Self, Voices and Embodiment: A Phenomenological Analysis.

OBJECTIVE: The primary aim of this study was to examine first-person phenomenological descriptions of the relationship between the self and Auditory Verbal Hallucinations (AVHs). Complex AVHs are frequently described as entities with clear interpersonal characteristics. Strikingly, investigations of first-person (subjective) descriptions of the phenomenology of the relationship are virtually absent from the literature. METHOD: Twenty participants with psychosis and actively experiencing AVHs were recruited from the University of Illinois at Chicago. A mixed-methods design involving qualitative and quantitative components was utilized. Following a priority-sequence model of complementarity, quantitative analyses were used to test elements of emergent qualitative themes. RESULTS: The qualitative analysis identified three foundational constructs in the relationship between self and voices: 'understanding of origin,' 'distinct interpersonal identities,' and 'locus of control.' Quantitative analyses further supported identified links of these constructs. Subjects experienced their AVHs as having identities distinct from self and actively engaged with their AVHs experienced a greater sense of autonomy and control over AVHs. DISCUSSION: Given the clinical importance of AVHs and emerging strategies targeting the relationship between the hearer and voices, our findings highlight the importance of these relational constructs in improvement and innovation of clinical interventions. Our analyses also underscore the value of detailed voice assessments such as those provided by the Maastricht Interview are needed in the evaluation process. Subjects narratives shows that the relational phenomena between hearer and AVH(s) is dynamic, and can be influenced and changed through the hearers' engagement, conversation, and negotiation with their voices.

A 20-year multi-follow-up of hallucinations in schizophrenia, other psychotic, and mood disorders.

BACKGROUND: Hallucinations are a major aspect of psychosis and a diagnostic feature of both psychotic and mood disorders. However, the field lacks information regarding the long-term course of hallucinations in these disorders. Our goals were to determine the percentage of patients with hallucinations and the relationship between hallucinations and recovery, and work attainment. Method The present study was a prospective evaluation of the 20-year trajectory of hallucinations in 150 young patients: 51 schizophrenia, 25 schizoaffective, 25 bipolar with psychosis, and 49 unipolar depression. The patients were studied at an index phase of hospitalization for hallucinations, and then reassessed longitudinally at six subsequent follow-ups over 20 years. RESULTS: The longitudinal course of hallucinations clearly differentiated between schizophrenia and bipolar disorder with psychosis, and suggested some diagnostic similarities between schizophrenia and schizoaffective disorder, and between bipolar disorder and schizoaffective disorder and depression. Frequent or persistent hallucinatory activity over the 20-year period was a feature of 40-45% of schizophrenia patients. The early presence of hallucinations predicted the lack of future periods of recovery in all patients. Increased hallucinatory activity was associated with reduced work attainment in all patients. CONCLUSIONS: This study provides data on the prospective longitudinal course of hallucinations, which were previously unavailable to the field, and are one of the key features of psychosis in major psychiatric disorders. This information on the clinical course of major psychiatric disorders can inform accurate classification and diagnosis.

A self-assessment program for multidisciplinary mental health teams.

OBJECTIVE: The authors describe a self-assessment training program for multidisciplinary mental health teams that was developed in a public multihospital system, the process of implementing the training at a state psychiatric hospital, and a measurement instrument, the Scale for Leadership Assessment and Team Evaluation (SLATE), which they have used for self-assessment of multidisciplinary teams and which is currently being studied. They assessed whether changes in team self-assessments could be seen after the training program. METHODS: A total of 102 mental health professionals from 12 inpatient units representing the disciplines of psychiatry, psychology, nursing, social work, and occupational and activity therapy completed the SLATE before and after participation in a training program that consisted primarily of team self-assessment in the context of treatment planning sessions. The training program included structured feedback, didactics, consultation, and videotaping of sessions. Aggregate data were used to compare mean item scores for the SLATE overall and for its four subscales (team, psychiatrist, participation, and treatment plan) at baseline and after the training. RESULTS: Scores increased significantly for the overall SLATE and for all four subscales, indicating improved team functioning in the areas addressed. The increase in mean score was greatest for the subscale that assessed the leadership of the psychiatrist. CONCLUSIONS: Treatment planning sessions can be used successfully by multidisciplinary mental health teams to examine team functioning in various areas in a self-assessment model. Participation in a training program that included videotaping of sessions, consultation, and structured attention to team functioning was associated with improved ratings of team functioning.

