Considerations for the Writing of Certification Letters Endorsing Use of Emotional Support Animals

Emotional support animals (ESAs) are different from service animals, therapy animals, and other disability-related assistance animals. Although pet ownership may confer psychological benefits, limited research has supported the use of ESAs to realize such benefits. If clinicians are asked to write a letter of support for use of an ESA, they need to be familiar with relevant federal, state, and local laws that regulate ESAs and with the essential components of an ESA evaluation. This article provides an overview of terminology; federal, state, and local laws related to ESAs; and clinical and ethical considerations for clinicians who decide to write these letters. The authors also review liability issues related to writing these letters, including those related to ESA aggression.

A Systematic Approach to the Detection of False PTSD

Posttraumatic stress disorder (PTSD) can occur after a traumatic experience and can cause severe symptoms that interfere with a person's psychological, physical, interpersonal, occupational, and social functioning. It is important to accurately identify genuine cases of PTSD and, as part of the differential diagnosis, to rule out instances of false PTSD. False PTSD diagnoses can adversely affect treatment planning, resource management, and research. The subjective nature of stressors, stereotypic presentation of symptoms, wealth of resources detailing how to malinger PTSD, and the high stakes for individuals involved in criminal, civil, and disability evaluations create challenges for making an accurate diagnosis. This article presents a systematic approach to help clinicians and forensic evaluators distinguish genuine PTSD from false variants of the disorder. It describes the types of false PTSD to be considered as alternative diagnoses, including malingered PTSD (for external gain, such as receiving a disability pension or evading criminal consequences), factitious PTSD (for internal gain, such as assuming the victim or hero/veteran role), and misattributed PTSD (legitimate psychopathology misdiagnosed as PTSD). The authors describe clinical features and psychological testing that may be leveraged to aid in reaching a more valid diagnosis.

Sex Offenders in the Digital Age

With most youths now using the Internet and social networking sites (SNSs), the public has become increasingly concerned about risks posed by online predators. In response, lawmakers have begun to pass laws that ban or limit sex offenders' use of the Internet and SNSs. At the time of this article, 12 states and the federal government have passed legislation attempting to restrict or ban the use of SNSs by registered sex offenders. These laws have been successfully challenged in 4 states. In this article, we discuss examples of case law that illustrate evolving trends regarding Internet and social networking site restrictions on sex offenders on supervised release, as well as those who have already completed their sentences. We also review constitutional questions and empirical evidence concerning Internet and social networking use by sex offenders. To our knowledge, this is the first paper in the psychiatric literature that addresses the evolving legal landscape in reference to sex offenders and their use of the Internet and SNSs. This article is intended to help inform forensic mental health professionals who work with sex offenders on current concerns in this rapidly evolving legal landscape.

Skin stem cell hypotheses and long term clone survival--explored using agent-based modelling

Epithelial renewal in skin is achieved by the constant turnover and differentiation of keratinocytes. Three popular hypotheses have been proposed to explain basal keratinocyte regeneration and epidermal homeostasis: 1) asymmetric division (stem-transit amplifying cell); 2) populational asymmetry (progenitor cell with stochastic fate); and 3) populational asymmetry with stem cells. In this study, we investigated lineage dynamics using these hypotheses with a 3D agent-based model of the epidermis. The model simulated the growth and maintenance of the epidermis over three years. The offspring of each proliferative cell was traced. While all lineages were preserved in asymmetric division, the vast majority were lost when assuming populational asymmetry. The third hypothesis provided the most reliable mechanism for self-renewal by preserving genetic heterogeneity in quiescent stem cells, and also inherent mechanisms for skin ageing and the accumulation of genetic mutation.

An approach to evaluating competence in assessing and managing violence risk

OBJECTIVE

The authors developed and evaluated a tool for assessing competency in violence risk assessment and management.

METHODS

The Competency Assessment Instrument for Violence Risk (CAI-V) was based on the literature on violence risk assessment, which was complemented by feedback from faculty focus groups. In an objective structured clinical examination, 31 faculty observers used the CAI-V to rate the performance of 31 learners' (26 psychiatry residents and five psychology interns) risk assessments of standardized (simulated) patients. In an interrater reliability study, six faculty members rated video-recorded risk assessments.

RESULTS

The CAI-V had good internal consistency reliability (α=.93). Senior learners performed better on the CAI-V than junior learners, supporting the instrument's concurrent validity. Interrater reliability was good (intraclass correlation coefficient=.93). Participants reported that the CAI-V provided a helpful structure for feedback and supervision.

CONCLUSIONS

The results supported the potential of this new approach for appraising competency in violence risk assessment and management.

Utility of decision support tools for assessing acute risk of violence

The authors evaluated the utility of 3 decision support tools for assessing acute risk of violence in patients undergoing behavioral emergencies that warranted hospitalization. Information available at the time of admission to a short-term psychiatric unit was coded from the medical charts of 100 patients using the Historical, Clinical, Risk Management-20 (HCR-20), the Hare Psychopathy Checklist-Screening Version (PCL-SV), and the McNiel-Binder Violence Screening Checklist (VSC). Nurses rated violence that later occurred during hospitalization with the Overt Aggression Scale. Scores on all 3 instruments were associated with the likelihood of violence. The strongest predictive relationships were obtained for indices of clinical risk factors rather than historical risk factors. The results suggest that decision support tools, particularly those that emphasize clinical risk factors, have the potential to improve decision making about violence risk in the context of behavioral emergencies.

