Protect and Provide: Perceptions of Manhood and Masculinities Among Disabled Violently Injured Black Men in a Hospital-Based Violence Intervention Program

Exploring the post-injury lives of those who have survived gunshot wounds is essential to understanding the entire scope of firearm violence. The lives of Black male firearm violence survivors are transformed in various ways due to their injuries both visible and invisible. This study explored how Black men who suffer from disabilities via a firearm negotiated their masculine identities. Semi-structured, qualitative interviews were conducted with 10 violently injured Black men participating in a hospital-based violence intervention program. Survivors expressed their thoughts on how their injuries impacted their manhood and masculinities. Three themes emerged: (1) perceptions of manhood, (2) loss of independence and burden on others, and (3) and mobility. These themes highlighted and described how their lives were impacted post-injury and characterized their psychological and physical experience of recovery. The research findings suggest the need for more qualitative studies to further explore the relationship between firearm injury, Black masculinity, and perceptions of manhood. While Black men are understudied in health research and invisible in disability research, they continue to be hyper-invisible when discussing violently acquired disabilities.

Not All Survivors Are the Same: Qualitative Assessment of Prior Violence, Risks, Recovery and Perceptions of Firearms and Violence Among Victims of Firearm Injury

Qualitative exploration into the risk, experiences, and outcomes of victims of firearm injury is imperative to informing not only further research, but prevention and intervention strategies. The purpose of this study was to explore prior violent exposures, risks, recovery, supportive services, outcomes, and views of firearms and violence among survivors of firearm assaults and unintentional injuries. Adults treated at a level 1 trauma center in Seattle, WA, for assault and unintentional firearm injuries were interviewed utilizing a semistructured instrument. Interview responses were coded to identify common themes and representative quotes are reported. Sixteen participants were interviewed. Notable themes included the following: (a) prior violent exposures were experienced by half of survivors, mostly through community violence; (b) risk for firearm injury was felt to be related to general societal violence, unsafe communities, and firearm practices; (c) important aspects of recovery included family/social support, mental health care and financial support services; (d) notable outcomes included psychological problems such as PTSD and anxiety, changes in relationships, and developing a new sense of purpose or mission in life; (e) generally negative views toward firearms, supporting restricted access and firearm safety practices; (f) acknowledgement of the complexity of firearm violence in society with prevention geared toward equitable education, economic opportunities and safety net programs to reduce community violence; and (g) disappointment in the criminal justice system. These findings demonstrate the varied experiences, needs, and outcomes after injury, but highlight the significance of community and societal violence, and need for improved mental health services. Integration of mental health services and victim assistance programs into trauma centers and hospital-based violence intervention programs is imperative for all survivors. Encouraging survivors to engage in new aspirations after injury can be empowering, and there is an unmet need for victim support and advocacy within the criminal justice system.

Assessment of Reasons for Ownership and Attitudes About Policies Among Firearm Owners With and Without Children

IMPORTANCE

Given the dangers that firearms in the home pose to children, it is critical to engage parents in effective firearm safety counseling. This requires a broader understanding of how the presence of children in the home is associated with motivations surrounding gun ownership.

OBJECTIVE

To examine the association of having children in the home and gun owners' attitudes and beliefs.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study analyzed data from the National Lawful Use of Guns Survey conducted in 2019. A representative sample of 3698 adult gun owners nationwide were randomly invited to participate, with a 56.5% survey response rate. Survey responses were weighted to account for survey nonresponse and selection bias, and comparison groups were matched by age. Statistical analysis was performed in 2020.

MAIN OUTCOMES AND MEASURES

Reasons for gun ownership, symbolic meaning of guns, and attitudes toward gun policies.

RESULTS

Of the 2086 respondents, 383 (18.4%) had children in the home, 68.7% (95% CI, 66.4%-71.0%) were male, 8.2% (95% CI, 6.8%-9.7%) were Black, 76.3% (95% CI, 73.8%-78.6%) were White, 79.4% (95% CI, 77.5%-81.2%) were living in metropolitan areas, 51.3% (95% CI, 48.9%-53.8%) identified as Republican; 34.7% (95% CI, 32.6%-36.9%) were aged 60 years or older. Despite the majority of respondents feeling safe in their local communities (respondents with children: 93.4% [95% CI,: 89.3%-96.0%]; without children: 88.9% [95% CI, 87.0%- 90.6%]), 92.3% (95% CI, 87.0%-95.6%) of respondents with children stated the primary reason for gun ownership was to protect their family, compared with 68.6% (95% CI, 65.2%-71.8%) of respondents without children. On logistic regression analysis, having children in the home remained an independent factor associated with reasons for gun ownership. Gun owners with children were more likely than those without children to feel that guns make them feel more valuable to their family (23.5% [95% CI, 18.9%-28.8%] vs 17.0% [95% CI, 15.0%-19.2%]). Among those with children, 35.2% (95% CI, 30.0%-40.8%) believed gun laws should be more strict compared with 40.7% (95% CI, 38.1%- 43.3%) of those without children.

