Psychiatric Case Research Articles

Acquiring Transversal Knowledge in the Area of Clinical Psychology and Psychotherapy

During the last five years, efforts in bringing together and coordinating several groups of clinical psychologists have been made, psychologists who were in various stages of training (mostly young, recently licensed specialists, working under supervision in the field of Clinical Psychology and Psychotherapy). These groups have been defined by their live exposures of their psychiatric cases, followed by theoretical – clinical discussions on different approaches. The objective was to highlight possible ways of working in groups, in which the main goal was to manage a clinical situation in favor of the patient, by compiling a profile obtained from combining different projections in the mind of each participant.

Patterns of psychiatric emergency at tertiary referral psychiatric hospital

Background Psychiatric emergency has been extensively studied over years with different transcultural presentations. Objective The aim of the study was to assess sociodemographic aspects and clinical diagnoses of psychiatric emergency cases attending emergency room (ER) at tertiary referral mental hospital and to study some of the clinical contributions of admitted patients through ER. Patients and methods During 3-month period, 3666 attendants to psychiatric ER were submitted for this cohort study. Patients were submitted to medical assessment and psychiatric evaluation by semistructured clinical interview. Of them, 283 were admitted and further submitted to Mini–Mental State Examination, Brief Psychiatric Rating Scale, and Crisis Triage Rating Scale at ward. Results A total of 3666 patients (2352 male and 1314 female) who were aged 33.44±11.5 years, age range of 8–70 years, with psychiatric emergency attended Al Taif Psychiatric Hospital ER, KSA. The most prevalent psychiatric diagnoses were schizophrenia-related disorders in 30.4%, mood disorders in 28.8%, substance-related disorders in 21.4%, anxiety in 9.6%, developmental disorders (MR) in 3.2%, personality disorders in 0.6%, somatoform disorders in 0.14%, and neurological disorders in 2.2%, whereas 3.3% of ER attendants had no formal psychiatric disorder. The main cause for attending ER was refill of medicine in 31%, followed by natural exacerbation of illness in 26%, then familial conflict in 16%, and finally social problem in 15% of patients. The hospitalization rate was found to be 7.7%; most admitted patients were alert. Hospitalized male patients were found to be more severe and had less social support with little cooperativeness from their families than female patients. Conclusion Psychiatric emergency constitutes a significant route for providing service for mentally ill patients. Family education and early detection of psychiatric disorders minimize the burden of psychiatric illness.

Reconstructing Harry: a genealogical study of a colonial family 'inside' and 'outside' the Grahamstown Asylum, 1888-1918.

Recent scholarship has explored the dynamics between families and colonial lunatic asylums in the late nineteenth century, where families actively participated in the processes of custodial care, committal, treatment and release of their relatives. This paper works in this historical field, but with some methodological and theoretical differences. The Foucauldian study is anchored to a single case and family as an illness narrative that moves cross-referentially between bureaucratic state archival material, psychiatric case records, and intergenerational family-storytelling and family photographs. Following headaches and seizures, Harry Walter Wilbraham was medically boarded from his position as Postmaster in the Cape of Good Hope Colony of South Africa with a ‘permanent disease of the brain’, and was committed to the Grahamstown Asylum in 1910, where he died the following year, aged 40 years. In contrast to writings about colonial asylums that usually describe several patient cases and thematic patterns in archival material over time and place, this study’s genealogical lens examines one white settler male patient’s experiences within mental health care in South Africa between 1908 and 1911. The construction of Harry’s ‘case’ interweaves archival sources and reminiscences inside and outside the asylum, and places it within psychiatric discourse of the time, and family dynamics in the years that followed. Thus, this case study maps the constitution of ‘patient’ and ‘family’ in colonial life, c.1888–1918, and considers the calamity, uncertainty, stigma and silences of mental illness.

Schizophrenia and violent crime: a population-based study.