Tg.AC genetically altered mouse: assay working group overview of available data

In a Government/Industry/Academic partnership to evaluate alternative approaches to carcinogenicity testing, 21 pharmaceutical agents representing a variety of chemical and pharmacological classes and possessing known human and or rodent carcinogenic potential were selected for study in several rodent models. The studies from this partnership project, coordinated by the International Life Sciences Institute, provide additional data to better understand the models' limitations and sensitivity in identifying carcinogens. The results of these alternative model studies were reviewed by members of Assay Working Groups (AWG) composed of scientists from government and industry with expertise in toxicology, genetics, statistics, and pathology. The Tg.AC genetically manipulated mouse was one of the models selected for this project based on previous studies indicating that Tg.AC mice seem to respond to topical application of either mutagenic or nonmutagenic carcinogens with papilloma formation at the site of application. This communication describes the results and AWG interpretations of studies conducted on 14 chemicals administered by the topical and oral (gavage and/or diet) routes to Tg.AC genetically manipulated mice. Cyclosporin A, an immunosuppresant human carcinogen, ethinyl estradiol and diethylstilbestrol (human hormone carcinogens) and clofibrate, an hepatocarcinogenic peroxisome proliferator in rodents, were considered clearly positive in the topical studies. In the oral studies, ethinyl estradiol and diethylstilbestrol were negative, cyclosporin was considered equivocal, and results were not available for the clofibrate study. Of the 3 genotoxic human carcinogens (phenacetin, melphalan, and cyclophosphamide), phenacetin was negative by both the topical and oral routes. Melphalan and cyclophosphamide are, respectively, direct and indirect DNA alkylating agents and topical administration of both caused equivocal responses. With the exception of clofibrate, Tg.AC mice did not exhibit tumor responses to the rodent carcinogens that were putative human noncarcinogens, (di(2-ethylhexyl) phthalate, methapyraline HCl, phenobarbital Na, reserpine, sulfamethoxazole or WY-14643, or the nongenotoxic, noncarcinogen, sulfisoxazole) regardless of route of administration. Based on the observed responses in these studies, it was concluded by the AWG that the Tg.AC model was not overly sensitive and possesses utility as an adjunct to the battery of toxicity studies used to establish human carcinogenic risk.

Relevance of interrater agreement to violence risk assessment

This study considered whether assessments of violence risk in which 2 clinicians reach similar conclusions are more accurate than the conclusions of either clinician alone when their assessments disagree. One hundred ten physicians and 44 nurses estimated the probability of physical assault of 478 patients admitted to a short-term locked psychiatric inpatient unit. The level of assessed risk showed a substantial correspondence with the likelihood of later violence when the physician and nurse ratings were highly concordant. As the extent of agreement between the physician and nurse ratings decreased, the strength of the association between the risk assessments and the occurrence of violence decreased accordingly.

The relationship between command hallucinations and violence

OBJECTIVE

The purpose of this study was to describe the relationship between command hallucinations and violent behavior.

METHODS

One hundred and three psychiatric inpatients completed measures of command hallucinations, other psychotic symptoms, violent behavior, and social desirability response biases.

RESULTS

Thirty percent of the patients reported having had command hallucinations to harm others during the last year, and 22 percent of the patients reported they complied with such commands. Logistic regression analyses suggested that patients who experienced command hallucinations to harm others were more than twice as likely to be violent, even when the analysis controlled for demographic variables, history of substance abuse, and social desirability response biases.

CONCLUSIONS

The results support the clinical utility of asking about command hallucinations when assessing the risk of violence in patients with major mental disorders.

The relationship between patients' gender and violence leading to staff injuries

OBJECTIVE

Although recent research has found similar rates of violence by female and male patients who have serious mental disorders, it is less clear whether violence by female patients is as likely to result in injury as violence by male patients. This study examined the relationship between violent patients' gender and injury to staff members on an inpatient unit.

METHODS

All injuries to staff caused by violent behavior by patients on a locked university-based short-term inpatient unit were identified in a search of institutional records from October 1988 to June 1999. We reviewed the medical charts of the 76 patients who injured staff members to compare their demographic and clinical characteristics with those of 314 patients hospitalized during the same period who did not injure staff.

RESULTS

Nearly half of the injuries (45 percent) were caused by female patients. Moreover, the proportion of injuries caused by female and male patients was similar to the proportion of females and males in the comparison group. Multivariate logistic regression analysis showed that patients' gender was not associated with injury to staff, even when the analyses controlled for other correlates of violence such as history of violence, violent thought content expressed in the admission mental status examination, and history of noncompliance with medication.

CONCLUSIONS

The findings suggest that injuries to staff members on a unit treating both men and women are as likely to be caused by violence by female patients as by male patients. When a female patient exhibits signs of an elevated risk of violence, the significance of that risk should not be discounted on the basis of her gender.

Resource document on mandatory outpatient treatment

Mandatory outpatient treatment, or outpatient commitment, refers to court-ordered treatment for patients who suffer from severe mental illness and who are unlikely to be compliant with such treatment without a court order. Many states already have commitment statutes that permit mandatory outpatient treatment, and others are considering enacting new legislation or amending existing statutes. This Resource Document was prepared under the auspices of the American Psychiatric Association's Council on Psychiatry and Law to provide information to those who are drafting mandatory outpatient treatment legislation. It begins with a review of the history of mandatory outpatient treatment and recent empirical findings, followed by a detailed discussion of the salient issues in mandatory outpatient treatment. The document concludes with a statement of recommendations concerning key provisions in statutory schemes of mandatory outpatient treatment programs. This Resource Document endorses the view that mandatory outpatient treatment can be a useful intervention for a small subset of noncompliant patients with severe and chronic mental illness who go in and out of psychiatric hospitals through the so-called "revolving door."

Are the mentally ill dangerous?

The author reviews studies that address the question, "Are the mentally ill dangerous?" She points out that as psychiatrists, we have the responsibility of evaluating the mentally ill and making judgments about their dangerousness that may restrict their civil liberties. Therefore, the more practical question for us is: "Which mentally ill, under what circumstances, are dangerous?" She discusses data from her research group and others that show that short-term predictions of violence can be relatively accurate, that we are better at predicting violence for some patients than for others, that specific symptom patterns in the acute phase of illness are related to violent acts, that the most likely victims of violence by decompensating psychiatric patients are caretakers rather than strangers, and that a history of violence, co-morbid substance abuse, and treatment noncompliance are related to a higher risk of violence in psychiatric patients.