CONCLUSIONS AND RELEVANCE

These findings suggest that acknowledging parental motivations for gun ownership is a pivotal component of educational efforts toward firearm injury prevention. These findings can guide clinicians to engage in effective individual counseling and community level efforts to reduce pediatric gun injuries.

A Prospective US National Trauma Center Study of Firearm Injury Survivors Weapon Carriage and Posttraumatic Stress Disorder Symptoms

OBJECTIVE

To describe the demographic, injury-related, and mental health characteristics of firearm injury patients and trace firearm weapon carriage and PTSD symptoms over the year after injury.

SUMMARY AND BACKGROUND DATA

Based on the increasing incidence of firearm injury and need for novel injury prevention strategies, hospital-based violence intervention programs are being implemented in US trauma centers. There is limited data on the long-term outcomes and risk behaviors of firearm injury survivors to guide this work.

METHODS

We conducted a secondary analysis of a pragmatic 25-trauma center randomized trial (N = 635). Baseline characteristics of firearm-injured patients (N = 128) were compared with other trauma patients. Mixed model regression was used to identify risk factors for postinjury firearm weapon carriage and PTSD symptoms.

RESULTS

Firearm injury patients were younger and more likely to be black, male and of lower socioeconomic status, and more likely to carry a firearm in the year before injury. Relative to preinjury, there was a significant drop in firearm weapon carriage at 3- and 6-months postinjury, followed by a return to preinjury levels at 12-months. Firearm injury was significantly and independently associated with an increased risk of postinjury firearm weapon carriage [relative risk = 2.08, 95% confidence interval (1.34, 3.22), P < 0.01] and higher PTSD symptom levels [Beta = 3.82, 95% confidence interval (1.29, 6.35), P < 0.01].

CONCLUSIONS

Firearm injury survivors are at risk for firearm carriage and high PTSD symptom levels postinjury. The significant decrease in the high-risk behavior of firearm weapon carriage at 3-6 months postinjury suggests that there is an important postinjury "teachable moment" that should be targeted with preventive interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02655354.

Empowering the affected: Informing community-based solutions through interviews with survivors of interpersonal firearm violence-Perspectives of survivors of firearm injuries

BACKGROUND

Firearm violence remains epidemic in the United States, with interpersonal gun violence leading to significant morbidity and mortality. Interpersonal violence has strong associations with social determinants of health, and community-specific solutions are needed to address root causes. We hypothesized that open-ended interviews with survivors of interpersonal firearm violence would identify themes in individual and community-level factors that contribute to ongoing violence.

METHODS

Between July 2017 and November 2019, we performed a mixed-methods study in which qualitative and quantitative data were obtained from survivors of interpersonal firearm violence admitted to our urban level I trauma center. Qualitative data were obtained through semistructured, open-ended interviews with survivors. Quantitative data were obtained via survey responses provided to these same individuals. Qualitative and quantitative data were then used to triangulate and strengthen results.

RESULTS

During the study period, 51 survivors were enrolled in the study. The most common cause of firearm violence reported by survivors was increased gang and drug activity (n = 40, 78%). The most common solution expressed was to reduce drug and gang lifestyle by offering jobs and educational opportunities to afflicted communities to improve opportunities (n = 35, 69%). Nearly half of the survivors (n = 23, 45%) believe that firearm violence should be dealt with by the affected community itself, and another group of survivors believe that it should be through partnership between the community and trauma centers (n = 19, 37%).

CONCLUSION

Interviews with survivors of firearm violence at our urban level I trauma center suggest that drug and gang lifestyle perpetuate ongoing violence and that this would best be overcome by improving access to quality education and job opportunities. To address endemic firearm violence in their communities, trauma centers should identify opportunities to partner in developing programs that provide improved education, job access, and conflict mediation.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level I.

Psychiatric Sequelae Among Community Social Service Agency Staff 1 Year After a Mass Shooting

This cross-sectional study examines the prevalence of mental health disorders and substance use among professional staff members at community social service agencies 1 year after a mass shooting in Pittsburgh, Pennsylvania.

Firearm-related experiences and perceptions among United States male veterans: A qualitative interview study

BACKGROUND/OBJECTIVE

Male veterans ages 55-74 comprise a disproportionate number of suicide deaths among United States veterans, for whom a majority of suicides are firearm-related. Little is known about the firearm-related experiences and beliefs of veterans, which could be informative for firearm-related lethal means safety interventions. The aim of this qualitative study was to identify themes relevant to developing such interventions among older male veterans.

METHODS

We conducted semi-structured qualitative interviews with seventeen United States male veterans, ages 50-70, who were eligible to receive Veterans Health Administration services, and were current or former firearm owners or users. Transcripts were analyzed via thematic analysis using an inductive approach.