Previous studies have found that patients with schizophrenia are more likely to be violent than the general population. The aim of this study was to investigate the association between schizophrenia and violent crime in the Israeli population. Using the Israeli Psychiatric Hospitalization Case Registry we identified 3187 patients with a discharge diagnosis of schizophrenia. For each proband we identified parents and siblings, and gender- and age-matched controls for patients, parents and siblings. Information on violent crimes was obtained from police records. Patients with schizophrenia were at increased risk for violent crimes compared with controls [odds ratio (OR) 4.3, 95% confidence interval (CI) 3.8-4.9], especially women (OR 9.9, 95% CI 6.2-15.7). Risk for violent crimes was higher among patients with co-morbid substance misuse than in patients without such co-morbidity (OR 5.1, 95% CI 4.2-6.3). The results of this study suggest that increased risk of violence is part of the clinical picture of schizophrenia and needs to be recognized as a legitimate, essential, aspect of clinical management.

Assessing psychological health: the contribution of psychological strengths

Balanced assessment of mental health involves assessing well-being and strengths as well as psychopathology. The character strengths of curiosity, gratitude, hope, optimism and forgiveness are assessed in 214 new undergraduates and their relationships to mental health, subjective well-being and self-esteem explored. Scoring the mental health scale for psychiatric caseness, case and non-case students did not differ in character strengths, positive affect or life satisfaction, supporting a dual-factor model. Hope pathways and gratitude predicted mental health. Gratitude, hope agency and exploratory curiosity predicted positive affect. Gratitude and hope agency predicted life satisfaction. Hope agency, hope pathways, exploratory curiosity and gratitude predicted self-esteem, with absorption curiosity as a negative predictor. The benefits of assessing strengths are discussed and interventions designed to develop them.

Neighborhood ethnic density and psychotic disorders among ethnic minority groups in Utrecht City

Recent studies have shown increased incidence of non-affective psychotic disorders (NAPD) among ethnic minorities compared to the native population, but not, or less so, in areas with a high own-group proportion. The aim is to investigate this ethnic density effect in Utrecht and whether this effect is due to higher rates of NAPD among Dutch persons in areas with high minority proportions. We also explore the geographical scale at which this effect occurs and the influence of social drift prior to NAPD. NAPD cases in the Psychiatric Case Registry Middle Netherlands (N = 2,064) and living in Utrecht during 2000-2009 were analyzed in a Poisson model in relation to both individual-level and district- vs. neighborhood-level characteristics. With increasing minority density, especially of the neighborhood, the rate ratios of NAPD significantly decreased among both non-Western (from 2.36 to 1.24) and Western immigrants (from 1.63 to 1.01), in comparison with Dutch persons. This was partly explained by higher rates of NAPD among Dutch persons in areas with high minority density. But there was also a trend to lower NAPD rates among non-Western minorities in these areas (P = 0.074).This trend was significant among Surinamese/Antilleans (P = 0.001) and Moroccans aged 18-30 years (P = 0.046). Among the Dutch, a social drift to minority-dense neighborhoods prior to NAPD registration was found. Our findings support the beneficial association with own-group presence at the smaller scale neighborhood level. Findings show also that this association is more pronounced in immigrant vs. native comparisons and is not found within all ethnic groups.

Psychiatric case management. Chronic Disease Management application experience in a public Mental Health Service

Aim of this study is to investigate the possible effectiveness of a specific program management needs of patients at high impact health care, case management (CM). The welfare impact is evaluated in terms of the severity of the presented disorder or to other characteristic factors of the individual patient, such as: adherence to the proposed treatments, possible resistance to drug treatment, cognitive structure, the presence of comorbid medical pathologies, abuse/addiction and, more generally, all bio-psycho-social functioning variables that can complicate the treatment of the patient. Twenty five outpatients with chronic schizophrenia (age mean 49,5 yrs) were evaluated through the Camberwell Assessment of Need (CAN20) and Life Skill Profile (LSP) before and after 1 year of CM treatment. General psychopathology was assessed by the Clinical Global Impression (CGI) and the Brief Psychiatric Rating Scale (BPRS). Demographic data were collected, as well as data related to the severity of the disorder: number of hospitalizations and number of switch in drug treatment in the year before the study. Between T0 and T1 there is a significant improvement on CGI-G, BPRS (total and HOST factor), LSP and CAN TOT in patients treated with CM. Moreover, in CM treated patients a 58% reduction of hospitalizations is noted in the year of study. There is a possible effectiveness of CM in improving patient's clinical and social needs in chronic psychiatric diseases. The CM reduces the number of hospitalizations.

