Case-Control Retrospective Study of Child Sexual Abuse History among Psychiatric Consultations in a General Hospital Emergency Room.

BACKGROUND: A history of childhood sexual abuse (CSA) has been linked to a variety of physical and psychiatric illnesses, including ischemic heart disease and post-traumatic stress disorder (PTSD). OBJECTIVES: To determine the prevalence of past CSA and re-traumatization among hospital psychiatric consultations and to determine whether a CSA group in a hospital setting shared characteristics with community samples described in the literature. METHODS: We divided 228 consecutive psychiatric consultations into two groups. One group comprised patients with a past history of CSA while the other group had no such history. Both groups were further divided into a subgroup that presented with features of re-traumatization. RESULTS: In the cohort, 38% described a history of CSA. Twenty patients were identified as presenting with features of re-traumatization. There were significant differences between the two groups. The patients with a history of CSA were more likely to have arrived at the emergency department (ED) during the preceding 12 months with a diagnosis of PTSD, personality disorder, and substance use disorder. There was a greater proportion of patients in the CSA group who had grown up in an ultra-Orthodox Jewish household and who currently identified as being secular. CONCLUSIONS: The characteristics of the patients with past CSA in this study are similar to community-based samples, except for a significant gender difference. To the best of our knowledge, this study is the first to investigate CSA history during hospital ED psychiatric consultations. A history of CSA should be considered during psychiatric consultations in a general hospital ED admission.

Alcohol Related Harm: Knowledge Assessment of Medical and Nursing Staff in a General Hospital.

BACKGROUND: The prevalence of alcohol related harm (ARH) in Israel has traditionally been low. The lack of familiarity with ARH may derive from the fact that in the past there was limited clinical exposure to these harms. However, ARH is becoming more common in Israel but it is unclear whether the medical and nursing workforce's knowledge is adequate to manage these problems. Our main objective was to assess knowledge regarding ARH among medical and nursing staff (MNS) in an Israeli university affiliated general hospital. We also aimed to compare knowledge of different MNS groups Methods: One hundred and twenty-seven MNS including consultants (senior physicians), residents, interns and nursing staff completed the Knowledge of Psychiatric Aspects of Alcohol Questionnaire (KPAAQ), a validated measure of knowledge concerning ARH comprised of five categories. RESULTS: There was no significant difference between the four MNS groups in overall mean KPAAQ scores that varied from 45% (nurses) to 54% (interns). However, direct comparisons indicate that physicians scored higher than nurses (p=0.02). overall. The mean score for the KPAAQ category "alcohol withdrawal syndrome" was below 40% for all MNS groups. Physicians scored significantly higher than nursing staff (p=0.005). All MNS mean scores were greater than 63% for the category "alcohol in pregnancy." This was the highest category score. CONCLUSIONS: Assessment of knowledge regarding ARH among MNS in a general hospital with a standardized instrument demonstrated no significant difference in knowledge of ARH among nursing staff, interns, residents and consultants apart from knowledge about alcohol withdrawal. However, the overall score of the physicians as a whole was significantly higher than the nursing group. These findings suggest a need to implement educational interventions in MNS to increase knowledge of ARH so as to promote the provision of brief interventions for patients with ARH.

Preliminary results of a controlled educational intervention on alcohol related harm among medical students with a 12-month follow-up.

BACKGROUND: There are no studies that use validated questionnaires on Alcohol Related Harm (ARH) in order to assess retention of educational programs among medical students. Objective of study to assess retention of an educational inter-vention on ARH among medical students. METHOD: Seventeen fifth year medical students were assessed with the Knowledge of Psychiatric Aspects of Alcohol Questionnaire (KPAAQ) 12 months after an educational intervention on ARH and compared with a control group. RESULTS: Significant retention was found in the study group. CONCLUSIONS: This preliminary research is the first controlled study on medical student retention of an ARH educational intervention using a validated questionnaire.

Psychopathology of Israeli Soldiers Presenting to a General Hospital Emergency Department: Lessons for the Attending Physician and Psychiatrist.