RESULTS

Six themes were identified: 1) Firearm experiences were usually facilitated by male family members and occurred at an early age; 2) Safety lessons during early firearm encounters focused on preventing unintentional injuries through safe firearm handling and using "common sense;" 3) Firearms serve an important social function across veterans' lifespans (e.g., hunting with friends); 4) Veterans perceive firearms as useful for protection; 5) Veterans believe that not everyone should have access to firearms, and some described scenarios in which they acted to limit others' access during unsafe situations; and 6) Veterans have preferences for who is involved in firearm safety discussions.

CONCLUSIONS

We identified themes relevant to developing firearm-specific lethal means safety interventions among older male veterans. Findings suggest potential obstacles (e.g., sociocultural value of firearms) to affecting changes in firearm behaviors, and factors that could potentially facilitate interventions (e.g., family involvement). Consideration of these findings may be important for developing personalized, effective interventions for this population.

What are the long-term consequences of youth exposure to firearm injury, and how do we prevent them? A scoping review

The long-term consequences of exposure to firearm injury-including suicide, assault, and mass shootings-on children's mental and physical health is unknown. Using PRISMA-ScR guidelines, we conducted a scoping review of four databases (PubMed, Scopus, PsychINFO, and CJ abstract) between January 1, 1985 and April 2, 2018 for articles describing long-term outcomes of child or adolescent firearm injury exposure (n = 3582). Among included studies (n = 31), most used retrospective cohorts or cross-sectional studies to describe the correlation between firearm injury and post-traumatic stress. A disproportionate number of studies examined the effect of mass shootings, although few of these studies were conducted in the United States and none described the impact of social media. Despite methodologic limitations, youth firearm injury exposure is clearly linked to high rates of post-traumatic stress symptoms and high rates of future injury. Evidence is lacking on best practices for prevention of mental health and behavioral sequelae among youth exposed to firearm injury. Future research should use rigorous methods to identify prevalence, correlates, and intervention strategies for these at-risk youth.

Firearm-related behaviors following firearm injury: changes in ownership, carrying and storage

Individuals who sustain nonfatal gunshot wound (GSW) injuries are at substantially increased risk of subsequent firearm injury. There is a dearth of literature examining what, if any, firearm-related behavior changes occur among adults as a result of GSW injuries. Using survey data on firearm-related behaviors from an ongoing randomized controlled trial, we sought to describe changes in reported firearm-related behaviors among GSW patients following their injury. Our results suggest that patients with a GSW, especially firearm owners, may change their firearm-related behaviors following injury, some by increasing firearm-related safety and others by increasing frequency of behaviors that may place them at increased risk of subsequent injury. This study highlights the need for further examination of firearm-related behavior change among GSW patients and development of interventions to promote firearm safety among this population.

Characteristics of Veteran and Civilian Suicide Decedents: A Sex-Stratified Analysis

INTRODUCTION

Few studies have examined characteristics distinguishing Veteran and civilian suicide decedents. An understanding of unique risk factors for Veteran suicide is critical to develop effective preventive interventions. This is particularly imperative for female Veterans, who have near double the suicide mortality rate of same-aged female civilians. The objectives of this study were to examine whether Veteran and civilian suicide decedents differed on risk factors and suicide-event characteristics, and to determine whether predictors changed based on sex.

METHODS

Data from 116,515 suicides collected by the National Violent Death Reporting System in 27 states between 2003 and 2015 were analyzed in 2018 in sex-stratified analyses. Logistic regression models examined population differences in risk factors and suicide-event characteristics.

RESULTS

Relative to male civilians, male Veterans were more likely to have a contributing physical health problem (AOR=1.10, 95% CI=1.06, 1.14) and to use a firearm for their suicide (AOR=1.41, 95% CI=1.36, 1.47); they were less likely to have substance use problems (AOR=0.70, 95% CI=0.66, 0.75), depressed mood (AOR=0.93, 95% CI=0.90, 0.97), or financial problems (AOR=0.91, 95% CI=0.86, 0.97). Female Veterans were more likely to use a firearm for their suicide (AOR=1.39, 95% CI=1.19, 1.63) relative to female civilians.

CONCLUSIONS

Firearm use as a suicide method was a key distinguishing feature of Veteran suicide. Means restriction and firearm safety are pertinent to preventing Veteran suicide. Given low utilization of mental health care and frequent presence of physical health problems in this population, safe storage messages may have a greater preventive impact if delivered in primary care or other nonpsychiatric settings.