Use of the Extended Strengths and Difficulties Questionnaire (SDQ) to Predict Psychiatric Caseness in Hong Kong

The extended Strengths and Difficulties Questionnaire (SDQ) provides information on problem behaviours and impairment measures. Western studies found impairment measures to be as good as symptom scores in predicting clinical caseness. The high levels of comorbidities among child psychiatric disorders also meant that disorders not specifically captured by the questionnaire could be identified. This study examines its applicability among Chinese school children in Hong Kong. Results found that impairment measures were more predictive of clinical status than were symptom scores. Children with low symptom but high impairment ratings had profiles that were intermediate between the low symptom low impairment and high symptom low impairment groups. The extended SDQ is useful in identifying children who might otherwise be missed if symptom scores alone were used in screening. The acceptance of child psychiatric care in Hong Kong is a multi-step process that depends on how symptoms are perceived.

Psychiatric Consultant Helps Shape Care of Wide Range of Patients

Psychiatric Consultant Helps Shape Care of Wide Range of Patients

Genealogien von Gewaltstrukturen in Kinderheimen

The paper, with Germany as an example, discusses traditional lines of modernisation processes that would dominate structures of violence in children’s homes until the 1970s. The psychiatrisation of childhood took place since the mid-19th century (Michel Foucault), beginning with anti-masturbation campaigns, and using the biological heredity model of degeneration theory. With the help of the heredity paradigm, the Christian standardisation of a “sinful way of life” entered the sciences and as such became the basis for the medicalisation of the “incorrigible child”. The psychiatric theory of degeneration, having used the category of “psychopathic inferiority” to summarise physical, sexual and social deviations ever since the 1880s, finally provided the passepartout for the legal concept of “neglect”, which became relevant for court injunctions ordering coercive education. Christian sexual morals and work morale having been welded onto the “science of neglect” (Detlev J. K. Peukert) and the forensic “power of normalisation” (Michel Foucault), children in homes became psychiatric cases in two ways: as descendants of “degenerate” parents (such as, for instance, “workshy” people, vagabonds, unmarried mothers, prostitutes) and as incorrigible on account of negative sex-stereotypical characteristics (“instinct-driven”, “unruly”, “lazy”). Especially during National Socialism the psychiatric model of diagnosis became the instrument for coercive sterilisation and for the medical murder of patients, measures which also affected children in homes; but within the framework of growing biopolitically motivated violence, it had already become possible in the 19th century for such children to be the victims of medical experiments in the name of medical-scientific progress.

Five Year Review of Disease Profile of Inmates in Three Prison Formations in Kaduna State, Nigeria: A Case Control Study

Prisons have been in existence in most parts of Nigerian since her inception as a country and it has served as correctional institutions for custody, reformation, rehabilitation and reintegration. The inmates are reported to exhibit poorer health status than the general population due to overcrowding and poor sanitary conditions which provided a favourable breeding ground for various disease conditions. However, existing information on the overall disease profile of Nigerian prisons is scanty. This study assessed a five year disease profiles of inmates in three prison formations in Kaduna state, northwestern, Nigeria. A retrospective study of 24,327 cases of the inmate's monthly morbidity statistics from January 2007 to December 2011 was carried out. Statistical Package for Social Sciences (SPSS) software packages was used for data analysis. Psychiatric cases (24.1%) constituted the most prevalent disease category among inmates. This was followed by gastrointestinal diseases (22.6%), diseases of the respiratory tract (10.9%), dermatology/allergy (5.4%) and cardiovascular diseases (2.4%). Among the specific conditions examined malaria (21.6%) was found to be the most prevalent condition, followed by accidents/deliberate harms (3.6%), and tumours (0.6%). Tuberculosis and HIV/AIDS constitute 0.2% and 0.1% respectively. There is a huge communicable and non communicable disease burden among inmates in Kaduna State, Nigeria. We recommend health education, adequate sanitation, proper nutrition and mental care interventions in order to provide adequate health care to inmates. Keywords : Inmates, Disease profile, Kaduna State, Nigeria.

