Prior nonfatal firearm injuries in detainees of a large urban jail

Detainees of large urban jails have may health risks including injuries related to violence and firearms. A survey of 582 randomly selected detainees entering the Cook County Department of Corrections during the summer of 1994 found that 51 percent had previously entered hospitals for violence-related injuries, and 26 percent survived prior gunshot wounds. Patterns of firearm injuries were different from patterns of violence affecting the general population. Factors common to those with prior firearm injuries included witnessing a shooting at an early age, tattoos, previous sexually transmitted diseases, easy access to a semiautomatic weapon, and prior incarceration. Implications and prevention strategies are discussed.

[Are there predictors for impulsive, homicidal-suicidal acts of violence]

Patient's statements or fears that they may "go crazy" and harm themselves or persons around them are rare, but extremely difficult for all participants to deal with. On the basis of the existing, unsatisfactory literature as well as an analysis of 196 incidents of homicidal-suicidal violence designated by German media as "running amok" and fulfilling defined criteria, we examined whether or not there are predictors for the degree of potential danger inherent in such threats. Impulsive, homicidal-suicidal acts of violence among patients with psychiatric disorders often occur in environments characterised by chronic psychosocial estrangement and isolation. Extremely distressing situations may trigger the course of violence, but the actual act is often planned during a seemingly peaceful interval. Personalities with a high affinity to weapons and a tendency toward acting out seem to increase the potential risks. Such events should be treated analogous to suicidal crises, with a strategy that takes the individual disorder into consideration. The parameters investigated in this paper are not sufficient, even in different combinations, to offer a satisfactory explanation or predict the occurrence of this extremely rare behaviour; further research is necessary.

A shooting incident in an elementary school: effects of worker stress on public safety, mental health, and medical personnel

The effects of impact of event and five categories of worker stress were studied with 140 police, fire, medical, and mental health personnel who were involved in emergency service work following a shooting in an elementary school. A questionnaire distributed 6 months after the incident was utilized. Public safety personnel reported a recollection of significantly fewer intrusive thoughts than medical and mental health professionals immediately following the incident. Groups did not differ in intrusive or avoidance scores on the Impact of Event Scale 6 months after the event and all groups showed a significant decrease in both scores over time. Stepwise linear regression showed that a self-reported qualitatively heavy work load predicted intrusiveness and avoidance of thoughts both immediately after and at the 6-month anniversary of the incident. Additionally, time pressure and quantitatively heavy work load also predicted avoidance score at the time of the incident. Results are discussed in terms of control models of anxiety and as foci for debriefing with affected personnel.

Survivors of self-inflicted firearm injury. A liaison psychiatry perspective

OBJECTIVE

To examine the clinical profile and, in particular, the psychopathology of 33 survivors of self-inflicted firearm injury.

DESIGN

An eight-year retrospective case history analysis. Information was obtained from databases in the Psychiatry, Trauma and Medical Records departments of Westmead Hospital.

RESULTS

In the sample most survivors of self-shooting were young men who did not suffer from major depression or psychosis. Most shootings occurred in the context of interpersonal disputes with sexual partners or family members.

CONCLUSIONS

Most patients who survive self-inflicted firearm injuries have shot themselves impulsively in a crisis, are not psychotic, and have ready access to firearms. Psychiatric care is usually given in the trauma ward. Close cooperation is required between psychiatric and surgical teams in management. Recommendations to assist in the more accurate assessment of patients with self-inflicted firearm injury include: careful scrutiny of alleged accidental shootings; the inclusion of police information in the assessment; routine drug screening and determination of blood alcohol level; repeated interviews and corroboration of patient claims by family and friends; and psychiatric review of all patients with self-inflicted injury.

Witnessed suicides

Suicides that take place in the presence of others have not been the topic of systematic scientific inquiry. The so-called witnessed suicides account for a small percentage of all suicides but offer a unique view into the dynamics of self-destructive behavior. An epidemiologic and forensic description of 50 witnessed suicides drawn from a 15-year series of over 1,000 cases is presented. A taxonomy is developed based on the role played by the witness and related to previous work on self-destructive behavior and its motivation. Brief vignettes are used to illustrate some of the interpersonal dynamics associated with these deaths.

The impact of availability, attraction and lethality of suicide methods on suicide rates in Germany

Substantial fluctuations have prevailed in both the rate and particular methods of suicide in the Federal Republic of Germany during the past 40 years. The current study examines the extent to which the availability, attraction and lethality of particular methods of suicide affect suicide rates. A close relationship existed in the period from 1949 and 1989 between the peaks of the suicide rate and the percentage of low threshold suicide methods according to De Catanzaro, whereby suicide in this context is understood to mean suicide by shooting or intake of solid, liquid or gaseous poisons. Our hypothetically expected lesser compensation between high and low threshold methods for women was confirmed. Between 1963 and 1976 the rate of suicide committed using domestic gas receded dramatically. Within the same period, however, the rate of suicide committed using other poisons rose accordingly.