BACKGROUND: There is scant research on the psychopathology of Israeli soldiers who present to a general hospital emergency department (ED). OBJECTIVES: To assess the psychopathology among a cohort of Israeli soldiers who presented to a general hospital ED for mental health assessment. METHODS: The demographic and clinical characteristics of 124 consecutive soldiers who presented to the ED for psychiatric assessment between January 2008 and September 2012 were reviewed. Twenty-seven soldiers from the cohort were contacted for follow-up by telephone on average 52 months later. RESULTS: The reasons for presentation to the ED, usually during the early stages of military service, included self-harming behavior, suicidal ideation, somatoform complaints, and dissatisfaction with their military service. Psychiatric diagnoses included adjustment disorder and personality disorder. Self-harming behavior/suicidal ideation was significantly correlated with unspecified adjustment disorder (P = 0.02) and personality disorder (P = 0.001). At follow-up, there was a lack of substantial psychopathology: none of the subjects engaged in self-harming behavior/suicidal ideation and a consistent trend was observed toward clinical improvement. CONCLUSIONS: Psychiatric intervention of soldiers who present to a general hospital ED because of emotional difficulties may provide the opportunity for crisis intervention and validation of the soldier's distress. To the best of our knowledge this is the first Israeli study of psychopathology among soldiers who presented to an ED.

Risperidone-Induced Nocturnal Enuresis Successfully Treated With Reboxetine.

There are few reports in the literature and scarce research on the topic and the treatment of antipsychotic medication-induced urinary incontinence or nocturnal enuresis (NE) despite the significant frequency of these adverse effects.Treatment for antipsychotic medication-induced urinary incontinence has been reported in relation to clozapine with response to numerous pharmacological strategies such as ephedrine, oxybutynin, intranasal desmopressin, trihexyphenidyl, and amitriptyline.We report a case of NE induced by risperidone which has been successfully treated with reboxetine.To the best of our knowledge, this article is the first report of an atypical antipsychotic medication-induced NE treated with reboxetine.Reboxetine may be an effective treatment for risperidone-induced NE. Further research is required to confirm our finding and apply this treatment for NE caused by other neuroleptics.

Prevalence and characteristics of cluster B personality disorder in a consultation-liaison psychiatry practice.

OBJECTIVE: Quantitative studies on cluster B-personality disorder (PD) in the general hospital are scarce. The aim of this study is to examine the prevalence and characteristics of cluster B-PD patients in a consultation-liaison practice. METHODS: Files of 258 consecutive patients referred for psychiatric consultation were examined. Cluster B patients were compared with the remaining patients. RESULTS: Eleven point six percent of these patients were diagnosed with a cluster B-PD. On univariate analysis, cluster B patients were more likely to be younger (P < 0.001), unmarried (P = 0.005), and without organic medical illness (P < 0.001).These patients had a shorter admission (P < 0.0001), and were more frequently treated in the emergency room (66.6% versus 37.5%, P = 0.02).There was a trend toward comorbid substance use disorder (P = 0.09). On multivariate analysis, cluster B patients presented significantly with self-harming behavior/ideation (80% versus 18%, OR = 12.07; 95% CI = 4.37-33.31; P < 0.0001). CONCLUSIONS: In view of the high prevalence of cluster B-PD in our preliminary study, general hospital staff requires practical skills for managing these high-maintenance patients. We believe that this study and further research will promote evidence-based recommendations for consultation-liaison psychiatrists.

[Obsessive compulsive disorder (OCD) in the ultra-orthodox community--cultural aspects of diagnosis and treatment].

