Self-inflicted gunshot wounds: lethality of method versus intent.

The authors studied 30 patients treated at an urban trauma center for self-inflicted gunshot wounds, most or all of which would have been fatal without emergency treatment. About half the patients had used alcohol or drugs immediately before wounding themselves, and slightly more than half had experienced interpersonal conflict just before the incident. Thirteen of the 30 were women. Only nine were given diagnoses of major depressive episode or dysthymia; none of the patients had written suicide notes. These data indicate that the reported demographic and clinical characteristics of impulsive, violent self-injury must be reexamined.

Sleep restriction for the inpatient treatment of insomnia.

This study evaluates the efficacy of sleep restriction therapy for treating insomnia on an inpatient psychiatric unit. A depressed patient with concomitant chronic pain and severe insomnia was treated with a sleep restriction procedure. This procedure consisted of curtailing the amount of time spent in bed and then gradually increasing it contingent upon improved sleep efficiency. The treatment was found to be effective for increasing total sleep time from an initial baseline of 2.5 h of sleep per night to 6 h of sleep per night at discharge time. Clinical gains were well maintained immediately after discharge and at a 4-month follow-up.

The general hospital as a center of biopsychosocial training.

Utilization of general hospitals as training sites for undergraduate and graduate medical education provides special opportunities for integration of biologic, psychologic, and social factors in health care. For medical students, the general hospital environment ideally facilitates learning a core of psychiatric knowledge and the biopsychosocial approach to all illness while attracting some students to psychiatric careers. By spending much of their internship year in the general hospital, psychiatric residents integrate psychiatry into the rest of medicine and develop collegial relations with nonpsychiatrists. Residency training in the general hospital perpetuates this integrative experience and allows in-depth training in consultation-liaison psychiatry. Despite the multiple advantages of general hospitals in training students and residents, limitations of this setting also exist.

Psychiatric aspects of respirator treatment and pulmonary intensive care.

The interrelations among physiology, psychology, and technology have been explored in this chapter with respect to respirator treatment and to pulmonary intensive care. The comprehensive care of these patients mandates an understanding of not only the mechanical aspects of ventilators, but also the psychological impact that these devices and intensive care settings may have on patients, their families, and the health care professionals committed to their care.

Psychiatric symptoms in endocrine diseases. Keys to identifying the underlying disorder.

Several important points should be considered regarding psychiatric symptoms in endocrine disorders. The presence of cognitive deficits in a patient presenting with anxiety, depression, or another apparently "functional" psychiatric complaint should raise the index of suspicion of organic etiology, with endocrine disorders high on the list. Psychiatric symptoms secondary to endocrine disturbance generally reverse, albeit slowly, with treatment of the primary hormonal abnormality. When significant disruption of cognitive functioning is evident, residual deficits may develop. Treatment with psychotropic agents for symptomatic relief of psychiatric complaints should be undertaken with great caution in patients with endocrine disorders.

Psychotropic management of behavioral disorders after head trauma.

A rational basis for the psychopharmacologic management of behavioral disturbances after head trauma has been presented that is predicated on research in neurotransmitter changes that evolve subsequent to head trauma. The paucity of human studies in this area mandates the use of experimental models and evidence garnered from provocative challenges to suggest the underlying neurotransmitter profile in various behavioral abnormalities. Multiple neurotransmitter circuits exist that provide parallel, duplicate, and redundant systems for these behaviors. Certainly, alternative explanations could be offered for the examples cited above. Furthermore, measurement of neurotransmitter metabolite concentration in cerebrospinal fluid does not allow specific inferences to be made regarding topographic correlation and neurotransmitter function. Nor does it afford assessment of regional differences in psychotropic influence on neurotransmitter receptors. New imaging techniques (eg, positron emission tomography) will certainly aid in this determination. Current investigations, however, support the concept that neurotransmitter changes do occur after head injury, that these alterations exist during the time that "recovery" occurs, and that psychotropic agents influence this recovery process. Further research is needed to clarify neurotransmitter changes after head injury and to identify psychotropic intervention strategies that facilitate the recovery process.