Ten-year outcome: patients with schizoaffective disorders, schizophrenia, affective disorders and mood-incongruent psychotic symptoms.

BACKGROUND: It is unclear whether outcome in schizoaffective disorders is more similar to schizophrenia or affective disorders. AIMS: To provide longitudinal data on clinical course and outcome in schizoaffective disorders versus schizophrenia and affective disorders, and determine whether mood-incongruent psychotic symptoms have negative prognostic implications. METHOD: A total of 210 patients with schizoaffective disorders, schizophrenia, bipolar manic disorders and depression were assessed at hospitalisation and then followed up four times over 10 years. RESULTS: At all four follow-ups, fewer patients with schizoaffective disorders than with schizophrenia showed uniformly poor outcome. Patients with mood-incongruent psychotic symptoms during index hospitalisation showed significantly poorer subsequent outcome (P < 0.05). CONCLUSIONS: Schizoaffective outcome was better than schizophrenic outcome and poorer than outcome for psychotic affective disorders. Mood-incongruent psychotic symptoms have negative prognostic implications. The results could fit a symptom dimension view of schizoaffective course.

Psychological assessment, treatment, and outcome with sex offenders.

The frequency and impact of sexual offenses have led to the recent enactment of sexual "predator" laws. Such laws are intended to reduce sexual violence through treatment and involuntary confinement. Sixty years ago, similar laws identifying "sexual psychopaths" were enacted and, in many states, eventually repealed for multiple reasons; among those reasons was an inability to demonstrate that treatment had any significant impact on recidivism. That inability forced us to reexamine, among other issues, the population(s) which undergo treatment, the outcomes that are used to measure treatment effectiveness, and the processes that constitute treatment itself. Those issues are considered in this paper through a review of treatment programs based on psychodynamic, behavioral, and cognitive-behavioral theories. Although the evidence is sparse, it is fair to conclude that the latter have been found to be effective. We call for dynamic measures, effective treatments, and the resources necessary for both developments.

Medical students and AIDS: knowledge, attitudes and implications for education.

Second year medical students at a large midwestern university were surveyed about their attitudes regarding AIDS. Results indicated: (1) students with homosexual and/or HIV-positive friends were significantly more tolerant toward AIDS patients, (2) over half the students believed that treating AIDS patients may be hazardous and that their education had not prepared them to treat these patients safely, (3) one-third believed they had the right to refuse to treat AIDS patients, and (4) AIDS-phobia was significantly associated with homophobia. These data suggest that medical educators may need to help students overcome AIDS-phobia before some students will be able to incorporate instruction about AIDS since AIDS-phobia may inhibit this learning. Didactic instruction must be coupled with modeling by educators of non-prejudicial attitudes and strict adherence to medical professionalism.

Medical student homophobia.

OBJECTIVE: To determine whether homophobia existed in a sample of the second-year medical school class before beginning a course on Human Sexuality. METHOD: We administered a questionnaire to a sample of the second-year class at an introductory lecture to the course on Human Sexuality. This questionnaire asked twelve questions regarding attitudes about homosexuality, and incorporated questions from other surveys used previously. RESULTS: The data indicated significant homophobia. One-quarter of the students reported believing homosexuality is immoral and dangerous to the institution of the family, and expressed aversion to socializing with homosexuals. Nine percent believed homosexuality to be a mental disorder and 14% felt more homophobia since AIDS. CONCLUSIONS: Medical student homophobia, if left unchallenged, will hinder care provided to homosexual patients. Physician homophobia may disallow a healthy doctor-patient relationship and may cause a decrease in patients' ability to disclose sensitive issues.

Are sex offenders treatable? A research overview.