Theatre, Society, and Stigma: Mental Illness on Stage

The paper describes an approach to theatre as an educational intervention in society linking the artist, the psychiatrist, and social groups with an interest in mental illness. An exploration of narratives and diagnostic criteria from psychiatric case studies led to the creation of two dramatic monologues focusing on awareness and impact of bipolar disorder on intimate personal relationships, particularly on the evolving transactional roles between the partner/caregiver and partner/patient. The paper argues that devised performance based on themes and characters that emerge from within the field of psychiatry may be used to address perceptions of mental illness and stigma for general community audiences. It concludes that psychiatrically informed material can be successfully translated into original dramatic performances to address current educational and social issues and raise social awareness in thought-provoking and stimulating ways to members of the public.

EPA-1216 – Ethical issues in psychiatry require reflectivity: presuppositions, tacit assumptions and implicit values

Background and aim Psychiatrists and other Mental Health Professionals (MHP) are facing ethical problems in their daily practice. MHP usually can rely on their moral competence when dealing with ethical questions. However, in challenging situations doubts may arise concerning the ethical legitimacy of one's decisions. In Clinical Ethics Consultation (CEC), an ethics consultant aims at helping MHP to make ethically sound decisions. In psychiatry, CEC is less common than in somatic medicine. What is the additional benefit of using CEC when dealing with ethical problems in psychiatry? Methods A conceptual framework of CEC in Psychiatry is presented highlighting its reflective components. Two CEC cases from our service will be evaluated: A) a child psychiatric case where parental conflict split the team on prioritizing values in the care of the child; B) a geronto-psychiatric case with team dissent on the appropriate outpatient follow-up care for an alcohol-addicted patient. Results In both cases, consensus was reached; moreover, underlying ethical components were articulated, e.g. A) the importance of a continuous informed consent process with the parents, B) the conflict of respecting the patient's autonomy versus the duty to prevent harm. Discussion While the MHP experienced their difficulties, they benefited from ethics support formulating their own arguments precisely. Intuitive or emotional aspects of disagreement were transformed and entered into a target-oriented discourse on values and norms. CEC provides the discoursive framework and – in the person of the ethics consultant – the methodological competence to strengthen ethical reflectivity to the clinical setting.

Editor's Introduction: Wars

With this issue, jml contributes to the centenary remembrance of the Great War. The hostilities demarcated by that war, however, were not confined to 1914–1918. The current collection of essays treats aggressions (and not only armed ones) that, beginning on the threshold of World War I, reach all the way to the present. Our memorial purview takes for its object the impact on literature of a century of global conflict. Jill Richards’s lead-off study, about the suffrage census strike in 1911, argues that the suffrage cause was betrayed by its enemies’ translation of women’s diverse aims into a mythical equivalent of a unified nation-state — a unity with no grounding in the cross-currents of reality. Perhaps, the essay suggests, war would be less thought of as an ultimate solution to conflicts if governments and populations patiently tolerated plural, contradictory phenomena. Luke Thurston’s account of May Sinclair implicitly reinforces Richards’s argument. It argues that Sinclair, bent on participating in the Great War, but blocked from doing so by women’s subordination to the male-centered effort, refused to recognize her disappointment. In Thurston’s view, Sinclair felt inward equivalents of Richards’s pluralities, none of which was rightly to be sacrificed to a masculinizing, coercive regulation. Outwardly, however, according to Thurston, Sinclair used her fiction to make the sacrifice, and thereby wrongly repressed the inevitable conflicts of self-division and public life. But what of the soldiers who, traumatized by the battlefield, found their inward conflicts insupportable, and yearned to replace them with self-renewing psychological integration? Carolyn Steffens’s and Elizabeth Covington’s essays address the therapies that sought to heal combatants’ self-division, and that are portrayed in fiction about the Great War by Pat Barker and Rebecca West. The novelists, according to both essayists, replace orthodox (i.e., Freudian) ideas about trauma and therapy with unorthodox perspectives (for example, W.H.R. Rivers’s). The replacement — providing, in comparison with routine psychiatric case histories, “a competing . . . cultural logic” — suggests that literary historians who rely on present-day “trauma theory” have new things to learn from the fictions of 1918 and 1991–95. Contrasts between unified and self-divided modes of consciousness unfold as our essays move towards representations of World War II and beyond it.