Adolescent PTSD and developmental consequences of crack dealing

The effect of crack dealing on emotionally disturbed adolescents in two African-American inner-city communities is examined and illustrated by case examples. Crack dealing was most often found to have dynamics and consequences separate from those of crack use. These include post-traumatic stress disorder and other significant emotional disturbances arising from the violence associated with crack dealing, and the shaping of adolescent identity by the associated culture of violence and guns. Implications for school drug abuse education are explored.

Misidentification delusions, facial misrecognition, and right brain injury

Individuals suffering from misidentification syndromes may present with right hemispheric pathology and deficits in facial recognition. In addition, misidentification delusions have been associated with aggressive behaviour. The possible linkage between misidentification phenomena, facial recognition, and aggression is discussed, illustrated by the case of a patient suffering from an organic delusional disorder.

Suicidal behavior in the nursing home and a postsuicide intervention

The suicidal elderly patient in the nursing home has been the focus of inadequate attention. Given the longer life expectancy, we can project that the nursing home as a context of end-life care will be utilized by increasing numbers of elderly. This article presents a case of a suicide in a nursing home and a review of the relevant current literature. A mental health consultation to the administration and staff of the nursing home following the suicide is presented as an effective way to promote healing and limit adverse sequelae. In addition, a view of the concept of institutional care to the elderly is discussed. Relocation to a nursing home as a catalyst for suicidal behavior and the notion of "goodness of fit" as it applies to resident adaptation to the nursing home is posited. A continuum of suicidality is proposed. Suicidal ideation and Intentional Life Threatening Behaviors (ILTBs) are described as adapting to the context of the nursing home, and examples are offered. The article concludes with a model of suicide probability in the nursing home resident.

Reaction to trauma: A cognitive processing model

We integrated existing cognitive processing models of posttrauma reactions into a longitudinal model. Data were obtained after a multiple shooting in a city office block. The subject group comprised 158 office workers who were in the building at the time of the shootings. The methodology of this research was a repeated measures survey, with data collection at 4, 8, and 14 months posttrauma. Measures included the Impact of Events Scale (IES) and the Symptom Checklist-90-Revised. A path analysis was performed with the IES as an indication of cognitive processing. Intrusion and avoidance were shown to mediate between exposure to trauma and symptom development. Intrusion was also found to be negatively related to subsequent symptom levels. The findings provide provisional support for a cognitive processing model.

Ethical dilemmas in child and adolescent consultation psychiatry

Ethical issues in child and adolescent psychiatry consultation arise frequently but seldom are discussed in a public setting. This case of an adolescent victim of a surgical accident illustrates many aspects of consultation psychiatry. The consult question itself, of behavior management, is not unusual, although in this case the question is complicated by the sequelae of trauma, psychosocial chaos, and the staff's angry feelings toward the patient. In addition, potential surgical wrongdoing at the referring hospital brings up the more difficult ethical questions of the consultant's responsibilities, which must be to the patient and his family, as well as to the attending and referring physicians.

Treatment of posttraumatic stress disorder with eye movement desensitization

This case report describes the successful treatment of a posttraumatic stress disorder (PTSD) using eye movement desensitization (EMD). The client, a 40-year-old male, presented with an 8-year history of PTSD following an incident in which he was shot with a hand gun and left dying. Using EMD treatment, this trauma was quickly desensitized. Two earlier traumas with similar themes then emerged and they too were desensitized. Test results, taken pre-treatment and posttreatment, along with the client's verbatim account of cognitive and behavioral changes 8 months later, converged to document the successful treatment outcome.

Malignant memories: PTSD in children and adults after a school shooting

Sixty-four children and 66 adults were screened for post-traumatic stress disorder 6 to 14 months after a school shooting. Although there were no differences in overall frequencies of DSM-III-R diagnoses or cluster endorsements, there were developmental influences. Post-traumatic stress disorder was associated more with emotional states recalled from the disaster than with proximity. Emotional states mediated the formation of malignant memories leading to symptomatology, suggesting that postdisaster intervention be offered on the basis of degree of emotional reaction as well as proximity.

Firearm victims--who were they?

OBJECTIVE

To determine the characteristics of victims killed by firearms, whether they died by suicide, homicide or accident, and the types of firearms involved.

DESIGN

A retrospective and descriptive study.

SETTING AND SUBJECTS

Coronial autopsy data were obtained from the Brisbane Laboratory of Pathology and Microbiology. All 587 firearm deaths during the period 1980-1989 were included.