OBJECTIVE: Recent legislation in several states providing for civil commitment and preventive detention of sexually violent persons has stirred legal, clinical, and public policy controversies. The mandate for psychiatric evaluation and treatment has an impact on public mental health systems, requiring clinicians and public administrators to direct attention to treatment options. It is a common view that no treatments work for disorders involving sexual aggression. The authors examine this assumption by reviewing research on the effectiveness of treatment for adult male sex offenders. METHODS: MEDLINE was searched for key reviews and papers published during the years 1970 through 1998 that presented outcome data for sex offenders in treatment programs, individual case reports, and other clinically and theoretically important information. RESULTS: Although rigorous research designs are difficult to achieve, studies comparing treated and untreated sex offenders have been done. Measurement of outcome is flawed, with recidivism rates underestimating actual recurrence of the pathological behavior. Outcome research suggests a reduction in recidivism of 30 percent over seven years, with comparable effectiveness for hormonal and cognitive-behavioral treatments. Institutionally based treatment is associated with poorer outcome than outpatient treatment, and the nature of the offender's criminal record is an important prognostic factor. CONCLUSIONS: Although treatment does not eliminate sexual crime, research supports the view that treatment can decrease sex offense and protect potential victims. However, given the limitations in scientific knowledge and accuracy of outcome data, as well as the potential high human costs of prognostic uncertainty, any commitment to a social project substituting treatment for imprisonment of sexual aggressors must be accompanied by vigorous research.

Detection of minimization of psychopathology on the Rorschach in cleric and noncleric alleged sex offenders.

The assessment of response-bias is critical in forensic psychological evaluations of alleged sex offenders because sex offenders frequently minimize psychopathology or personal limitations. This study tested predictions based on prior research that minimization on the Rorschach would be reflected by higher P, D, A, Lambda, and PER, and lower R, Blends, and Zf. We divided a sample of cleric and noncleric alleged sex offenders according to (a) whether they showed minimization on the MMPI, and (b) whether they admitted to their charges. We then compared these groups on the purported Rorschach validity indices. Our results do not support the use of any of these Rorschach scores in the assessment of minimization. We recommend that in forensic psychological evaluations, the Rorschach should not be used to assess defensiveness and is best used in combination with other psychometric instruments more sensitive to response-bias.

Temporal patterns of veterans' psychiatric service utilization, disability payments, and cocaine use.

This study examined temporal patterns of service utilization, disability benefits, and substance use. Specifically, it investigated whether the first day of the first week of each month (when disability payments are disbursed) was associated with increased emergency room (ER) use and more frequent cocaine use among psychiatric patients. All 1993 psychiatric ER presentations (n=1,448) at a Veterans Administration hospital were reviewed in order by the week of each month in which they occurred. A random subsample of only those admitted to an inpatient psychiatric service (n=143) was further assessed for amount of disability payments received and recent cocaine use. This study found that for the total population of patients utilizing the ER, most ER visits occurred during the first week, followed by weeks two, three, and four respectively. The highest percentage (49%) of patients who used cocaine were those admitted during the first week of the month, followed by week two (39%), week four (28%) and week three (25%). For the subsample of patients admitted to inpatient services, patients hospitalized during the fourth week of the month were those receiving the highest disability payments. This study found that cocaine users have the most ER visits during the first week of the month following receipt of benefits. Current data, if confirmed, would suggest public policy changes, such as payment of entitlement money to cocaine users through a third-party payee and stipulated treatment for psychiatric patients with substance use disorders as a condition of payment. Ethical and political issues, including confidentiality and patient autonomy, would need to be considered in any such policy changes.

Underdiagnosis of PTSD and substance use disorders in hospitalized female veterans.

Discharge diagnoses of 31 female veterans and 31 male veterans hospitalized at a large urban VA medical center were examined to elucidate possible biases in clinicians' diagnostic practices. Only one woman in the sample was diagnosed as having posttraumatic stress disorder, compared with seven men. All men given this diagnosis were combat veterans. Although about half of each group had a drug-positive urine screen on admission, only 11 women received a diagnosis of a substance use disorder, compared with 24 men. VA clinicians may need further training and experience assessing the presentation of PTSD and substance use disorders in women.

Interactive behavior in bipolar manic and schizophrenic patients and its link to thought disorder.