Post-Discharge Needs of Victims of Gun Violence in Chicago: A Qualitative Study

The purpose of this study was to understand the post-discharge needs of violently injured patients and their families to improve health outcomes and reduce the impact of gun violence. We recruited 10 patients from the trauma registry of a Midwestern university hospital with a Level 1 Trauma Center (L1TC). After obtaining the informed consent, semi-structured, face-to-face, in-depth interviews were conducted. Discussions focused on post-discharge needs and resources to facilitate the recovery and rehabilitation process, and aid in community reintegration. Interviews were audiotaped and transcribed verbatim. Transcripts were analyzed thematically in stages of open, axial, and selective coding methods. Seven main themes were identified at the hospital and community level. These included the following: (a) feeling stigmatized by hospital personnel, (b) patient-provider communication, (c) feeling discharged too soon, (d) issues in obtaining medicines, (e) challenges with Chicago Police Department, (f) transportation to trauma center for follow-up care, and (g) concerns with returning back to the community. Patients reported the need for mental health counseling for themselves and their family, more follow-up, and help with financial paperwork among others. For the victims of gun violence, there exists a chasm between injury and care, and an even wider one between care and rehabilitation. The findings can inform health care, social workers, and rehabilitation professionals in their efforts to better address the myriad of unmet needs pre- and post-discharge. For trauma centers, the identified needs provide a template for developing an individualized- and community-centered resource pathway to improve outcomes and reduce suffering for this particularly vulnerable subset of patients.

The Difference Between Living and Dying: Victim Characteristics and Motive Among Nonfatal Shootings and Gun Homicides

Using both official and unofficial data sources, researchers examined nonfatal (n = 617) and fatal shooting (n = 159) victim characteristics over an 18-month period in Indianapolis. This research revealed that the typical shooting victim was male, non-White, almost 29 years old, had been arrested prior to inclusion in this study, and had been shot more than once. Interestingly, this research supports the notion that nonfatal shooting and homicide victims are different, especially as they relate to victim age, gunshot wound severity, and shooting motive. It highlights the need for better gun violence data collection beyond what currently exists. Striving for improved, more comprehensive cross-sector data collection has implications beyond just police policy and practice to include public health and prevention efforts.

Narcissistic Symptoms in German School Shooters

School shooters are often described as narcissistic, but empirical evidence is scant. To provide more reliable and detailed information, we conducted an exploratory study, analyzing police investigation files on seven school shootings in Germany, looking for symptoms of narcissistic personality disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) in witnesses' and offenders' reports and expert psychological evaluations. Three out of four offenders who had been treated for mental disorders prior to the offenses displayed detached symptoms of narcissism, but none was diagnosed with narcissistic personality disorder. Of the other three, two displayed narcissistic traits. In one case, the number of symptoms would have justified a diagnosis of narcissistic personality disorder. Offenders showed low and high self-esteem and a range of other mental disorders. Thus, narcissism is not a common characteristic of school shooters, but possibly more frequent than in the general population. This should be considered in developing adequate preventive and intervention measures.

Non-fatal gunshot trauma among a sample of adolescents in Djibouti: prevalence and sociodemographic associations

Firearm trauma is the second most common cause of serious injury among adolescents in the Republic of Djibouti. The aim of this study was to explore the sociodemographic correlates of serious injury and non-fatal gunshot trauma among adolescents in Djibouti. Using multinomial logistic regression, we compared a sample of adolescents (N = 1,711) who self-reported a non-firearm-related serious injury (n = 587) and those who reported a firearm-related injury (n = 101) with non-injured participants (n = 1,023) during a 12-month recall period. Analyses targeted demographic, behavioral, social, mental health, and family factors. After adjusting for covariates, participants reporting a non-firearm-related serious injury were more likely to report having been involved in physical fights (relative risk ratio [RRR] = 145; confidence interval [CI] = [1.04, 2.02), being bullied (RRR = 2.83; CI = [2.24, 3.56]), feeling lonely (RRR = 1.48; CI = [1.11, 1.96]), having signs of depression (RRR = 1.27; CI = [1.02, 1.58]), and be truant from school (RRR = 1.68; CI = [1.25, 2.28]). Those who reported a gunshot injury recorded being bullied (RRR = 2.83; CI = [1.77, 4.53]) and physically attacked at higher rates (RRR = 1.78; CI = [1.09, 2.89]). Serious injuries, whether firearm related or not, are important threats to adolescent health in Djibouti with potentially serious health-related correlates. More research, particularly multilevel designs, are needed to explain context-relevant factors associated with serious trauma in Djibouti.