Flexible Assertive Community Treatment, Severity of Symptoms and Psychiatric Health Service Use, a Real life Observational Study

Background: Introduction of Flexible Assertive Community Treatment (FACT) may be associated with increased remission rates and changes in patterns of care. The present paper reports on differences in psychosocial functioning and health care use between patients in FACT and two groups of patients not currently provided with a specific model of community service. Methods: The ongoing "Pharmacotherapy Monitoring and Outcome Survey" provided routine outcome measures of patients using antipsychotics in the north of the Netherlands. Level of psychosocial functioning was assessed using the Health of the Nations Outcome Scales (HoNOS) and matched with psychiatric health care consumption obtained from the Psychiatric Case Register. Patients who never received FACT, patients ever in FACT but not at assessment date, and patients in FACT were identified. Data were subjected to multilevel linear regression analysis. Results: Data showed that most patients in FACT also had non-FACT episodes after the start of FACT. Furthermore, patients in FACT displayed higher levels of psychosocial functioning and used more outpatient care than the other two groups. Conclusions: Patients in FACT receive more outpatient care and have better psychosocial functioning. However, causal inferences cannot be derived from these data. In addition, membership of a FACT-team in this setting did not last indefinitely.

Case formulation and management using pattern-based formulation (PBF) methodology: clinical case 1

A tool for psychiatric case formulation known as pattern-based formulation (PBF) has been recently introduced. This paper presents an application of this methodology in formulating and managing complex clinical cases. The symptomatology of the clinical presentation has been parsed into individual clinical phenomena and interpreted by selecting explanatory models. The clinical presentation demonstrates how PBF has been used as a clinical tool to guide clinicians' thinking, that takes a structured approach to manage multiple issues using a broad range of management strategies. In doing so, the paper also introduces a number of patterns related to the observed clinical phenomena that can be re-used as explanatory models when formulating other clinical cases. It is expected that this paper will assist clinicians, and particularly trainees, to better understand PBF methodology and apply it to improve their formulation skills.

Argyrophilic grain disease as a neurodegenerative substrate in late-onset schizophrenia and delusional disorders

To study the relationship between neurodegenerative diseases including argyrophilic grain disease (AGD) and late-onset schizophrenia and delusional disorders (LOSD; onset ≥40 years of age), we pathologically examined 23 patients with LOSD, 71 age-matched normal controls, and 22 psychiatric disease controls (11 depression, six personality disorder, two bipolar disorders, and three neurotic disorders cases). In all LOSD cases (compared to age-matched normal controls), the frequencies of Lewy body disease (LBD), AGD, and corticobasal degeneration (CBD) were 26.1 % (11.3 %), 21.7 % (8.5 %), and 4.3 % (0.0 %), respectively. There was no case of pure Alzheimer's disease (AD). The total frequency of LBD, AGD, and CBD was significantly higher in LOSD cases than in normal controls. Argyrophilic grains were significantly more severe in LOSD than in controls, but were almost completely restricted to the limbic system and adjacent temporal cortex. In LOSD patients whose onset occurred at ≥65 years of age (versus age-matched normal controls), the frequencies of LBD and AGD were 36.4 % (19.4 %) and 36.4 % (8.3 %), respectively, and AGD was significantly more frequent in LOSD patients than in normal controls. In LOSD patients whose onset occurred at <65 years of age, the frequencies of LBD, AGD, and CBD were 16.7, 8.3, and 8.3 %, comparable to those of age-matched normal controls (10.2, 5.1, and 0.0 %). In all psychiatric cases, delusion was significantly more frequent in AGD cases than in cases bearing minimal AD pathology alone. Given these findings, LOSD patients may have heterogeneous pathological backgrounds, and AGD may be associated with the occurrence of LOSD especially after 65 years of age.