The research was designed to assess whether bipolar manic patients are unique in showing excessive interactive behavior and whether interactive behavior is linked to positive thought disorder in mania and other psychotic disorders. We compared the interactive behavior of manic patients versus schizophrenics and nonpsychotic patients. Degree of interactive behavior and severity of thought disorder were assessed in an inpatient sample of 140 patients, including 38 bipolar manic patients, and control samples of 40 acute schizophrenic patients, 32 nonpsychotic patients, and 30 chronically hospitalized schizophrenic patients. The assessment battery used standardized tests to assess interactive behavior and thought disorder. Manic patients displayed significantly more interactive behavior on all three tests than the other three patient groups. Interactive behavior made a greater contribution to the thought disorder of manic patients than to the thought disorder of the other three diagnostic groups. The other two acute patient groups also showed relationships between interactive behavior and thought disorder. The chronic schizophrenics did not show this pattern. The data indicated that many types of acute patients show some interactive behavior, but bipolar manic patients demonstrate more excessive interactive behavior than do other patients. There is a closer link between excessive interactive behavior and thought disorder in manic patients.

Psychological aspects of sexual functioning among cleric and noncleric alleged sex offenders.

Cleric sexual misconduct with minors is a problem receiving increased attention from the media, victims groups, and church authorities. Mental health professionals are increasingly being asked to assist church and civil authorities to help better understand the problem of cleric sexual misconduct with minors. In the current study we compared self-reported sexual functioning among cleric alleged child molesters, noncleric alleged child molesters, and normal control subjects. We hypothesized clerics would differ from nonclerics and normals in reported sexual functioning. Our sample included 30 Roman Catholic clerics and 39 nonclerics who were alleged to have engaged in sexual misconduct with minors, and 38 normal control subjects, all of whom took the Derogatis Sexual Functioning Inventory (DSFI) as part of their forensic psychiatric evaluation. Our results indicated clerics were more likely to report fewer victims, older victims, and victims of male gender than noncleric alleged child molesters. Clerics differed from nonclerics and normal control subjects on several dimensions of self-reported sexual functioning. Lower offense rate histories among clerics suggest that, as a group, clerics may be less seriously psychologically disordered than noncleric child molesters. Low DSFI scores among Roman Catholic clerics may be accounted for in part by their unique training and socialization process. Future studies should attempt to study the influence of social desirability on DSFI scores. Normative data from nonoffending celibate clergy are needed.

Can psychosis be malingered on the Rorschach? An empirical study.

Can psychosis be faked on the Rorschach? We examined this question by comparing 2 groups of subjects with a high incentive to malinger, persons accused of serious crimes. All subjects were administered both the Minnesota Multiphasic Personality Inventory (MMPI) and the Rorschach and were assigned to honest (N = 35) and malingered (N = 13) groups on the basis of MMPI validity scales. The Rorschach protocols of these 2 groups were compared to assess how successfully malingerers could deliberately produce records that appeared psychotic on empirically derived Rorschach indices of psychosis. Despite an attempt to portray themselves as psychotic on the MMPI, subjects in the malingered group did not differ from honest responders on Rorschach variables that distinguish psychotic from nonpsychotic patients, but did differ in the number of dramatic responses produced. Our data suggest that the combination of the MMPI and Rorschach provides a powerful psychometric technique for detecting deliberate malingering of psychosis.

Mental health care needs of female veterans.

Gender differences in diagnosis, demographic and family characteristics, and trauma histories among psychiatric outpatients at a Veterans Affairs clinic were examined. Among the 51 women and 46 men, significantly more women had affective disorders and schizoaffective disorder; significantly more men had anxiety disorders, schizophrenia, and substance use disorders. Although women had sharply higher rates than men of every type of trauma except combat trauma, more male veterans received a diagnosis of posttraumatic stress disorder. Men were four times more likely to be married. Women were more likely than men to be the sole caretakers of minor children. These differences have important treatment and policy implications. The findings confirm that recently initiated VA programs recognize important treatment needs of female veterans.

State psychiatric hospital patients with past arrests for violent crimes.