Angiogenesis is an early event in the development of chemically induced skin tumors

In this study we have analyzed the vascular response induced in the two-stage carcinogenesis model in SENCAR mice. The role of angiogenesis has not been explored in this model, which is the paradigm of multistage carcinogenesis and a model for neoplastic lesions derived from exophytic premalignant lesions (e.g. colon carcinoma, bladder papilloma). We investigated if angiogenesis is involved in the formation of papillomas and in the progression from papilloma to carcinoma. To this end we analyzed the vasculature of normal and hyperplastic skin, focal epidermal hyperplasias that are precursors of papillomas, papillomas at different stages and squamous cell carcinomas. We also analyzed the vascularization of papillomas induced in two strains of mice that differ in their susceptibility to malignant progression. We show here that angiogenesis is turned on in the earliest stages of papilloma formation. In late stages, regardless of state of progression, the predominant response is an increase in the size of blood vessels. Thus, in the SENCAR mouse model, representative of exophytic tumors, the angiogenesis switch is a very early event, probably mechanistically related to the development of the primarily exophytic lesions. Therefore, the density of blood vessels cannot be used as a predictor of malignant progression in this model.

The relationship between confidence and accuracy in clinical assessment of psychiatric patients' potential for violence

The authors studied the relationship between confidence and accuracy in clinical assessments of psychiatric patients' short-term risk of violence. At the time of entry to the hospital, physicians (N = 78) estimated the probability that each of 317 patients would physically attack other people during the first week of psychiatric hospitalization. The clinicians also indicated the degree of confidence they had in their estimates of violence potential. Nurses rated the occurrence of inpatient physical assaults with the Overt Aggression Scale. The results showed that when clinicians had a high degree of confidence, their evaluations of risk of violence were strongly associated with whether or not patients became violent. At moderate levels of confidence, clinicians' risk estimates had a lower, but still substantial relationship with the later occurrence of violence. However, when clinicians had low confidence, their assessments of potential for violence had little relationship to whether or not the patients became violent. The findings suggest that the level of confidence that clinicians have in their evaluations is an important moderator of the predictive validity of their assessments of patients' potential for violence.

Ultraviolet B-induced squamous epithelial and melanocytic cell changes in a xenograft model of cancer development in human skin

We previously demonstrated that precancers (actinic keratoses and dysplasias) and squamous cell carcinomas (SCCs) develop in one quarter of human neonatal foreskins grafted onto recombinase-activating gene-1-knockout mice treated once with 7,12-dimethylbenz[a]anthracene (DMBA) followed by chronic intermediate-range ultraviolet (UV) B light irradiation. The goals of this study were to determine if a longer UVB exposure followed by further observation would increase the number of precancers and invasive cancers and to evaluate whether this model results in changes in p53 expression and cell proliferation similar to those seen in sun-damaged normal skin, actinic keratoses, and SCCs. The treatment consisted of a single dose of DMBA followed by 500 J/m2 UVB radiation administered three times weekly for at least 5 mo. Histologic changes (cysts, hyperplasias, precancers, and/or invasive cancers) were seen in 24 of 25 treated xenografts but not in controls. Ten of 25 grafts (40%) had two or more histological changes, and two human SCCs developed. After seven or more months of UV exposure and a total time from DMBA treatment to killing of 12-18 mo, 83% (15 of 18) of specimens developed squamous precancer or SCC of human origin, and 44% (eight of 18) developed melanocytic hyperplasia or melanoma. The change from moderate dysplasias to SCC required longer UV exposure (median, 11 mo), and 5 mo more observation than did the development of mild dysplasias (median UV exposure, 7 mo; median DMBA to death time, 12 mo). There was a direct correlation between both p53 expression and cell proliferation and the degree of histologic alteration both in squamous epithelial and melanocytic cells.

Squamous cell hyperplastic foci: precursors of cutaneous papillomas induced in SENCAR mice by a two-stage carcinogenesis regimen

We have conducted a series of experiments to characterize the lesions that are precursors of cutaneous papillomas in SENCAR mice initiated with 7,12-dimethylbenz(a)anthracene (DMBA) and promoted with 12-O-tetradecanoylphorbol-13-acetate (TPA). The first grossly detectable lesions at sites where papillomas subsequently developed were papules, slightly raised areas of skin ranging in diameter from 0.25 to approximately 1.5 mm. Papules were first detected in DMBA-initiated mice 21 days after the start of dosing with TPA. Of 78 DMBA/TPA-induced papules tracked during 15 weeks of TPA treatments, 68% progressed to papillomas, 9% persisted as papules, and 22% completely regressed. Histological evaluation of serial sections of 69 DMBA/TPA-induced papules revealed that they were focal hyperplastic lesions that we refer to as squamous cell hyperplastic foci (SCHF). These hyperproliferative lesions appeared to progress through two distinct stages. Stage I SCHF were characterized as regular hyperplastic foci involving the interfollicular epidermis and the outer root sheaths of 1 or more hair follicles down to the level of the sebaceous glands. Stage II SCHF were foci of irregular epithelial hyperplasia with increased fibrovascular stroma and involved from 3 to >10 hair follicles. Prominent dilated capillaries and inflammatory cell infiltrates were frequently associated with both stage I and II SCHF. Ha-ras gene codon 61 mutations were detected in 7 of 10 stage I SCHF and 13 of 14 stage II SCHF microdissected from histological sections and 7 of 7 of whole papules by mutation-specific PCR analysis. These data provide molecular evidence that SCHF are foci of initiated cells. Further study of these lesions may contribute to more fully defining the sequence of molecular and cellular changes necessary for tumorigenesis in mouse skin. SCHF may also have utility as early indicators of potential skin tumorigenicity in cancer bioassays.

