Tales of the crypt for psychiatrists: mourning, melancholia, and mortuary malpractice.

Death awaits all, leaving in its wake relatives and friends affected by the loss of a loved one. Immediately following death, the funeral process begins, resulting in permanent burial in a cemetery. This report investigates the dysfunctional interactions between grief-stricken relatives and mortuaries that are associated with civil litigation for negligence. Psychiatric evaluations of 25 bereaved plaintiffs from nine separate lawsuits were performed. In addition, medical records and legal pleadings were reviewed as sources of additional information. General themes from the clinical material are identified and illustrated by two cases. Surviving relatives are in an acute state of emotional turmoil, rendering them exquisitely sensitive to lapses in expected routine and perceived disrespect toward the decreased. These issues are intensified when the circumstances of the death were traumatic, when the relationship with the deceased was ambivalent, when specific cultural and religious factors are present, and when the influence of litigation is felt. If the burial process is disrupted, civil suits for negligence may be filed that exacerbate grief and challenge the psychiatrist's efforts to resolve diagnostic ambiguity in the face of emotionally charged cultural and religious practices.

Liability of psychiatric consultants.

Psychiatric consultants generally have limited exposure to malpractice liability because they undertake circumscribed responsibilities. To date, courts recognize the main responsibility for the patient rests with the primary care physician. Consultants' central responsibility is to the consultee, although they often assume a more direct role vis à vis the patient. Malpractice liability requires a doctor-patient relationship and is thus dependent on the extent of responsibilities assumed by each physician caring for the patient. The best protection, therefore, is a quality clinical evaluation combined with documentation that delineates the boundaries of responsibility assumed in the care of each patient.

Heterogeneous distribution of gastric mucosal blood flow with restraint stress in the rat.

Cold water immersion restraint (CWIR) is associated with gastric hypercontractility and gastric corpus erosions in the rat. Because the gastric blood flow response to CWIR has not been well defined, we performed the following study. Rats were implanted with force transducers, subjected to CWIR for 2 hr, and then blood flow was determined by the iodo[14C]antipyrine autoradiographic (IAP) technique. When compared to control animals, the CWIR-treated animals displayed foci of gastric corpus hyperemia with a marked and significant increase in blood flow in all layers of the gastric corpus. There was approximately a 100% increase in the mucosa and a 50% increase in the muscularis externa. The hyperemia was not uniform, but rather alternated every 2.1 +/- 0.2 mm with regions of low blood flow. Blood flow in the antrum and duodenum was unaffected by CWIR. We conclude that CWIR is associated with alternating regions of high and low blood flow only in the gastric corpus. Reduction of corpus mucosal blood flow might be due to the powerful gastric contractions associated with CWIR.

Strong gastric contractions cause mucosal ischemia.

Contractions of a segment of bowel result in alterations of its blood flow. However, the precise temporal and spacial relationships between contractions and mucosal blood flow are unknown. Rats were fitted with strain gauge force transducers and implanted with silver wire electrodes into the muscularis externa of the stomach. In vivo microscopic observation of motility and of the gastric mucosal blood flow was performed during electrical field-stimulated contractions. Contractions originated in the midcorpus, were 0.237 +/- 0.018 cm wide, traveled along the corpus at 0.133 +/- 0.024 cm/s, and had a duration of 5.9 +/- 0.1 s. Antral contractions were 0.174 +/- 0.032 cm wide, traveled at 0.070 +/- 0.009 cm/s, and had a duration of 5.6 +/- 0.7 s. During the contraction, capillary flow velocity in the corpus decreased from a basal value of 410 +/- 105 to 206 +/- 104 microns/s at the peak of a contraction. Five seconds after the contraction was released hyperemia was observed with the flow velocity increasing to 570 +/- 102 microns/s. In the antrum, flow stopped completely during the contraction irrespective of the initial flow velocity and no hyperemia occurred with release of the contraction; rather, flow velocity slowly returned to baseline values. In both regions the flow reductions were in phase with the contractions as measured by the force transducers. These studies provide direct evidence that strong gastric contractions can effectively reduce or stop gastric mucosal blood flow.

Role of oxyradicals in cold water immersion restraint-induced gastric mucosal injury in the rat.

Cold water immersion restraint of the rat results in focal gastric mucosal erosions. The lesions are associated with powerful, prolonged-duration gastric contractions. Phasic gastric contractions may attenuate gastric mucosal blood flow, resulting in ischemia followed by reperfusion. Therefore, the conditions of cold-water-immersion restraint might lead to mucosal injury by an oxyradical-mediated mechanism. To test this hypothesis, we studied the effect of oxyradical inhibition on cold water immersion restraint-induced lesions. In separate groups of rats subjected to cold water immersion restraint (6-10 animals per group), oxyradical inhibition was achieved by chronic feeding of a sodium tungstate diet, oral administration of allopurinol, or intraperitoneal administration of dimethylsulfoxide. None of these regimens significantly attenuated the number of lesions per stomach, the total lesion area, or the percent of corpus mucosa containing lesions. We conclude that oxyradicals do not play a role in the pathogenesis of cold water immersion restraint-induced lesions.

Behavioral medicine in the general hospital.

The application of behavioral procedures to the treatment of medical disorder has greatly expanded the techniques available to the psychiatrist practicing in the general hospital. While there are diverse behavioral strategies that have proven quite useful, the bases for these are limited and readily implemented in the hospital setting. In this paper, the behavioral methods of assessment and various strategies of treatment of medical, psychophysiological, and "psychosomatic" disorders are overviewed.

How to write a psychiatric consultation.

The written psychiatric consultation is the distillation, the official permanent record, and the one universal element of the consultation process. Both the document and process present a good and growing opportunity for service and teaching. The authors offer a conceptual and practical scheme to help potential consultants make decisions about the content, style, and wording of their written communications. Each of the components of the consultation document, including headings, openings, history, examination, and formulations, is considered in terms of its effects on the liaison with the consultee and the care of the patient.

Behavior therapy for irritable bowel syndrome. A case report.

The behavior analysis and treatment of a patient with chronic irritable bowel syndrome are presented. The usefulness of this approach in a patient with a poor treatment prognosis is discussed.