OBJECTIVE: This study examined associations between four types of major psychopathology--schizophrenia, schizoaffective disorder, and bipolar and unipolar affective disorders--and history of violent crime. The effects of demographic variables, substance abuse, psychosis, and paranoia on history of violent crime were also determined. METHODS: Diagnostic assessments using the Schedule for Affective Disorders and Schizophrenia and Research Diagnostic Criteria identified 172 state hospital inpatients with the four diagnoses of interest, as well as those with co-existing substance use disorders. Based on arrest records, patients were categorized according to the most violent crime for which they had been arrested. RESULTS: Patients with schizoaffective disorder were significantly more likely than those in the other diagnostic groups to have been arrested for a violent crime. Similar results were found for psychotic patients compared with nonpsychotic patients, patients who had paranoid schizophrenia compared with patients who had schizophrenia without paranoid features, and patients who had co-existing substance abuse compared with those with no history of substance abuse. Patients from racial minority groups and male patients were also more likely than white patients and female patients to have been arrested for a violent crime. CONCLUSIONS: Demographic features, a diagnosis of schizoaffective disorder, psychosis, paranoid symptoms, and substance abuse may all be associated with violent behavior.

Predicting the "revolving door" phenomenon among patients with schizophrenic, schizoaffective, and affective disorders.

OBJECTIVE: A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals. METHOD: Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations. RESULTS: Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations. CONCLUSIONS: Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

Comparison of MCMI-II and 16PF validity scales.

We administered the Millon Clinical Multiaxial Inventory-II (MCMI-II; Millon, 1987) and the Sixteen Personality Factors Inventory (16PF; Cattell, Eber, & Tatsuoka, 1970) to 131 outpatients in marital therapy and tested the correlation between the validity scales of the two instruments. The results indicated that MCMI-II Disclosure and Debasement scales were positively correlated with the 16PF Fake-Bad scale and negatively correlated with the 16PF Fake-Good scale. The MCMI-II Desirability scale was significantly correlated with the 16PF Fake-Good scale.

Course and outcome in bipolar affective disorder: a longitudinal follow-up study.

OBJECTIVE: A number of recent studies have questioned whether, despite modern treatment, the natural course of bipolar illness today still involves multiple relapses and impaired psychosocial functioning. This prospective follow-up study examined longitudinal outcome in a large group of inpatients with affective disorders. METHOD: Fifty-one bipolar manic patients and 49 unipolar depressed patients were interviewed three times: 1) during hospitalization, 2) approximately 2 years after discharge, and 3) approximately 4.5 years after discharge. Subjects were treated under routine conditions and assessed for global adjustment, rehospitalization, and work and social functioning. RESULTS: Only 41% of the bipolar group had a good overall outcome by the time of the 4.5-year follow-up. The bipolar patients had more severe work impairment than the unipolar group. More than one-half of the bipolar patients were rehospitalized at least once during the 4.5-year follow-up period. Outcome for both diagnostic groups improved significantly over time. CONCLUSIONS: Many contemporary bipolar patients demonstrate gradual improvement in the first several years after hospitalization. However, a subgroup approaching 60% still experience poor posthospital adjustment in one or more areas of functioning.

Recurrent affective syndromes in bipolar and unipolar mood disorders at follow-up.

BACKGROUND: It is in dispute whether affective relapse disrupts psychosocial functioning to the same extent in depressed and manic patients. METHOD: A prospective, naturalistic, longitudinal follow-up of 84 unipolar and bipolar affectively disordered in-patients was conducted to examine the extent of recurrent affective syndromes and their relationship to overall outcome. Global adjustment relative to relapse was assessed at 2- and 4.5-year follow-ups. RESULTS: Nearly half of the bipolar patients had subsequent syndromes, which were often associated with uniformly poor psychosocial functioning. Fewer than one-quarter of those with recurrences had steady work performance. Bipolar patients taking lithium alone had fewer recurrences than those taking lithium as well as neuroleptics (P < 0.05). Bipolar and unipolar patients relapsed with equal frequency, but unipolar relapse was less often associated with readmission to hospital, work impairment, or uniformly poor functioning. CONCLUSION: Affective relapse in bipolar disorders was more detrimental to overall functioning than was recurrence in unipolar depression.