Management of threats of violence under California's duty-to-protect statute

OBJECTIVE

This is the first study to assess clinical practices under one of the new duty-to-protect statutes, some version of which has been passed in many states. In 1985, California enacted a statute enabling psychotherapists to limit their liability when a patient makes a serious threat of violence by 1) making reasonable efforts to warn the victim of the threat and 2) notifying local police.

METHOD

The authors examined all duty-to-protect notifications over a 5-year period in San Francisco by reviewing police and court records.

RESULTS

Police received only 337 notifications, typically made by nondoctoral staff members at public facilities such as psychiatric hospitals and crisis clinics. Patients most commonly directed their threats toward family members. Of the patients who made threats resulting in notifications, 51% had prior arrest records, and 14% had subsequent arrests. Only 52% of the patients who made threats were civilly committed.

CONCLUSIONS

The findings suggest that 1) clinicians rarely discharge the duty to protect in the manner specified by the law, 2) many patients whose threats result in notifications have extensive involvement with the criminal justice system, and 3) family intervention may have clinical relevance in many duty-to-protect situations.

Characteristics of psychiatric inpatients who stalk, threaten, or harass hospital staff after discharge

OBJECTIVE

The purpose of this study was to identify demographic and clinical characteristics of psychiatric inpatients who stalk, threaten, or harass hospital staff after discharge.

METHOD

The authors retrospectively summarized the demographic and clinical characteristics of 17 inpatients who engaged in this type of behavior and a comparison group of 326 inpatients.

RESULTS

The patients who stalked, threatened, or harassed staff after discharge were significantly more likely than the comparison patients to have a diagnosis of personality disorder and/or paranoid disorder, erotomanic subtype, and to have a history of physically assaultive or fear-inducing behavior. The data suggest that they were more likely to be male and never married and to have histories of multiple hospitalizations, suicidal or self-injurious behavior, and substance abuse or dependence.

CONCLUSIONS

The findings reveal several risk factors that may be useful in identifying a subgroup of patients who pose a risk of directing aggressive behavior toward hospital staff after discharge.

A naturalistic study of clinical use of risperidone

Follow-up data on 97 of the 101 patients at a university-based psychiatric hospital for whom risperidone had been prescribed between February 1994, when the medication was introduced, and October 1996 were reviewed an average of 102 weeks after the start of the medication. Only 28.9 percent of the patients were still on risperidone at follow-up. Patients who were maintained on risperidone were able to tolerate a higher dose with fewer side effects. The most common reasons for discontinuation were failure to achieve a therapeutic effect, noncompliance, and adverse side effects. The findings of this naturalistic study represent a cautionary consideration for the remarkable enthusiasm that surrounded the introduction of risperidone.

Comparison of the skin tumor-promoting potential of different organic peroxides in SENCAR mice

The skin tumor-promoting activities of three organic peroxides were evaluated and compared to the activity of benzoyl peroxide, a well-characterized tumor promoter. Two of the compounds (di-t-butyl peroxide and dicumyl peroxide) were dialkyl peroxides and the other (di-m-chlorobenzoyl peroxide) was a diacyl peroxide. These compounds were selected based on a previous study in which we evaluated their capacity to induce epidermal hyperplasia, ornithine decarboxylase activity, and dark basal keratinocytes, which have been reliable short-term markers of tumor promotion. Dicumyl peroxide was a weak tumor promoter despite its high activity in inducing hyperplasia. Like benzoyl peroxide, di-m-chlorobenzoyl peroxide generally had intermediate activity as an inducer of short-term markers of tumor promotion and was a moderately effective tumor promoter. However, compared to benzoyl peroxide, di-m-chlorobenzoyl peroxide was more toxic to the skin, which may have limited its tumor-promoting activity. The final compound, di-t-butyl peroxide, which was essentially inactive in short-term assays, was also totally inactive in promoting papillomas or carcinomas in initiated skin. Tumor-promoting efficacy generally showed an inverse association with thermal stability for the compounds tested, suggesting that the rate of formation of free radicals is a key factor contributing to tumor promotion by organic peroxides. However, a number of other factors can potentially affect the activity of different organic peroxides as tumor promoters. Each compound evaluated had a different spectrum of activities, and these compounds should be useful for studying mechanisms of organic peroxide-induced tumor promotion.

Evidence that initiated keratinocytes clonally expand into multiple existing hair follicles during papilloma histogenesis in SENCAR mouse skin

We have previously shown that the precursors of cutaneous papillomas in SENCAR mice initiated with 7,12-dimethylbenz[a]anthracene and promoted with 12-O-tetradecanoylphorbol-13-acetate are focal hyperplastic lesions that we refer to as squamous cell hyperplastic foci (SCHF). Ha-ras gene codon 61 mutations were frequently found in SCHF, providing evidence that these lesions represent clones of initiated cells. We report here the pathogenesis of multiple hair follicle involvement in more advanced SCHF and describe the role of the hair follicle in papilloma histogenesis. Detailed histological evaluation of 83 SCHF and 25 early papillomas revealed a morphological continuum from the least developed SCHF, involving only one hair follicle, to advanced SCHF and early papillomas, which involved more than 10 hair follicles. These results provide evidence of the recruitment of additional hair follicles as SCHF progress. In advanced SCHF and early papillomas the bulk of the epithelial component in all cases consisted of several markedly hyperplastic adjacent hair follicles, whereas the involved interfollicular epidermis (IFE) was generally less hyperplastic. All of the hair follicles involved in SCHF appeared to have been preexisting, based on their pattern of spacing, that they were consistently normal appearing below the level of the sebaceous glands, and that they were in the same phase of the hair cycle as surrounding, uninvolved hair follicles. Also, no evidence of follicular neogenesis was observed in serially sectioned SCHF, and coalescence of smaller lesions was rare. To investigate whether the involvement of multiple hair follicles in SCHF was due to expansion of initiated cells into existing hair follicles or, possibly, to a paracrine mechanism, we analyzed different levels of three serially sectioned SCHF and one early papilloma for Ha-ras mutations. These analyses revealed cells with Ha-ras gene codon 61 mutations at multiple levels that involved different hair follicles. Overall, our results provide evidence that as initiated cells clonally expand, they spread across the IFE and populate the upper permanent portions of existing hair follicles. The abnormal proliferation of the infundibula of the hair follicles involved in SCHF appears to give rise to most of the epithelial component of papillomas.