Behavior change following head injury: clinical assessment and intervention.

Behavioral change after head injury is a multiply determined event which requires careful assessment of biologic, psychologic, and social parameters prior to the initiation of a treatment plan. Under certain conditions, the prudent use of neuropsychopharmacologic agents may substantially augment the rehabilitation process. While some data exist relative to therapeutic efficacy of these agents, further investigation is required to better define the complementary roles of pharmacotherapy and psychosocial intervention in these individuals.

Emergency psychopharmacology.

A review of the literature pertinent to the emergency use of psychotropic agents is presented. Four general principles (underlying organicity, target symptoms, route of administration, and side effect profiles) governing the choice of psychotropic agent are discussed. Pharmacologic management approaches to commonly encountered behavioral emergencies, including drug-related disorders, assaultive patients, suicidal patients, agitated patients, and stuporous/withdrawn patients, are outlined.

Forgetting rates for verbal, pictorial, and figural stimuli.

Literature on forgetting rates is reviewed and related methodological issues are discussed. Descriptive data from 50 subjects are provided for tests which were developed to assess forgetting rates for words, pictures and designs. The three tests are well-matched on initial learning at criterion and have comparable variance and skewness of score distributions. Forgetting rates were similar across the initial 10-min retention interval, but there was a more rapid loss of words than pictures and designs from 10 min to 2 hr, especially in male subjects. Memory for words and pictures steadily declined between 10 min and 48 hr, but there was no further loss for designs after 2 hr. These findings suggest that nonverbal memory storage is more stable than verbal memory storage over intervals of hours to days. Modest sex differences are discussed in terms of potential differences in organization of brain function. The potential utility of these tests in further elucidating the nature of memory impairment in clinical populations is addressed.

Carbamazepine-lithium toxicity in brain-damaged adolescents.

For several years carbamazepine has been used to treat intractable mania and it is frequently used in combination with lithium. Reports of toxicity have appeared in the past 2 years and some risk factors have been suggested. This paper reports four cases of brain-damaged adolescents treated with carbamazepine and lithium for both seizure and behaviour control who developed this reported neurotoxic phenomenon.

Group therapy with moderately neurologically damaged patients.

The diagnosis and psychosocial treatment of moderately head injured clients requires three elements. First, there should be a stated frame of reference for the understanding of client behavior within the constraints of the injury. Second, and related to the first, there should be at work a practice theory that is consistent with the therapist's view of human behavior. Third, interventions must be consistent with both. In this article, the authors describe and discuss all three needed elements. The membership perspective serves as the practice theory and as the foundation for the operationalization of group therapy with the head injured client.

The trauma of paediatric and adolescent brain injury: issues and implications for rehabilitation specialists.

The purpose of this article is to define critical issues facing rehabilitation specialists providing services to children or adolescents with a brain injury and their families. These issues will be identified as they evolve temporally--from the period immediately after the injury to many years post-trauma. As the young person heals, the focus of the issues and the recommendations (based on both the clinical experience of the authors as well as the extensive body of literature already in existence) will change from those more appropriate to rehabilitation specialists working in the medical environment to those employed in education and the psychosocial realm. However, the boundaries between these realms, because of the all encompassing nature of the injury, are fluid. Finally, the purpose of this article is also to establish the need for rehabilitation specialists who are educated about traumatic brain injury; who are well versed in the physical, cognitive and emotional sequellae of the injury; who recognize the unique needs and expectations of this population and are willing to adjust; and who are willing to face the challenge that their clients face.

Neuropsychiatric interventions with head injured children and adolescents.

With increasing numbers of surviving head injured children and adolescents, there is a growing need to provide child neuropsychiatric services as a necessary component for their comprehensive rehabilitation. This paper discusses the critical role child psychiatry should have in pediatric head injury rehabilitation and outlines a framework for neuropsychiatric interventions including the use of neuropsychoactive medications. Case examples highlight the principles and practicalities of interventions.