Can Assertive Community Treatment Remedy Patients Dropping Out of Treatment Due to Fragmented Services?

Previously, many patients with severe mental illness had difficulties to engage with fragmented mental health services, thus not receiving care. In a Dutch city, Assertive Community Treatment (ACT) was introduced to cater specifically for this group of patients. In a pre-post comparison, changes in mental health care consumption were examined. All mental health care contacts, ACT and non-ACT, of patients in the newly started ACT-teams were extracted from the regional Psychiatric Case Register. Analyses of mental health care usage were performed comparing the period before ACT introduction with the period thereafter. After the introduction of ACT, mental health care use increased in this group of patients, although not all patients remained under the care of ACT teams. ACT may succeed in delivering more mental health care to patients with severe mental illness and treatment needs who previously had difficulties engaging with fragmented mental health care services.

Cancer mortality among psychiatric patients treated in a community-based system of care: a 25-year case register study

Cancer mortality data allow assessing, at the same time, the risk of developing the disease and the quality of care provided to patients after the oncologic diagnosis. This study explores the risk of death caused by a single tumor site in a psychiatric population treated in a community-based psychiatric service. All patients with an ICD-10 psychiatric diagnosis, seeking care in 1982-2006 (25 years), were included. Data were drawn from the South Verona Psychiatric Case Register (PCR). Mortality and cause of death were ascertained using different procedures and sources. Standardized mortality ratios (SMRs) were used to compare the observed number of deaths with the expected number using as reference a population in the Veneto region. Having been admitted to the hospital (SMR = 1.32), having a short interval from registration (1.52), having a diagnosis of alcoholism (2.03), and being a middle-aged male (1.83) were factors showing an increased risk of death from cancer. Increased SMRs were found for cancer of the oral cavity (22.93), lymphoma, leukemias, Hodgkin's lymphoma (8.01), and central nervous system (CNS) and cranial nerve tumors (4.75). The SMR decreased for stomach tumors (0.49). Patients with alcoholism (5.90 for larynx), affective disorders (20.00 for lymphomas), and personality disorders (28.00 for SNC) were found to be exposed to a high risk of cancer death in specific sites. Psychiatric patients showed different patterns of site-specific cancer mortality when compared with the general population. The 20-fold higher risk of dying from hematological neoplasms needs further investigation. Chronic use of phenothiazines could be involved in the relative protection from stomach and prostate cancer found in psychiatric patients.

Worden etnische verschillen in de toegankelijkheid en het gebruik van de jeugd-GGz minder?

Are ethnic group differences in accessibility and patterns of care in child and youth mental healthcare declining? The organisation of childcare in the Netherlands was changed radically in the past ten years. Very little is known about the changes in accessibility and continuity of mental healthcare for patients aged 0 to 18 years after the new Childcare Act passed into law on 11 January 2005. Data from the Rotterdam psychiatric case register were used to investigate changes in incidence rates and patterns of care in the years 2001-2003 and 2008-2010. The number of new patients in child and youth mental healthcare was higher in the years 2008-2010 then in the previous period. Child and youth mental healthcare reaches fewer patients from ethnic groups as compared to the native population. Over 40% of new patients stayed in care for a brief period. Treatment episodes in mental health care were 3 to 4 months. The number of short treatments and the number of more intensive care have increased, but this concerned mainly the native population. Since the new Childcare Act passed into law, accessibility of mental healthcare for ethnic groups has not improved much. No differences between ethnic groups in short- or long-term dropout were found, but more research is needed into changes in health care demand and service delivery.