Utility of the initial therapeutic alliance in evaluating psychiatric patients' risk of violence

OBJECTIVE

Evaluation of patients' potential for violence is an important component of care in psychiatric emergency and inpatient settings. Although situational variables are widely acknowledged to influence the risk of violence by psychiatric patients, most past research has been limited to patient attributes and has neglected the interpersonal context in which violence occurs. To the authors' knowledge, this is the first study to assess a new type of situational risk factor, the quality of the initial therapeutic alliance between the therapist and patient, as a predictor of the risk of violent behavior during short-term hospitalization.

METHOD

The admitting physician's written initial evaluation for each of 328 patients hospitalized on a locked inpatient unit was reviewed by using a standardized alliance scale. The checklist measures the patient's level of active collaboration with the treatment process. Acute symptoms were rated at admission by physicians using the Brief Psychiatric Rating Scale. Nurses rated aggressive behavior in the hospital with the Overt Aggression Scale.

RESULTS

Patients who had a poorer therapeutic alliance at the time of admission were significantly more likely to display violent behavior during hospitalization. Logistic regression analysis showed that the quality of the initial therapeutic alliance remained a strong predictor of violence even when other clinical and demographic correlates of violence were considered concurrently.

CONCLUSIONS

The results suggest a new class of situational, interactional variable--reflected in the quality of the therapeutic relationship--that may be useful in evaluating patients' potential for violence. Implications for risk management are discussed.

The impact of hospitalization on clinical assessments of suicide risk

OBJECTIVE

Clinicians' assessments of patients' suicide risk at admission to and discharge from a psychiatric hospital were examined to learn how clinical estimates of risk changed over the course of hospitalization and to identify which demographic and clinical characteristics were associated with higher estimates of risk at admission and discharge.

METHODS

Seventy-one treating physicians evaluated risk of self-harm of 241 patients at admission to and discharge from a short-term inpatient unit. Risk within the next week (short-term risk) and within the next year (long-term risk) was estimated. At discharge and admission, the physicians also rated patients' symptoms using the Brief Psychiatric Rating Scale. Nurses rated self-directed aggression during hospitalization with the Overt Aggression Scale.

RESULTS

Ratings of short-term risk were lower at discharge than at admission, whereas ratings of long-term risk showed relatively little change. At both discharge and admission, the estimated risk of self-harm was associated with a history of suicidal behavior and with acute symptoms, such as depression, anxiety, and emotional withdrawal. At discharge, the estimated risk was also associated with substance abuse, severity of psychosocial stressors, and living alone.

CONCLUSIONS

Clinicians appeared to view their hospital-based interventions as influencing variables relevant to short-term risk of suicide but as having little impact on long-term risk. Implications are discussed for management of suicide risk and for medicolegal assertions regarding prevailing community practices that are made in litigation alleging negligent release of patients from hospitals.

Application of the Tarasoff ruling and its effect on the victim and the therapeutic relationship

OBJECTIVE

The Tarasoff case and subsequent court decisions and legislation in many jurisdictions established a duty to protect the intended victims of patients who pose a serious threat of violence. An approach that has been legally sanctioned is to warn the intended victim. This study examined the effects of such warnings on the warned persons and on the therapeutic relationship.

METHODS

All second-, third-, and fourth-year psychiatric residents (N = 46) in a university-based psychiatric residency program in San Francisco were interviewed about their experiences related to issuing Tarasoff warnings.

RESULTS

Almost half of the residents (N = 22) reported having issued a Tarasoff warning. Most warnings were issued for patients seen in inpatient units and emergency rooms. In almost half of the cases, the resident was unable to contact the intended victim but did report the threat to a law enforcement agency. In almost three-fourths of the cases in which the intended victim was contacted, the individual already knew of the threat. The most common reaction among those warned was anxiety mixed with thankfulness; most expressed an intent to modify their behavior to increase safety. The second most common reaction was denial that the patient would ever hurt them. Clinicians reported that in most cases issuing the warning had a minimal or a positive effect on the psychotherapeutic relationship.

CONCLUSIONS

Many of the anticipated negative effects of the Tarasoff decision have not materialized.

Impact of a smoking ban on a locked psychiatric unit

BACKGROUND

This study prospectively evaluated the impact of a complete smoking ban on a locked psychiatric unit.

METHOD

The setting was a 16-bed inpatient unit with 83% (134/162) involuntary patients, no off-unit smoking area, no possibility of granting smoking passes, and a mean length of stay of 2 weeks. The effect of a complete smoking ban was measured by surveys of both staff and patients before and after the ban. In addition, objective indicators of ward disruption were measured, including rates of aggression, use of p.r.n. medications, need for seclusion and restraints, elopement, and discharges against medical advice.