Swedish hunters' safety behaviour and experience of firearm incidents

Since any firearm injury is potentially lethal, it is of great interest to prevent firearm incidents. This study investigated such incidents during hunting and Swedish hunters' safety behaviour. A 48-item questionnaire was posted to a random sample of 1000 members of the Swedish Association for Hunting and Wildlife Management. The questions considered demographics, hunting experience/hunting habits/safety behaviour/attitudes and experience of careless weapon handling, hunters' weapons and safety behaviour relating to weapons, health status, firearm incidents and their preventability, and personal comments on the questionnaire. The response rate was almost 50%. The mean age of the responders was 54 years; 5% were females. Almost none (1%) reported hunting under the influence of alcohol. Young age and male sex were positively associated with risk behaviour, although the presence of multiple risk behaviours in the same responder was not common. A very high degree of compliance with Swedish laws regarding weapon storage was reported. One-quarter of the responders had witnessed a firearm incident caused by another hunter, which in most situations did not result in human injury or death. An unsafetied weapon was the most common reported "cause" of these incidents. Experience of a firearm incident was not uncommon and the majority of the responders considered the incident in question to be preventable. This study provides a picture of the possible risk behaviour among hunters and the results suggest that future prevention work should target safer weapon handling.

[Paranoid delusions and homicides inside or outside the family]

Paranoia is a mental pathology which severely complicates interpersonal relationships. Its mechanisms and its delusional themes often mean that paranoid subjects have strained, or even violent relations inside and/or outside their family. These difficuIt relationships can sometimes even lead to serious assaults without causing death or more rarely result in homicides with frequent pre-incident indicators.

[Peculiarities of mental disorders and evaluation of life quality in military personnel wounded in local military conflicts]

The goal of research is the study of the peculiarities of clinico- psychopathologic varients of development of mental disorders and life quality in military personnel, wounded in local military conflicts in conditions of multidisciplinary military hospital. 317 patients aged 19-45 with mine-explosive wounds got in the Chechen Republic and Dagestan were examined. Analysis performed in early and secondary post stress period showed the predominance of border-line psychopathologic disorders and detected some peculiarities.

Posttraumatic symptoms following a campus shooting: the role of psychosocial resource loss

Conservation of resources (COR) theory has proven a useful framework for understanding posttrauma adjustment. A key tenet of this theory is the centrality of resource loss in determining adjustment. However, COR theory research has often been limited by retrospective research design, a focus on material loss (e.g., one's home), and a lack of attention to other adjustment predictors. This study examined whether psychosocial resource loss prospectively predicted PTSD symptomatology both immediately and 8 months following a campus shooting in a sample of college women (n = 691). Results supported that resource loss predicted symptomatology, even after controlling for other predictors, including prior trauma, psychological distress, initial PTSD symptomatology, and shooting exposure. Implications of the results for research and intervention following mass trauma are discussed.

Radiology leadership during a disaster event

The trauma of a mass casualty event in Fort Hood, TX very quickly impacted the imaging departments of 3 healthcare facilities in central Texas. In the aftermath,there was an opportunity to reflect and learn. When a mass casualty event or disaster takes place, radiology administration needs to be visible, lead staff, manage media attention and law enforcement presence,all while maintaining a high level of quality patient care. Issues of particular concern are training, coping mechanisms, and the impact of leadership. Military and civilian healthcare facilities have different capabilities in terms of training and operations when it comes to managing such an event.

Critical incident stress management (CISM) in support of special agents and other first responders responding to the Fort Hood shooting: summary and recommendations

On November 5, 2009, an individual entered the Fort Hood Soldier Readiness Processing (SRP) site and opened fire with a handgun. The result of the shooting was a total of 13 people killed and 31 wounded. A two-person critical incident peer support (CIPS) team from the United States Army Military Police School (USAMPS) provided critical incident stress management (CISM) in the forms of critical incident stress debriefings (CISD) and one-on-one crisis intervention for investigators and their spouses. This article provides a summary and discussion of the results of the interventions that were conducted. Key results for successful CISM were accessibility of CIPS team, the credibility of trained peers and the development of supportive relationships, the reduction of stigma by requiring attendance at interventions, and the commitment of the CIPS team to the principles of CISM (e.g., homogenous groups, utilizing a multicomponent approach, and facilitating the normalization of emotional reactions to the crisis). Recommendations include mandating critical incident peer support cells for Criminal Investigation Division (CID) units, Director of Emergency Services (DES) on military installations, and Military Police units; providing a pool of trained peers in the above-mentioned organizations; providing permanent funding for USAMPS' CIPS Course; and recognition of CIPS/CISMas an essential element of Comprehensive Soldier Fitness and Army Human Capital in promoting Soldier Family, and Civilian well-being and resiliency. This article would benefit leaders, chaplains, mental health professionals, and emergency services personnel in investigative, operational, and U.S. Army Garrison units.