Obsessive compulsive disorder (OCD) is reflected similarly in different communities, while symptoms are affected by the patient's cultural and spiritual world. An ultra-orthodox Jew with OCD will perform compulsive actions and will have obsessive thoughts related to the Jewish religious world. The religious symptoms do not necessarily correspond with the main commandments. Despite their significance, Shabbat or moral commandments such as respecting one's parents do not play a central role in the compulsive pattern. The religious compulsiveness of OCD patients focuses on commandments having to do with order and cleanliness and is characterized by repetition, checking and slowness. Obsessive thoughts and compulsive actions of ultra-orthodox OCD patients are usually based on the Jewish scriptures. One might assume that religion, as a framework with rules and dictated rituals, serves as a strong foundation for the development of OCD. However, it is estimated that the prevalence of OCD in the ultra-orthodox community is similar to the general population. Rabbis acknowledge OCD as a psychiatric illness and do not encourage the obsessive punctuality in following the commandments. An ultra-orthodox patient will first consult his rabbi, and after receiving his recommendation, will turn to psychiatric treatment. He might prefer to receive drug treatment rather than Cognitive Behavioral Therapy that may oppose his beliefs. Understanding the cultural background of the patient is essential, in particular when the patient is ultra-orthodox and the treatment is considered "secular". Therefore, cooperation with the patient's rabbi is important in order to obtain the patient's trust and develop a treatment plan.

A validated questionnaire to assess the knowledge of psychiatric aspects of alcohol use disorder.

BACKGROUND: To the best of our knowledge, there is no validated instrument for measuring knowledge of psychiatric aspects of alcohol use disorder (AUD) amongst medical students. Our aim was to develop an instrument for this purpose and to describe the instrument's psychometric properties. We also investigated whether the instrument could demonstrate a significant change in scores following an educational intervention consisting of a 60-minute PowerPoint lecture on AUD, associated handouts, and role-plays. METHODS: The Knowledge of Psychiatric Aspects of Alcohol Questionnaire (KPAAQ) was developed from the Kaplan and Saddock textbook synopsis chapter on alcohol related disorders. The questionnaire included 6 categories of clinically relevant material: metabolism of alcohol, short-term effects of alcohol, long-term effects of alcohol, AUD, alcohol withdrawal, and alcohol use in pregnancy. The KPAAQ was administered to 75 medical students in Years 4 and 5 from the Hebrew University in Jerusalem, Israel, during a relevant clinical rotation. Following the initial administration of the KPAAQ, the students attended a 60-minute lecture (in Hebrew) based on material from the University of Sydney's learning module on alcohol. The KPAAQ was readministered to the students immediately following the lecture. RESULTS: The KPAAQ demonstrated good reliability (Cronbach α =.92 for all questions) and validity r(209) =.674, P <.001. Knowledge of alcohol and alcoholism significantly increased after the educational intervention (F(2, 154) = 151.60, P <.001). Post hoc comparisons using the Scheffe test revealed a significant positive change in knowledge after students received the intervention (mean difference = 33, P <.001). CONCLUSIONS: These initial findings suggest that the KPAAQ is a reliable and valid instrument for assessing medical student knowledge of psychiatric aspects of AUD over 6 clinical categories.

Alcohol use disorder in an Israeli general hospital: sociodemographic, ethnic and clinical characteristics.

BACKGROUND: Alcohol consumption in Israel has increased over the last 20 years. Patients with alcohol use disorder (AUD) who present at a hospital enable early intervention. OBJECTIVES: To examine, for the first time, the characteristics of AUD patients in an Israel general hospital, and whether their alcohol use was documented in their files. METHODS: A group of 178 consecutive patients referred for psychiatric consultation was compared to a second group of 105 hospitalized patients who were not referred. These two groups were studied to compare risk factors for AUD. Patients in both groups were prospectively interviewed using a CAGE questionnaire, demonstrated as an effective screening instrument for AUD. Patients' files in both groups were examined for documentation of alcohol use. RESULTS: There was no significant difference between the prevalence of AUD in the two groups. The groups were then merged since no significant difference in the risk factor effects between the two groups was found. The risk factors for AUD in the final statistical analysis were lower educational status, living alone, being born in the Former Soviet Union and weaker religious observance. Post-traumatic stress disorder (PTSD), cigarette smoking and substance use were found to be independent risk factors. Soldier status was associated with significant alcohol misuse and AUD (CAGE1-4). Alcohol consumption was documented in the files of AUD patients in 48% of the first group and 21% of the second. CONCLUSIONS: Physicians often neglect to take a history of alcohol consumption. Routine use of the CAGE questionnaire is recommended in Israeli general hospitals. Special attention should be given to PTSD patients and to soldiers.