RESULTS

Although staff initially expressed concern about the ban's potential negative impact, after it began, t tests revealed that staff were significantly (p < .05) less concerned about patients' needing more medication, becoming restless, being too fragile to cope with withdrawal, leaving the unit against medical advice, or trying to elope. Staff were significantly (p < .02) more positive about the ban than were patients. Although patients, overall, had negative views toward the new policy, their opinions were somewhat less negative after its implementation. Rates of assaultive behavior, use of seclusion and restraints, use of p.r.n. medication, and against-medical-advice or elopement discharges did not change after the ban was in effect. When polled, 78% (40/51) of the staff voted to keep the ban.

CONCLUSION

This study found that staff anticipated negative consequences to a total smoking ban; however, their attitudes changed after it began. The ban had no significant impact on the ward milieu, and although patients were not in favor of it, they felt less negative over time.

Is adaptive coping possible for adult survivors of childhood sexual abuse?

Thirty adult women survivors of childhood sexual abuse who believed they were functioning well were selected through advertisements in local newspapers and presentations at an incest-survivor support group. Subjects were assessed by a battery of structured diagnostic interviews and standardized psychological measures, including the MMPI, the Trauma Symptom Checklist-40, and the Dissociative Experiences Scale. The results showed the existence of a subgroup of survivors of childhood sexual abuse who do not have devastating long-term psychological effects. Better adult psychological functioning was predicted by certain characteristics of the abuse, the family system, and the survivors.

Correlates of accuracy in the assessment of psychiatric inpatients' risk of violence

OBJECTIVE

The authors evaluated characteristics of patients whom clinicians accurately assessed as being at high or low risk for violence and patients for whom clinicians overestimated or underestimated the risk.

METHOD

At admission, physicians estimated the probability that each of 226 psychiatric inpatients would physically attack someone during the first week of hospitalization. Nurses rated assaultive behavior in the hospital with the Overt Aggression Scale. Acute symptoms were rated with the Brief Psychiatric Rating Scale.

RESULTS

For the group as a whole, assessed levels of risk were substantially related to later physical aggression (sensitivity = 67%, specificity = 69%). Multinomial logit analysis showed that patients with psychotic disorders such as schizophrenia, organic psychotic conditions, and mania were more likely to be accurately assessed by clinicians as being at high risk (true positives) than to be true negatives or false positives. A recent history of violence was associated with higher estimated risk but did not distinguish true positives from false positives. An admission mental status characterized by low levels of hostility, uncooperativeness, and suspiciousness and high levels of depression, guilt, and anxiety differentiated true negative patients from others, but symptom profiles did not differ among true positives, false positives, and false negatives. Clinical judgments emphasizing gender and race/ethnicity were associated with predictive errors: nonwhite and male patients tended to be false positives.

CONCLUSIONS

While clinicians can accurately classify the potential for violence in the majority of patients at admission, systematic errors characterize inaccurate assessments of the risk. Awareness of these patterns may help improve assessment of the risk of violence in clinical practice.

Benzoyl peroxide: an integrated human safety assessment for carcinogenicity

Topical benzoyl peroxide has been used in the treatment of acne for over 30 years, with no reports of adverse effects that could be related to skin carcinogenesis. Two case-control epidemiological studies have found a lack of association between the specific use of benzoyl peroxide and skin cancer. In addition to these findings in humans, 23 carcinogenicity studies in rodents with benzoyl peroxide, including 16 employing topical application, have yielded negative results. An increase in skin carcinomas was reported in 1 study in which benzoyl peroxide in acetone was applied to the skin of SENCAR mice for a 1-year period; however, this study did not employ adequate control groups to fully understand the unusual findings, and the results were inconsistent with those of 6 other similar studies. While benzoyl peroxide is not a complete carcinogen in animals and has weak or no mutagenic potential, it has been found to be a tumor promoter in mouse skin using experimental two-stage models of carcinogenesis. Consistently positive results have been obtained in tumor promotion studies in which SENCAR mice were exposed to initiating doses of potent experimental carcinogens followed by promotion with benzoyl peroxide in acetone. Negative results have been obtained in similar studies with commercial formulations. However, the results of promotion studies with benzoyl peroxide do not carry significant weight for human safety assessment as evidenced by (i) the absence of demonstrated carcinogenicity in humans of a number of rodent tumor promoters despite long-term human exposure; (ii) the observation that tumor promotion in mouse skin occurs only under specific experimental conditions and predominantly in highly sensitive strains; (iii) clinical use scenarios markedly different from the conditions resulting in tumor promotion in mouse skin; and (iv) the significant physiological differences between mouse and human skin. Thus, to date, available scientific evidence does not allow the results of these rodent promotion studies to be meaningfully applied to human safety assessment. As such, significant scientific progress must be made before human safety estimations can be derived from rodent promotion data.(ABSTRACT TRUNCATED AT 400 WORDS)

Ornithine decarboxylase expression in cutaneous papillomas in SENCAR mice is associated with altered expression of keratins 1 and 10

The patterns of expression of ornithine decarboxylase (ODC) and a number of keratinocyte differentiation products were examined in early papillomas by immunocytochemistry as an initial effort to develop phenotypic markers of the early stages of mouse skin tumorigenesis. Tumors were induced in SENCAR mice by initiation with 7,12-dimethylbenzanthracene, followed by once or twice weekly promotion treatments with 12-O-tetradecanoylphorbol-13-acetate. The patterns of immunocytochemical staining observed in early papillomas, collected after 7 weeks of promotion, were compared to those obtained with control skin and large, hyperkeratotic papillomas, collected after 23 weeks of promotion. In groups receiving 12-O-tetradecanoylphorbol-13-acetate, constitutive and induced ODC expression were evaluated either several days or 4.5 h after the last treatment, respectively. The major differentiation products in suprabasal keratinocytes are keratins, K1 and K10. These keratins were normally expressed in mildly hyperplastic epidermis, but staining became patchy in markedly hyperplastic epidermis. In early papillomas, K1 staining was patchy, and K10 staining occurred in very limited focal areas or was negative, such that the absence of staining delineated the lesions. Antibodies to the basal cell keratins, K5 and K14, stained both basal and suprabasal cells in hyperplastic epidermis and papillomas. Similarly, an antibody to keratin K6, which is expressed under conditions of hyperproliferation, uniformly stained the basal and suprabasal layers of hyperplastic epidermis and papillomas, demonstrating that the staining patterns observed with the antibodies to K1 and K10 were specific. Expression of ODC in the histologically normal skin of control mice was detected only in the hair follicles and depended on the hair cycle. Staining for induced ODC in mice treated with 12-O-tetradecanoylphorbol-13-acetate once weekly for 7 weeks was intense and diffuse throughout the suprabasal layers of the epidermis. In early and large papillomas, staining for constitutively expressed ODC was intense and diffuse in suprabasal cells. This intense staining for ODC occurred consistently in areas with decreased K1 and K10 expression, and, therefore, was associated with an altered pattern of differentiation. High constitutive ODC expression and decreased K1 and K10 expression will be useful phenotypic markers for studying the early stages of tumorigenesis in mouse skin.

