of MIST-VR is sensitive and specific to measuring skills relevant for laparoscopic surgery.

Clinical Competence↗
PubMed2005

The permanence of mental objects: testing magical thinking on perceived and imaginary realities.

This study tested participants' preparedness to acknowledge that an object could change as a result of magical intervention. Six- and 9-year-old children and adults treated perceived and imagined objects as being equally permanent. Adults treated a fantastic object as significantly less permanent than either perceived or imagined objects. Results were similar when a different type of mental-physical causality--a participant's own wish--was examined. Adults were also tested on the permanence of personally significant imagined objects (participants' images of their future lives). Although almost all participants claimed that they did not believe in magic, in test trials they were not prepared to rule out the possibility that their future lives could be affected by a magical curse.

Adolescent↗