Shared obsessive-compulsive disorder: broadening the concept of shared psychotic disorder.

OBJECTIVE: Folie a deux (shared psychotic disorder) is often described in the context of schizophrenia. In this article we present this syndrome in a non psychotic context. METHOD: We report a case of induced obsessive-compulsive disorder (OCD) in a married couple. Six months after the deterioration in the patient's OCD, his wife developed the same symptoms with no preceding history of an Axis I disorder. Neither spouse demonstrated psychotic symptomatology. The husband was successfully treated on an outpatient basis with Citalopram and Clonazepam. His wife's OCD spontaneously resolved without medication in parallel with the resolution of her husband's OCD. RESULTS: We highlight the uncommon phenomenon of shared psychiatric disorder occurring in the context of OCD. In the current psychiatric diagnostic nomenclature, (DSM IV and ICD10), there is no category for a non-psychotic shared psychiatric disorder. We raise the question of broadening the concept of shared disorder so as to include shared OCD and perhaps other shared psychiatric syndromes. CONCLUSIONS: More controlled studies are required in order to better understand the psychopathology and mechanisms of psychotic and non-psychotic shared disorders in psychiatry. We believe there are important treatment implications of such an understanding.

Demographic and clinical parameters of patients with high risk behavior in a general hospital: the use of constant observation.

BACKGROUND: General hospital staff are often required to care for physically ill patients who arouse concern regarding risk of harm to themselves or others. Some of these patients,will be placed under one-to-one "constant observation." This is the first Israeli study of general hospital patients with high risk behavior. OBJECTIVES: To examine a population of general hospital patients whose behavioral management required the use of constant observation. Demographic and clinical parameters including physical diagnoses were examined, and risk factors for constant observation were identified. The findings of this study were compared to those of previous studies. METHODS: This prospective observational study examined 714 inpatients referred for psychiatric consultation; 150 were found to require constant observation, and 156 who did not served as a control group. RESULTS: In this study younger age, suicidal concerns and alcohol/substance abuse were identified as risk factors for ordering constant observation. Ischemic heart disease and chronic obstructive pulmonary disease were the only physical diagnoses found to be significantly correlated with a longer duration of observation, regardless of admission duration. Constant observation was less frequently used in the management of organic brain syndrome patients in this study compared to other studies. CONCLUSIONS: Some of our results (predictive factors for constant observation) confirmed the findings of overseas studies. Our finding that a diagnosis of organic brain syndrome was not a predictive factor for constant observation was unexpected and requires further investigation. The correlation between a diagnosis of ischemic heart disease or COPD and duration of observation has not been reported previously and warrants further studies.

Constant Observation in the general hospital: a review.

The role of Constant Observation (COb) in the general hospital is addressed. The difficulties of managing acute psychological disturbance in the general hospital are described. Concerns about confused behavior and suicidal risk appear to be the most common reasons for ordering COb. Organic brain syndrome is the most common diagnosis made in patients receiving COb. Medico-legal, ethical and therapeutic aspects of COb are noted. To our knowledge there is no research evidence that COb significantly decreases the rate of suicide in the general hospital. It appears that the role of COb is enshrined in the general hospital as a result of medico-legal process in addition to its therapeutic role. Further research in this area is needed.

Quetiapine-associated depression in a patient with schizophrenia.

Depression has been reported as a side effect of a wide variety of drugs in clinical medicine. Neuroleptics may cause depression in persons with or without any past history of psychiatric illness. Clinically, these drug-induced depressions may go unnoticed and thus create therapeutic problems. The authors present a case of quetiapine-associated depression in a patient being treated for schizophrenia. To the best of our knowledge it is the first description of depression associated with quetiapine treatment. This case report suggests that atypical antipsychotics may be a cause of depression. This is noteworthy because these medications have been found in the past to have an antidepressant action. Further data based on controlled studies are needed.

Ziprasidone and weight gain.

We describe the case of a 12-year-old white male in whom significant weight gain occurred within 3 months of treatment with Ziprasidone. It is important that clinicians are aware of this possibility since this medication is marketed as one of the few antipsychotic medications not associated with significant weight gain.