The relationship between acute psychiatric symptoms, diagnosis, and short-term risk of violence

OBJECTIVE

Previous research on violence and mental disorder has typically focused on the relationship between diagnosis and risk of violence or between symptoms within a particular diagnostic category and risk of violence. The authors' goal was to evaluate whether the pattern of symptoms associated with short-term risk of violence varies depending on patients' diagnoses.

METHODS

Subjects were 330 patients with a variety of diagnoses who were hospitalized on a university-based, locked psychiatric inpatient unit. At hospital admission, physicians rated patients' symptoms using the Brief Psychiatric Rating Scale. Nurses rated whether patients became violent during hospitalization by completing the Overt Aggression Scale at the end of each shift.

RESULTS

Assaultive patients had different symptom patterns than nonassaultive patients. Symptoms patterns varied significantly across diagnostic groups, and the symptom patterns associated with violence also varied significantly across diagnostic groups. Higher levels of hostile-suspiciousness, agitation-excitement, and thinking disturbance were generally associated with violence, although these symptoms were less predictive of assaultiveness among schizophrenic patients than among patients in other diagnostic groups.

CONCLUSIONS

Symptom profiles represent a useful level of analysis for understanding the relationship between violence and psychopathology. However, the value of particular symptom profiles as indicators of imminent violence varies with diagnosis.

Staff gender and risk of assault on doctors and nurses

Clinical staff on acute psychiatric inpatient units often are asked to provide care for potentially violent patients. Documentation of which staff are at greatest risk of being assaulted is a necessary step in developing interventions to reduce that risk. The present study evaluated the relationship between staff gender and the risk of becoming a victim of assault while taking into account the professional discipline of the staff victims. The sample included all medical staff (n = 120) and nursing staff (n = 83) who worked on a short-term psychiatric unit between August 1988 and May 1991. Seventy-two percent of the medical and nursing staff were female and 28 percent were male. Five hundred ten assaults were directed toward medical and nursing staff during the study period. Staff gender was not significantly associated with the risk of being a victim of violence for the staff as a whole, the doctors, or the nurses. Staff discipline, however, was strongly associated with risk of assault. Nurses as a group were significantly more likely to be assaulted than were doctors. The findings suggest that violent behavior is a significant occupational hazard on acute inpatient units, and that the role relationship with the patient is more important than the gender of the clinician as a predictor of who is most likely to be assaulted. The authors discuss the implications of the findings for administrative decisions regarding staffing.

Clinical assessment of the risk of violence among psychiatric inpatients

OBJECTIVE

The authors evaluated the reliability and validity of a probabilistic approach to clinical assessment of short-term risk of violence.

METHOD

At admission, nurses and physicians independently rated the probability that each of 149 psychiatric patients would physically attack someone during the first week of hospitalization on a university-based locked inpatient unit. Ward behavior was measured with the Overt Aggression Scale.

RESULTS

There was a moderate level of agreement between nurses' and physicians' assessments of risk. Ratings of ward behavior showed an increase in the proportion of assaultive patients as the level of estimated risk of violence increased. Although the overall rate of assaults was overpredicted, there was a close correspondence between clinical estimates of patients' chances of becoming violent and the proportion of patients within each risk level who later displayed some type of inpatient aggression.

CONCLUSIONS

The reliability and validity of short-term estimates of the risk of violence among acutely disturbed inpatients may be higher than past violence research has suggested. These findings provide preliminary support for the utility of a probabilistic approach to assessment of the risk of violence.

Violence by geriatric patients who need psychiatric hospitalization

The authors examine issues related to violent behavior exhibited by elderly patients during episodes of mental illness that are severe enough to warrant psychiatric hospitalization. The medical records of 195 geriatric patients admitted to a psychiatric hospital over a 9-year period were reviewed. During the 2 weeks before admission, 20% of the geriatric patients physically assaulted others, 20% engaged in fear-inducing behavior, and 60% were not violent. Patients with senile organic psychotic conditions were significantly more likely to attack others than were patients with other diagnoses. The most common victims of the patients' violent behavior were family members. The authors discuss the implications of these findings for treatment of geriatric psychiatric patients and their families.

Clozapine and seizures

Clozapine is a newly released antipsychotic that is associated with a higher prevalence of seizures than traditional neuroleptics. The authors describe four patients who developed seizure activity during clozapine treatment and provide recommendations for clinical management of this problem.

Clozapine--a new and different neuroleptic

These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from a transcription, it has been edited by Homer A. Boushey, MD, Professor of Medicine, and Nathan M. Bass, MD, PhD, Associate Professor of Medicine, under the direction of Lloyd H. Smith, Jr, MD, Professor of Medicine and Associate Dean in the School of Medicine.