Alert: the dark side of chats--internet without boundaries

The web has some unique advantages: It eliminates barriers of space and time; information flows quicker and is more accessible to all; the markets are more effective; community and interpersonal communication is more evolved. However, the web is also anonymous, without supervision, freedom of speech is exploited, minors and other web users are exploited, racism and prejudice are encouraged. These manifestations of violence not only hurt many people but actually pose a threat to the existence of the web as a place for exchanging ideas and thoughts, as a tool for relaying messages in a liberal and democratic fashion. Today, it is not legally possible to stop any discussion group or chats, like the one in which Eran participated, which develop dialogues regarding death or suicide. A wise and proper use of the web will be achieved by agreements and not enforcement. It is a process of education in its widest meaning that will be accomplished through the acceptance of norms. Proper use of the web will be possible when all sides--users, site owners and suppliers--willingly commit to values of mutual respect, decency and protection of individual fundamental rights to freedom. The web, which is a great blessing to the communication between people, organizations and cultures, carries with it substantial risks, especially to young users. The rapid expansion of the web and the increase in the number of users has brought many social-ideological dangers alongside the many advantages. In order to deal with these issues, a few years ago I initiated an association known as Eshnav (www.eshnav.org.il) which acts to increase public awareness to the risks and dangers of the web. Eshnav's mission, established to commemorate Eran's memory, is to promote public awareness to the positive and negative aspects of using the web on society and its values, and to promote the wise and safe use of the web. Eran was in great distress and needed empathy, encouragement and support. Sadly, when his mind was filled with suicidal thoughts he stumbled upon a group on the web that embraced the culture of death and suicide discussions. In his darkest moments, when he was on the verge of an abyss, he was probably pushed by these discussions into his death, and he was only 19-years-old. When Eshnav was created we saw the dangers of an Internet with no boundaries, a place where this remarkable technology was grossly misused. This is from the association's statement: "In a world without fences and boundaries clearer rules of conduct are needed." We emphasized that "the web is like a new world that has yet to determine its own boundaries. As such, it poses new challenges, both moral and ideological, which cannot be met based on past experience as this phenomenon is still too new and uncharted. We must do the utmost to be vigil about making the Internet as safe as possible even when this new frontier is constantly shifting and evolving." Let us bow our heads in sadness in memory of Eran whose strength did not withstand the great distress he was in, and who let himself be dragged by the death culture and darkness on the web into an untimely grave. We shall find strength in our determination to create a responsible web community in which freedom of speech will not be abused to hurt the individual rights of each and every human being to life, respect, reputation and privacy.

[Are near-death experiences following attempted suicide important for suicide risk assessment? A case report]

We describe a 59-year old patient who reported a near-death experience following attempted suicide. The near-death experience induced reduction of suicidality. Previous studies suggested a high prevalence of near-death experiences following attempted suicide and that near-death experiences may decrease rather than increase subsequent suicide risk. Implications for suicide risk assessment are discussed.

Torture against children in rebel captivity in Northern Uganda: physical and psychological effects and implications for clinical practice

BACKGROUND

Although torture in adults is well documented, studies that document its use against children, especially during war, are rare. This study documented the use of torture against children and its physical and psychological consequences during the war in Northern Uganda.

METHODOLOGY

Changes to the skin were examined by medical assistants, photographs taken, and allegations of torture verified in an interview and the case histories filed upon admission to the rehabilitation centres. The sample included 183 children aged 12 to 18 (mean age 14.8, SD 2.9) of which 60 were physically examined in two rehabilitation centres. The impact of torture was assessed using the Impact of Event Scale Revised (IES-R) in a multiple regression model.

RESULTS

Medical examinations showed visible evidence of physical trauma. Torture methods included burns, beatings, carrying heavy objects, gunshots, cuts with bayonets and machetes, long distance treks, etc. resulting into scars and keloids in different parts of the body. The scars were consistent with injuries inflicted on purpose. The children scored highly on the subscales of IES-R indicating severe symptoms of posttraumatic stress. The experience of torture explained between 26 to 37 per cent of the variance in symptoms of posttraumatic stress.

CONCLUSIONS

The physical trauma is consistent with histories and reports filed upon admission to the rehabilitation centres indicating that the children were indeed tortured. As a result of the torture, the children were psychologically distressed. The challenge for clinicians is to employ a holistic approach of treating survivors of torture by recognising not only the physical complaints but stress symptoms as well. This is because the mental states of debilitation, dependency, dread and disorientation that is induced in victims may have long-lasting consequences just like the physical and psychological consequences.

[Attempted suicide by firearms: a retrospective study of 161 cases]

OBJECTIVES

To determine the specific clinical aspects of patients with suicidal behaviour by firearm and investigate the specificities of the suicide method.

BACKGROUND

Suicidal behaviour represents a major public health problem throughout the world. Attempted suicide and completed suicide by firearms rates are very high both in Europe and in the United States. Preventive aspects presently preoccupy the physicians and the politicians. However, methods of suicide are understudied in Europe for the benefit of psychopathological and epidemiological aspects of suicide. Only a minority of studies enquire into the clinical aspects according to the method of suicide. Nevertheless, most of the international studies have already demonstrated the efficacy of reducing the accessibility of weapons.

METHODS

A retrospective study including suicide attempters by firearm hospitalized in the general hospital of Poitiers between 1992 and 2005.