MAIN OUTCOME MEASURES

The proportions of deaths by suicide, homicide, accident or undetermined cause. In cases of homicide, we sought to define the relationship of the perpetrator to the victim.

RESULTS

The types of death were suicide 76%, homicide 18%, accidents 3% and undetermined 3%. Most homicides were of a domestic nature as opposed to crime. Small calibre rifles were the most common weapon; handguns were rarely used.

CONCLUSIONS

Recent debate regarding firearm legislation has failed to recognise the predominance of interpersonal and psychological issues in the causation of firearm deaths. Crime is a motive for only a minority. Medical practitioners may reduce firearm deaths both by organisational representation and individual efforts in clinical practice. In particular, attention should be given to the identification of individuals or families at risk, the detection and treatment of psychological disorder and advice regarding firearm disposal.

Pre-Vietnam contents of posttraumatic stress disorder veterans' service medical and personnel records

We reviewed the pre-Vietnam contents of the service medical and personnel records of 250 Vietnam combat veterans, in an attempt to identify factors predisposing to the development of posttraumatic stress disorder (PTSD). PTSD and non-PTSD veterans did not differ significantly on self-reported medical history items, sick call visits, or military efficiency and conduct ratings. There were trends for PTSD veterans to have lower arithmetic aptitude, more self-reported school difficulties, and (paradoxically) lower pulse rate at military induction.

Suicide and cancer in late life

In a controlled psychological autopsy study of suicide in late life, eight cases in which the victim's belief that he had cancer played a major role in the decision to end his life were examined. All victims were men. The majority had diagnosable major affective disorders, but none had been seen in mental health care settings. Other common characteristics were an active relationship with a primary physician, numerous losses, prior experience with cancer or debilitating disease, and a rigid, self-sufficient personality style. The cases illustrate the complex determinants of suicidal behavior in the elderly and suggest preventive strategies for the primary care setting.

Wisconsin Card Sorting Test performance based on location and size of neuroanatomical lesion in Vietnam veterans with penetrating head injury

We examined Wisconsin Card Sorting Test performance in a large group of brain-damaged patients and controls. No differences were found between patients with frontal lesions only and those with nonfrontal lesions. Patients with left dorsofrontal and anterior temporal lobe lesions committed the most perseverative errors. More analyses regarding requirements for information processing on the Wisconsin Card Sorting Test are needed.

Cognitive processing in post-trauma reactions: some preliminary findings

The current study investigated a model of post-trauma reactions proposed initially by McFarlane (1988 a). Two separate data sets, one obtained following a multiple shooting and the other reported by McFarlane following a natural disaster, were examined. The findings of both studies provide support for a cognitive processing conceptualization of the development of post-trauma reactions.

Dance/movement therapy in head injury rehabilitation

A case study is presented to illustrate the use of dance/movement therapy in the treatment of an individual with severe brain damage. Theoretical and practical perspectives, as well as selected principles of dance/movement therapy are delineated. A rationale for use of intentional/volitional movement as a treatment strategy is posited on the basis of neuroanatomical and neurophysiological constructs.

Psychiatric consultation for patients with self-inflicted gunshot wounds

The study describes 260 persons referred over a 12-year period for psychiatric consultation after shooting themselves. The population consisted primarily of young, white men between the ages of 20 and 29. The abdomen was the most common site of injury for both sexes. Previous suicide attempts and past psychiatric histories were uncommon, but alcohol was involved in 25% of cases. Major depression and alcohol abuse were the most common psychiatric diagnoses. Tasks for the psychiatric consultant include dealing with reactions of hospital staff, instituting appropriate suicide precautions, determining future suicidality and psychiatric disposition, and helping patients cope with family reactions to the suicide attempt and with the psychological effects of disfiguring injuries.

Neuropsychological outcome in children with gunshot wounds to the brain

During the years 1985-1987, 45 children were hospitalized at our institution for gunshot wounds (GSWs). Twelve suffered GSWs to the brain and five of these survived to be followed by the multidisciplinary team. The purpose of this article is to discuss the neuropsychological outcome of three children who sustained GSWs to the brain during this time period. At our institution, children return for regular follow-up appointments with the neurosurgeon, neuroscience clinical nurse specialist and neuropsychologist. The neurosurgeon conducts the neurological examination, and the nurse performs a developmental assessment and evaluates teaching and follow-up needs. During each appointment, the neuropsychologist administers a battery of tests to determine the effects of GSW on intelligence, language, spatial motor skills, academic achievement and adaptive behavior. Case reports are provided to illustrate the results, with nursing implications and future research in the area of outcome of GSW in children discussed.