The relationship of gender to violent behavior in acutely disturbed psychiatric patients

On the basis of extensive review of the medical records of 253 patients hospitalized in a locked psychiatric unit, the authors found that before hospitalization, men engaged in significantly more physical attacks and fear-inducing behavior than did women. During short-term psychiatric hospitalization, although men continued to engage in more fear-inducing behavior, women engaged in proportionately more physical attacks. To control for possible confounding variables, the authors repeated the analyses after stratifying by demographic and diagnostic variables that were distributed differently among men and women. The same pattern of relationships between gender and violence was found. The authors give case examples and discuss possible explanations and implications of the findings.

The relationship between admission symptoms and hospital assaults

Assessments at hospital admission of patients' potential for violence often rely on limited information, such as the patient's mental status, because detailed clinical and historical information may not be readily available. This study examined the relationship between symptoms at admission as measured by the Brief Psychiatric Rating Scale and later violence of 127 psychiatric inpatients. Patients who showed higher levels of thinking disturbance, hostile-suspiciousness, and agitation-excitement at the time of admission were at greater risk of becoming assaultive during the hospitalization. The findings suggest the usefulness of specific symptom profiles for identifying acute psychiatric patients at risk for violence.

Absence of papillomavirus in skin tumors induced in SENCAR mice by a two-stage carcinogenesis protocol

SENCAR mice are unusually sensitive to induction of papillomas and squamous cell carcinomas by initiation with 7,12-dimethylbenzanthracene (DMBA) and promotion by 12-O-tetradecanoylphorbol-13-acetate (TPA). Tumors induced by this protocol were tested for the presence of papillomavirus by immunohistochemistry, Southern blot, reverse Southern blot and dot blot hybridization techniques. Papillomavirus antigens were not detected in any of 235 tumors or 142 non-tumor-bearing skin samples analyzed. Southern blots and dot blots, using a mixed probe of cloned rodent papillomavirus DNA from the multimammate rat, Mastomys natalensis, and the European harvest mouse, Micromys minutus, did not reveal the presence of either episomal or integrated papillomavirus genomes in total cellular DNA extracts from the tumors or non-tumor-bearing skin. To circumvent the possibility that insufficient cross-homology existed to detect a papillomavirus genome with the mixed probe used, DNAs extracted from six papillomas were labeled and each used to probe reference blots that contained 25 cloned papillomavirus genomes excised from their vectors. No evidence for the presence of a papillomavirus genome was detected by this method. Therefore, it is unlikely that papillomaviruses play a role in the induction of tumors in SENCAR mice by two-stage carcinogenesis protocols.

Characterization of the induction of ornithine decarboxylase activity by benzoyl peroxide in SENCAR mouse epidermis

The induction of epidermal ornithine decarboxylase (ODC) activity by benzoyl peroxide (BPO) was characterized to evaluate the usefulness of this effect as a short-term marker of BPO-induced mouse skin tumor promotion. The maximal induced levels of ODC specific activity, after a single topical dose of BPO, were greater than 2-fold higher when a cold scraping method was used to prepare epidermis rather than the commonly used heat treatment method. Therefore, the cold scraping method was used for all the work reported here. Application of a single 20 mg dose of BPO to the dorsal skin of SENCAR mice caused a relatively small induction of epidermal ODC activity, to a level less than 1/40 that induced by a single 2 micrograms dose of 12-O-tetradecanoylphorbol-13-acetate (TPA). Furthermore, the time-courses of induction were different after single doses of TPA and BPO, with peak activities observed at approximately 6 and approximately 24 h after treatment respectively. In contrast, after a total of five 20 mg doses of BPO were topically applied (one dose every 2 days), ODC activity was transiently induced to an average level greater than 15 times after a single dose. Additionally, on this dosing regimen, the peak of ODC activity shifted to approximately 4 h after the last treatment, so that the time-course of ODC induction resembled that after multiple applications of TPA. The extent of epidermal ODC induction by BPO was found to be a complex function of the frequency of dosing and the number of treatments. However, when BPO treatments were administered from 1 to 7 days apart, similar maximal induced levels of ODC activity were eventually achieved after application of multiple doses. Importantly, the dose-response for the induction of ODC activity by five doses of BPO (applied one dose every 2 days) was highly correlated with published data on the dose-response for tumor promotion by this organic peroxide, indicating that ODC induction is a good short-term marker of BPO-induced tumor promotion in SENCAR mice.

Violent behavior and length of psychiatric hospitalization

The relationship between violent behavior and length of hospitalization was studied in a retrospective chart review of 253 patients admitted to a university-based acute inpatient unit. Violent behavior was defined as physical attacks on persons or fear-inducing behavior before admission or during initial hospitalization, and its value as a predictor of length of stay was assessed in multiple regression analyses that also included 20 demographic and clinical variables. Violence per se was not an important predictor of length of stay, but violence associated with a diagnosis of schizophrenia was an important predictor. Schizophrenic patients who physically attacked others shortly after admission were more likely to have an extended stay than other patients. The study demonstrates the importance of considering clinically meaningful patterns, such as the interaction between diagnosis and violent behavior, when predicting length of stay.

Relationship between preadmission threats and later violent behavior by acute psychiatric inpatients

The medical charts of 253 patients admitted to an acute psychiatric inpatient unit were reviewed for evidence of threats of violence within the two weeks before admission and violent behavior during the first three days of hospitalization. Fifty-eight percent of the patients who had made threats before admission required seclusion for dangerous behavior in the hospital, and 32 percent of the patients who had made threats physically assaulted someone in the hospital. The association between preadmission threats and subsequent violence was especially strong among schizophrenic patients. Compared with schizophrenic patients who did not threaten others, those who had made preadmission threats were more likely to be physically and verbally assaultive and were more likely to require seclusion. Manic patients who had made threats were more likely than those who had not made threats to be verbally assaultive while in the hospital.