RESULTS

We included 161 patients with self-inflicted gunshot wounds, among which 88% of patients were males. Most of them did not live alone and had children. Some of them had a past history of attempted suicide, some of them using a violent method. The acting out has mostly been committed at home and the firearm used was frequently a hunting gun. Interpersonal conflicts have been mostly reported by the patient with self-inflicted gunshot wounds. The prevalence of alcoholic behaviour and major depression is very important. Personality disorders are overrepresented in the study, notably paranoiac and borderline disorders.

DISCUSSION

Our sample is one of the largest compared to the other studies that often did not exceed 30 patients. Some results are contrary to those of populations of suicide attempters, whereas there are some similarities within the completed suicide population. Finally, paranoiac personality disorder is significantly associated with suicidal behaviour by firearm.

CONCLUSIONS

Some clinical characteristics have been reported as far as suicide attempters by firearm are concerned. Actually, there are some significant differences between suicide attempters by firearm and other suicide attempters. These results are very important for the perspective of preventing suicidal behaviour. However, it is essential to continue studies on the clinical aspects according to the method used in attempted and completed suicide.

Posttraumatic distress and physical functioning: a longitudinal study of injured survivors of community violence

This study examines the cross-lagged relationships between posttraumatic distress symptoms and physical functioning, using a sample of 413 persons who were hospitalized for injuries resulting from community violence. Posttraumatic distress was assessed at 1 week, 3 months, and 12 months postinjury, and posttraumatic physical functioning was assessed at 3 months and 12 months. Structural equation modeling was used to assess the prospective relationship between posttraumatic distress symptoms and physical functioning while controlling for demographic characteristics and objective measures of injury severity. Results indicate that posttraumatic distress and physical functioning are reciprocally related. Individuals with high levels of psychological distress at 1 week posttrauma have worse physical functioning at 3 months. Psychological distress at 3 months was not significantly associated with subsequent change in physical functioning at 12 months. Individuals with poor physical functioning at 3 months had higher than expected levels of psychological distress at 12 months. These findings demonstrate a reciprocal relationship between physical and mental health following traumatic injury. Interventions targeting physical recovery may influence subsequent mental health, and therapies aimed at improving early mental health may also have long-term benefits for physical recovery.

A Columbine study: giving voice, hearing meaning

On a quiet spring morning, the 20th of April 1999, Columbine High School emerged from relative anonymity as a typical suburban high school and became internationally recognized as a symbol of school violence and tragic loss. As a parent whose child was in the school at the time of the attack, I struggled to make sense of the tragedy. I decided to conduct research into the experience as a way to learn lessons that might help others exposed to community-wide trauma in the future. Through modified oral history interviews of other Columbine parents in combination with other qualitative research strategies, I collected and studied stories of the events of that day and the years following. An unexpected by-product emerged from the study, for it seemed that I was not only learning about crisis response and trauma care but also offering a means for parents to gain comfort in reflecting on their own experience. This paper describes the distinct approach that I employed to create a gateway to understanding this experience. It does not explicate the findings of the Columbine study but instead explores the potential for positive outcomes for those who, by giving voice to their stories, can connect to a deeper appreciation for their own experience.

Characteristics of persons with severe mental illness who have been incarcerated for murder

In this descriptive study, we analyzed data collected from multiple state agencies on 95 persons with severe mental illness who were convicted of murder in Indiana between 1990 and 2002. Subjects were predominantly suffering from a mood disorder, were white and male with a high school education or equivalent, were living in stabilized housing, and, to a lesser degree, were involved in significant intimate and familial relationships. Rage or anger, overwhelmingly directed toward intimate or familial relations by the use of a firearm or sharp object, was the most frequently mentioned motive for murder. Most of those studied had been raised in households with significant family dysfunction, had extensive histories of substance abuse and criminality, and had received little treatment for their mental and substance use disorders. Findings are contextualized and compared with similarly descriptive studies of nonlethal violence and persons with a mental illness; hospitalized, schizophrenic and psychotic murderers; and homicide offenders outside the United States.

Self-inflicted gunshot wound mimicking assault: a rare variant of factitious disorder

This paper presents the case of 52-year-old man who died in an attempt to prove factitious allegations of persecution. To the best of our knowledge, there are no other reported cases of a self-inflicted, long-distance gunshot injury causing death. We discuss other cases of crime-scene "staging" and review the literature on factitious disorders and malingering in our search for motive, and stress again the importance of crime scene analysis and investigation of circumstances in determining the manner of death.

Psychiatric Analysis of Suicide Attempt Subjects Due to Maxillofacial Gunshot

The studies of maxillofacial gunshot injuries mainly focused on evaluating the surgical interventions and physical outcomes of the procedures. In this study we aimed to analyze the pre- and post-injury psychiatric status of the patients with self-inflicted gunshot wounds to the face. This study is based on 12 subjects who attempted suicide resulting in extensive maxillofacial injuries using guns placed beneath their chins. The psychiatric evaluation was conducted by interview and using SCID-I, SCID-II, MMPI, Rosenberg Self-Esteem Scale and Suicide Probability Scale. Two subjects were healthy, 1 had bereavement, 6 had current and 5 had previous MDD (major depressive disorder), 2 had dysthymic disorder, 3 had alcohol abuse, 2 had drug abuse and 4 had antisocial personality disorder. The suicidal group was more socially introverted according to MMPI. According to Rosenberg self-esteem subscale, self esteem, the constancy of self respect and depressive mood subtests were statistically significant in the suicide group compared to the healthy controls (P < 0.01). Depressive spectrum disorders are the most common causes. It is obvious that untreated or undiagnosed depression may increase risk of committing suicide. The changes in the physical facial appearance after the suicide attempt caused impairment of self-esteem and the constancy of self-respect. Similar to other studies, none of our patients reattempted suicide and all tried to return to their pre-injury lifestyle and appeared to accommodate to the stigma of their physical deformities. Early diagnosis and treatment should be considered as a factor to reduce the risk for suicide attempt.

Psychological responses to the sniper attacks: Washington DC area, October 2002

BACKGROUND

This study assessed the psychological and behavioral responses of residents of the Washington DC metropolitan area to the October 2002 sniper shootings, as well as the association between measures of exposure to the shootings and elevated traumatic stress symptoms.

METHODS

Random-digit-dial telephone survey of 1205 adults living in Washington DC and two surrounding counties during the shootings, conducted May 2003. Main outcome measures included self-reports regarding traumatic stress symptoms, perceptions of safety, behavioral responses, and exposures to incidents.

RESULTS

Forty-five percent of residents reported going to public spaces such as parks and shopping centers less than usual, and 5.5% reported missing at least 1 day of work because of the sniper attacks. Women who reported living within 5 miles of any shooting incident were significantly more likely to report elevated traumatic stress symptoms-consistent with a probable diagnosis of post-traumatic stress disorder-than women who reported living farther from incidents (odds ratio = 4.2, 95% confidence interval = 1.9-9.3). Among men, there was no significant association between reported residential proximity and elevated traumatic stress symptoms.

CONCLUSIONS

These results suggest the substantial behavioral and psychological impact that traumatic events such as these sniper shootings can have on communities. They support the importance of clinicians and community leaders addressing psychological functioning in the setting of such events that threaten a population. The results further suggest that women who report residing closest to such incidents are at greatest risk for experiencing elevated symptoms of traumatic stress, and perhaps warrant special attention.

Officer-involved shooting: reaction patterns, response protocols, and psychological intervention strategies

Psychologists who work with law enforcement agencies may be called upon to respond to an officer-involved shooting (OIS). These need not be the most traumatic critical incidents in policing, but when they are, the reasons usually involve a mix of incident characteristics, officer response styles, and departmental handling. This article describes some of the psychological reactions experienced by officers during and following an OIS and provides a model of administrative, legal, mental health, and peer support services for officers in need. Finally, the article discusses several key roles that the police psychologist can play in the process of managing an OIS.

Management of Close-Range, High-Energy Shotgun and Rifle Wounds to the Face

Close-range, high-energy shotgun wounds of the face are life-threatening and devastating traumas of the face. Suicidal attempts are the main reason in the great majority of the patients in civilian life. There is no consensus on the timing of reconstruction for bone and soft tissue defects resulting from high-energy shotgun wounds. The conventional method is primary repair as soon as possible and serial debridements and definitive reconstruction in the delayed stage. An alternative to this approach is the immediate definitive surgical reconstruction of the patient during the first operation for acute management of trauma. We had 15 patients with close-range, high-energy shotgun wounds in 10 years. Six of 15 patients referred to our center for definitive reconstruction after the acute management of the patients were performed in another center and the rest were all admitted in the acute period. Either conventional approach with delayed reconstruction for 10 patients or immediate definitive surgical reconstruction for 5 patients was used. Immediate reconstruction eliminated disadvantages of the conventional method such as high infection and scarring rate and deformities resulting from contraction of tissues. The emotional conditions of the patients were evaluated and major depression signs were determined. Functional evaluation showed that there was great correlation between facial appearance after reconstruction and social activity level.

The management of ballistic trauma: an infection control perspective

This article discusses the relationship between ballistic trauma, clostridial contamination and potential wound infection and considers the implications for care by nurses and infection control teams. An overview of ballistics is presented followed by an examination of the pathophysiology of wounding and its effects. The philosophy of war surgery is balanced against civilian concepts and the differing management strategies that prevail. It explores the causes of, and relationship between, wound contamination and the seriousness of wound infection. Nurses, inexperienced in dealing and caring for these types of patients, should be aware and understand the beliefs, arguments and controversies that surround ballistic trauma management. By so doing, nurses and infection control teams will be able to provide an enhanced level of holistic nursing care.